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Minority stress and health : the health disparities of sexual minorities

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Title:
Minority stress and health : the health disparities of sexual minorities
Creator:
Atkins, Brendon G.
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Denver, CO
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University of Colorado Denver
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English

Thesis/Dissertation Information

Degree:
Master's ( Master of arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Sociology, CU Denver
Degree Disciplines:
Sociology
Committee Chair:
Burciaga, Edelina M.
Committee Members:
Duran-Aydintug, Candan
Alexander, Kari

Notes

Abstract:
Existing and emerging research have documented health disparities between sexual minorities (SM) and heterosexuals. This research consistently finds that SM experience poorer health outcomes when compared to their heterosexual counterparts. Minority stress is a commonly used theoretical model for understanding and examining this reality. Yet little work has directly tested this model as a mechanism for explaining these disparities in health. The present study addresses this gap by explicitly testing specific minority stressors postulated by the minority stress model to explain the disparities in two health outcomes. Results find that stigma and discrimination can explain the observed disparities in the current investigation and suggest that minority stress is one mechanism that can explicate the documented health disparities between SM and heterosexual individuals. In contrast to expectations of the study, no differences in health outcomes are found among SM in within-group comparisons.
General Note:
n3p

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University of Colorado Denver
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Auraria Library
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Copyright Brendon G. Atkins. Permission granted to University of Colorado Denver to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Full Text
MINORITY STRESS AND HEALTH: THE HEALTH DISPARITIES OF SEXUAL
MINORITIES
by
BREN DON G. ATKINS
B.A., University of Colorado, 2015
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Sociology Program
2018


This thesis for the Master of Arts degree by
Brendon G. Atkins has been approved for the Sociology Program by
Edelina M. Burciaga, Chair Candan Duran-Aydintug
Kari Alexander


Ill
Atkins, Brendon G. (M.A., Sociology Program)
Minority stress and health: The health disparities of sexual minorities Thesis directed by Assistant Professor Edelina M. Burciaga
ABSTRACT
Existing and emerging research have documented health disparities between sexual minorities (SM) and heterosexuals. This research consistently finds that SM experience poorer health outcomes when compared to their heterosexual counterparts. Minority stress is a commonly used theoretical model for understanding and examining this reality. Yet little work has directly tested this model as a mechanism for explaining these disparities in health. The present study addresses this gap by explicitly testing specific minority stressors postulated by the minority stress model to explain the disparities in two health outcomes. Results find that stigma and discrimination can explain the observed disparities in the current investigation and suggest that minority stress is one mechanism that can explicate the documented health disparities between SM and heterosexual individuals. In contrast to expectations of the study, no differences in health outcomes are found among SM in within-group comparisons.
This form and content of this abstract are approved. I recommend its publication.
Approved: Edelina M. Burciaga


IV
TABLE OF CONTENTS
I. INTRODUCTION...........................................1
II. BACKGROUND............................................4
III. LITERATURE REVIEW.....................................7
IV. METHODS...............................................24
Measures.........................................25
Analyses.........................................31
V. RESULTS...............................................32
VI. DISCUSSION............................................43
VII. CONCLUSION............................................50
VIII. REFERENCES............................................53
IX. APPENDIX A............................................59
X. APPENDIX B.............................................61


V
LIST OF TABLES
TABLE
1. Descriptive statistics of the STRIDE sample, overall and by sexual minority
status..........................................................................33
2. Descriptive statistics of the sexual minority sample, by sub-group............34
3. Logistic regression estimates of odds ratios (OR) predicting any lifetime physical
health condition................................................................37
4. Logistic regression estimates of odds ratios (OR) predicting any lifetime mental
disorder........................................................................38
5. Logistic regression estimates of odds ratios (OR) predicting health outcomes,
Lesbian women compared to gay men...............................................40
6. Logistic regression estimates of odds ratios (OR) predicting health outcomes,
Bisexual respondents compared to gay men........................................41
7. Logistic regression estimates of odds ratios (OR) predicting health outcomes,
Other LGB participants compared to gay men......................................42


1
INTRODUCTION
Sexual minorities/sexual minority (SM) individuals (folks who identify as something other than heterosexual, who are attracted to those of the same gender, or who engage in sexual behavior with those of the same gender) continue to face severe cultural and structural barriers that prevent this population from achieving any true measure of equity in health or in society (McClain, Thomas, & Yehia 2017). These barriers and continuing challenges set up SM for poorer health compared to heterosexual individuals. They create toxic, heterosexist environments and situations that continue to stigmatize and discriminate against nonheterosexual identities, exposing SM to stressors that in turn harm their health and wellbeing.
A large majority of sexual minority people (over two-thirds) report discrimination in their personal lives, and between 15% and 43% of SM report having been discriminated against in some form on the job (McClain, Thomas, & Yehia 2017; Sears & Mallory 2011). Hate crimes against members of the LGBTQ+ community1 continue to be prevalent, with gay men facing higher victimization rates than any other social group overall after transgender individuals (Stotzer 2012). Moreover, research over the past decade has demonstrated that SM suffer serious physical and mental health disparities compared to heterosexuals (Lick, Durso, & Johnson 2013; Russel & Fish 2016). Such realities demonstrate the continued need to study and document the health and well-being of sexual minority people. Because physical and mental health together shape our lives in fundamental and important ways, examining
11 mainly refrain from using the common acronym "LGBTQ+" (lesbian, gay, bisexual, transgender, queer) because this acronym includes both sexual and gender minority identities. These are separate identities and different populations, even as there can be overlap with some individuals who embody identities within both. Because in this study I study only sexual minorities, I refrain from using "LGBTQ+" except when explicitly referring to the larger community that constitutes both sexual and gender minorities, or when research articles examine both populations.


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how they look in this population documents the reality of their health for researchers and health practitioners.
Although research that documents this is important, it is also vital to explore the mechanisms that drive the disparities in health between SM and heterosexuals. Examining how or why SM come to have poorer health outcomes highlights an underexamined avenue of research and helps to explain these documented health disparities. This is an important part of the picture because it provides context to this reality and has the capacity to bring forward answers and solutions to the problem of not only SM health, but health disparities more generally. Furthermore, it elucidates some ways in which social inequalities are created and reproduced.
Minority stress (Meyer 1995; 2013) is one proposed explanation for how SM come to have poorer health compared to their heterosexual counterparts. According to minority stress, it is the stressors that SM face, and the hostile, heterosexist environments they are exposed to because of their sexual minority status that heighten their risk for poorer health outcomes. In this way it is the stressors and larger cultural context that drive these disparities, not the being a sexual minority itself. This framework is often invoked in the literature in the context of SM health, and some work has explored it as an important variable. However, little work has explicitly or directly tested minority stress as a mechanism that explains the poorer health of SM. I address this gap in the current investigation by testing whether specific minority stressors explain the relationship between sexual minority status and poor health.
Specifically, I address the following research questions:
o How do sexual minority individuals differ from heterosexuals as well as from each other in their physical health and mental health (outcomes)?


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o Does minority stress (defined as stigma, discrimination, and internalized homophobia) work as a mechanism that can explain these differences?
By drawing on a diverse sample of SM and heterosexual individuals, I address these important questions above and explore how minority stress acts as a mechanism that can explain the ways in which these stressors harm sexual minority folks and ultimately affect their health via poorer health outcomes and higher risk for poor health. I find that SM are over two times as likely to have any lifetime physical health condition or lifetime mental disorder compared to heterosexuals, and that minority stressors in the form of stigma and discrimination based on sexual orientation can explain this relationship. Ultimately, I argue that minority stress is a mechanism driving SM health disparities and which can explicate the documented poorer health outcomes of SM.


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BACKGROUND
Although I am investigating health disparities in the context of sexual minority status and sexual orientation, I will begin with a brief background of health disparities more generally. In the United States, health disparities have long been documented and discussed in scholarly research. This literature illustrates the complexities and nuances that come with studying them. Much of this work has examined health disparities related to race-ethnicity and socioeconomic status (SES) (Adler & Rehkopf 2008; Braveman 2006). I begin by providing a definition of health disparities, then briefly discuss the history of this research.
Health disparities do not have an agreed upon definition in the literature. Most conceptualizations of health disparities start with bases of social disadvantage that are avoidable (Braveman & Gruskin 2003; Braveman 2006). They result from both biological differences and social factors. As such, health disparities are also called “health inequalities” and “health inequities” in order to emphasize the unjust and social nature of them (Adler & Stewart 2010). As such, a health disparity is a difference in health status or health outcome between social groups that is unnecessary, avoidable, and unjust.
Adler & Rehkopf (2008) review some of the most common types of research in health disparities, which has typically examined disparities related to race-ethnicity and disparities related to SES, social class, or socioeconomic resources. Other historical investigations into disparities have examined sex and geography. Still other research has looked at both race-ethnicity and SES insofar as how they both matter and influence health (Kawachi, Daniels, & Robinson 2005).
The extent of health disparities varies by the outcome being observed, time, and geographic location within the US (Adler & Rehkopf 2008). Broadly speaking, there are


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substantial health disparities by race-ethnicity and SES. Blacks under the age of 65 experience higher all-cause mortality than non-Hispanic Whites under the age of 65 do, but these differ by the specific cause of death. For instance, data from the National Longitudinal Mortality Study (NLMS) demonstrate that Black men and women experience higher mortality than White men and women from homicide, hypertensive heart disease, and certain types of cancer. However, Black men and women experience lower mortality from causes such as suicide and leukemia compared to White men and women. These differences in mortality rates vary across the US and an interaction between local socioeconomic factors, race-ethnicity, and geography has been documented (Chen et al. 2006; Subramanian et al. 2005).
Turning to disparities by SES, an SES-health gradient has been demonstrated to exist in the US in which individuals experience better health status and health outcomes at each successive increase in SES (i.e., a “gradient”) (Glymour, Avendano, & Kawachi 2014; Adler & Stewart 2010). Individuals in the upper classes experience better health outcomes than individuals in the middle class, who in turn experience better health outcomes than individuals in lower classes. Moreover, lower SES is correlated with an increased risk of nearly every major cause of premature mortality (Glymour, Avendano, & Kawachi 2014).
Health disparities related to sex have also been explored and documented. Although women on average live longer than men, and men have been documented to have higher mortality rates, women suffer from elevated rates of morbidity and experience poorer health across a variety of health outcomes. By and large, men suffer more fatal, life-threatening conditions such as heart disease, cancer, and kidney disease, while women experience more chronic and acute conditions such as migraines, arthritis, upper respiratory infections, and


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infectious diseases (Verbrugge 1985; Bird & Rieker 1999; Gorman & Read 2006). Furthermore, women experience poorer health than men in self-rated health and disability (Read & Gorman 2006).
Although this overview is by no means exhaustive, it presents a brief overview of some of the work that has investigated health disparities. This work is important because it illustrates how identity impacts one’s health status. I will now discuss some of the work that has investigated health disparities with regard to sexual orientation and sexual minority status. This is another important identity status that impacts health and which continues to be under examined.


7
LITERATURE REVIEW
Sexual minority health disparities
A growing body of research has analyzed health disparities as they relate to sexual orientation or sexual minority (SM) individuals. This body of research has examined both mental health disparities and physical health disparities, although often not simultaneously.
In practice, this literature has only examined one while either ignoring the other or using one as a confounding factor of the other (Lick, Durso, & Johnson 2013). Findings have largely provided empirical support that sexual minorities as a group experience poorer health relative to heterosexuals, but these findings vary based on the outcome(s) being examined, the data or datasets used, the methodologies being employed, and how variables are measured.
Furthermore, studies vary depending on whether they are looking at between-group variation (sexual minority vs. heterosexual/non-minority) or within-group variation (comparing between sexual minority subgroups) (Meyer 2013). Advantages of looking at between-group differences include the ability to see how SM as a group differ from heterosexuals and to then document those differences; however, this means that the differences in health among SM are masked and not accounted for. By extension, looking at within-group differences allow the ability to see how SM differ in their health from each other, but then ignore how those differences compare with heterosexuals. As such, examining both types of differences give researchers wide range in documenting the myriad differences in health between and within these distinct social groups.
How sexual orientation or sexual minority status is measured similarly varies from study to study and has been shown to matter greatly to the findings. For instance, sexual orientation includes different dimensions: self-identification/identity, sexual attraction, and


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sexual behavior or sexual partners. These domains have important theoretical and methodological significance, and some studies point to the inability of using these interchangeably (Brewster & Tillman 2012). Some studies use only self-identification and characterize those who self-identify as gay, lesbian, and bisexual into separate categories. Others divide the sample into those who are 100% heterosexual and those who are not 100% heterosexual status. For instance, when a respondent reports “something else” or “not 100% heterosexual.” In these cases sexual minority individuals are all those who either self-identify as lesbian, gay, bisexual, something else, or are not 100% heterosexual. Other cases define sexual orientation based on those who report same-sex attraction or having had a same-sex partner in one’s lifetime or over a specified period of time.
In the sections that follow I summarize some main findings from myriad studies that have utilized various datasets to examine different types of health outcomes and comparison groups. I begin with research that has investigated sexual minority disparities in mental health, before turning to work on SM disparities in physical health.
Sexual minority disparities in mental health
Disparities in mental health by sexual minority status have been documented across many different samples and outcomes. These samples range from smaller, localized ones (Meyer, Dietrich, & Schwarz 2008; Odonnel, Meyer, & Schwarz 2011) to nationally representative ones (Hatzenbuelher et al. 2010; Barnes, Hatzenbuehler, Hamilton, & Keyes 2014; Gonzales, Przedworski, & Smith 2016; Scotte, Lasiuk, & Norris 2016). These studies examine different mental health outcomes, including suicidality, substance abuse/misuse, specific mental disorders like depression, and prevalence rates across multiple psychiatric


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mental disorders. Some of these studies demonstrate the need to look at how other social factors play a role in shaping these disparities. For instance, Hatzenbuehler and colleagues (2010) find that institutional discrimination in the form of constitutional amendments banning same-sex marriage shape the prevalence rates in psychiatric disorders of lesbian, gay, and bisexual (LGB) individuals. These researchers found higher prevalence rates among LGB individuals in states with amendments compared to states without, and that rates increased in states with such amendments. This points to how a heterosexist, anti-gay environment can contribute to SM health disparities. Barnes, Hatzenbuehler, Hamilton, & Keyes (2014) find a moderating role by education. Although LGB respondents with and without a Bachelor’s degree were more likely to have psychiatric disorders than heterosexuals, the odds of psychiatric disorders were consistently higher among LGB respondents without a Bachelor’s degree. Moreover, the protective effect of having a Bachelor’s degree was stronger in LGBs than it was in heterosexuals.
Other studies have compared sub-groups of SM and demonstrate the need to look at within-group differences of SM individuals. For instance, Meyer, Dietrich, and Schwarz (2008) assessed the lifetime prevalence of mental disorders and suicide attempts among a diverse sample of sexual minority respondents. They found that Black SM reported significantly fewer mental disorders, while Latino SM compared similar rates, compared to white SM. However, both Black and Latino SM reported a greater number of suicide attempts compared to their white counterparts. These researchers speculate that the early age of suicide attempts may have coincided with coming out about their sexuality and is therefore consistent with arguments that coming out and suicidal behavior may be “more potent” among Black SM , Latino SM, and other SM of color. Indeed, Battle and Ashley (2008) have


10
pointed to the greater reluctance among Black SM to come out, especially to their parents. This suggests disclosure of one’s sexual orientation is also an important stressor. Odonnel, Meyer, and Schwarz (2011) found results consistent with these findings. Minority race/ethnicity was found to be associated with a significantly increased risk of suicide attempts in youth. Taken together, this work demonstrates the need for work to look at within-group differences among SM individuals.
Finally, in an important review on mental health in LGBTQ+ and sexual minority populations (LGBTQ+ youth in particular), Russell and Fish (2016) document the overwhelming evidence of mental health disparities by SM status. These researchers emphasize adolescence as a “critical period” for mental health because mental disorders show onset during and directly following this stage. Studies examining adolescents trace the origins of SM mental health disparities to these years and have found disproportionate rates of mental disorders among LGBTQ+ youth. Furthermore, these researchers find that data from population-based studies illustrate overwhelming evidence that LGBTQ+ and SM individuals are at greater risk for poor mental health across developmental stages, with disparities both in symptoms and distress.
In particular, elevated rates of depression, mood disorders, PTSD, alcohol and substance use/abuse, suicidal ideation, suicidal behavior, suicide attempts, and psychiatric comorbidity have all been documented among SM individuals across many studies. Importantly, these researchers find that SM youth are approximately 3 times as likely to report suicidality, and statistically more likely to report and experience depressive symptoms compared to heterosexual youth. Bisexual youth are at an especially greater risk for poor mental health when compared to their heterosexual and lesbian/gay counterparts (Russell &


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Fish 2016; Marshal et al. 2011). Although great work on its own, this work does not directly test minority stress as a mechanism driving these poorer health outcomes. I address this gap in the current study to explore minority stress as one possible mechanism that can explicate these previous findings.
Sexual minority disparities in physical health
An emerging body of work has similarly examined SM health in the context of physical health. Many of these studies draw on nationally representative, population-based data such as the National Health and Nutrition Examination Survey and the National Health Interview Study. As with mental health disparities, these studies vary in the types of physical health outcomes they examine. Outcomes range from self-rated health (Conron, Mimiaga, & Landers 2010; Gorman et al. 2015; Hsieh & Ruther 2016), to functional limitations (Hsieh & Ruther 2016; Jackson et al. 2016); from risk factors for cardiovascular disease (CVD) (Conron, Mimiaga, & Landers 2010; Farmer et al. 2013; Farmer, Jabson, Bucholz, & Bowen 2013; Jackson et al. 2016), to sexually transmitted infections (Operario et al. 2015); and from immune functioning (Everett, Rosario, McLaughlin & Austin 2014), to mortality (Cochran & Mays 2011).
Lick, Durso, and Johnson (2013) document the growing body of literature focused on SM individuals in the context of physical health disparities. In reviewing this research, they found lesbian, gay, and bisexual (LGB) individuals to be at risk of a wide array of physical health problems, including poorer overall health, poor self-rated health, a higher number of acute physical symptoms (such as the common cold or headaches), a higher number of


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chronic conditions (like cancer and cardiovascular disease), activity limitations, disability, and even mortality.
In general, these studies have found SM to have a distinct disadvantage in physical health compared to their heterosexual counterparts. For example, Jackson and colleagues (2016) compared SM and heterosexuals in the prevalence of health outcomes, health behaviors, and health care services use. Lesbian women were more likely to be obese, to have suffered a stroke, and to have a functional limitation compared to heterosexual women. Gay men were more likely to have hypertension and heart disease compared to heterosexual men, and SM men overall were more likely to have a functional limitation. Operario et al. (2015) documented evidence that SM in the US experience disparities in different types of health outcomes (e.g. sexual health, health behaviors, etc.) that ultimately can contribute to morbidity and preventable mortality. In another study, Branstrom, Hatzenbuehler, Pachankis, & Link (2016) found LGB men and women to have a higher odds of high-preventable disease morbidity (but not in low-preventable diseases) than their heterosexual counterparts. (Preventable is defined as preventable through individual behaviors or medical intervention.) This remained after controlling for psychological distress and smoking. However, differences do emerge when comparing by SM sub-group and by sex.
For instance, Farmer et al. (2013) found that SM men taken as a whole had no significant differences in CVD risk compared to heterosexual men after adjusting for education and history of hard drug use. Once examining SM men sub-groups, bisexual men had an increased CVD risk compared to heterosexual men, whereas gay men and men who reported same-sex partners had no increased CVD risk. The increased risk in bisexual men was not attributable to differences in demographic characteristics or negative health


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behaviors. Meanwhile, in a subsequent study examining CVD risk among SM women, Farmer, Jabson, Bucholz, and Bowen (2013) found that SM women were at a significantly increased CVD risk relative to heterosexual women, and this remained after controlling for smoking and alcohol use. The authors suggest that they found a significantly increased CVD risk in SM women but not in SM men in the other study potentially because of the lower proportion of bisexually-identified SM men than bisexually-identified SM women. Alternatively, they reasoned that SM status may affect CVD risk differently for men and women.
Similarly, Gorman, Denney, Dowdy, and Medeiros (2015) found that bisexual men and women to be at a distinct disadvantage in health status compared to heterosexual and SM men and women. Bisexual men and women reported significantly poorer self-rated health than their heterosexual and gay/lesbian counterparts. Importantly, gay men and lesbian women reported better health than heterosexual men and women. This may well have been due to the advantage in SES that gay men and lesbian women reported relative to their heterosexual and bisexual counterparts. The authors conclude by emphasizing the need for separating out the subgroups within sexual minority populations, as combining them conflates the health status of gay/lesbian and bisexual individuals. These findings demonstrate how critically important it is to look at differences within sexual minority categories, as combining them into one broad category masks important differences among SM. As such, I make a point of looking at differences within SM in the current study.


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Stress and the impact of stress on health
Stress is an important factor with regard to health and has been recognized as a mechanism by which health disparities are formed and continue to affect population health (Thoits 2010). Perhaps the most important reason for this is because of the differential exposure to stress that individuals in different social locations experience. Social groups sit at different social locations in the social hierarchy on the bases social statuses such as race-ethnicity, gender, SES, sexual orientation, and so on. As a result, some statuses are at a disadvantage relative to others and are exposed to more stress as a result of this social location, whether it be from access to resources, financial distress, or experiences with discrimination and prejudice, among many others. Stress in turn has health effects “when it exceeds coping capacities, and especially when it is severe and/or chronic” (Adler & Stewart 2010, pp. 13).
An important and influential model to explain this process by which stress affects health (including physical health and mental health) is the stress process model and the contributions of Pearlin to this model (Aneshensel 2015; Pearlin 1989). It posits the construct of “stressors” that individuals are exposed to. The model emphasizes the impact of social structure on stressors and by extension the structural origins of them. It conceptualizes these structural origins as having three components: systems of stratification (SES, race, etc.), social institutions and the arrangement of statuses and roles, and interpersonal relationships (Aneshensel 2015). These components mold and shape the stressors that social groups and individuals are exposed to, and, coupled with life events and circumstances that people experience, challenge one’s adaptability to changing social situations and one’s way of living. In particular, this stress process model calls attention to the interconnections that exist


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between stressors and social and personal resources. In sum, it is the social patterning of exposure to these stressors and the concentration of them in specific segments or strata of society that contribute importantly to the concentration of disparities in the same segments.
Minority stress
One commonly utilized and helpful model for understanding disparities as they relate to sexual orientation in particular and sexual minority status more generally is minority stress. Proposed by and expanded on by Ilan Meyer (1995; 2013), minority stress is a model that can help understand the health disparities observed in LGBTQ+ and sexual minority populations. Derived from a variety of social and theoretical orientations that view stress as the conflict between individuals and their experiences in society (Merton 1968; Pearlin 1989), minority stress fundamentally can be described as psychosocial stress that is a consequence of minority status. As such, it is not exclusive to LGBTQ or sexual minority populations and can be extended to other minority social groups such as racial and ethnic minority groups (Meyer 1995). At issue is the social nature of it (“social stress”), the social conditions that exist, and the location in which SM are situated in them.
Meyer (1995; 2013) proposes three specific minority “stressors” that could serve as potential mechanisms by which this process functions: internalized homophobia, stigma, and experiences with discrimination and prejudice. Each of these are different kinds of psychosocial stressors but can be conceptualized as minority ones due to their relation to an individual’s minority status. These stressors are concerned with the negative societal attitudes and the stigma SM individuals must contend with in their lives. Internalized homophobia has been shown to be a significant correlate of mental health (Meyer 2013/ Discrimination is


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another significant stressor that many sexual minority individuals are exposed to. For example, in one study 75% of the LGB sample reported at least one occurrence of discrimination due to their sexual orientation, while 19% of the sample reported an occurrence attributed to gender nonconformity (Gordon and Meyer 2007).
Discrimination is a critical stressor in the context of minority stress and in understanding health disparities. For instance, there is strong evidence in a variety of disciplines that past and present forms of discrimination contribute to contemporary racial-ethnic inequities in income, wealth, and education, as well as evidence that it shapes societal distributions of health and disease (Krieger 2014). Understanding the role of discrimination in the stress-health relationship is critical for explaining health disparities and the social forces that drive and shape them. This is especially true for sexual minority health disparities where SM individuals are at risk of exposure to multiple forms of interpersonal and institutional discrimination, from individual acts of homophobia to the systemic realities of state-sanctioned heterosexism. Yet little work has explicitly tested this explanatory model that drives the process by which SM individuals come to experience poorer health outcomes. I aim to address this gap by hypothesizing and testing minority stress as one of these mechanisms in the current investigation.
In proposing this minority stress model, Meyer (1995) went on to test it with specific hypotheses that minority stress would posit. Meyer utilized three separate measures based on the three minority stressors mentioned above to analyze how well they would predict psychological distress outcomes (Dohrenwend et al. 1980). Results demonstrated that each minority stressor predicted all of the psychological distress outcomes when they were considered simultaneously, indicating that each stressor is independently associated with


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distress. Moreover, gay men who reported high minority stress (defined as gay men who had reported any discrimination, violence events, or who had scores above the sample mean of internalized homophobia or stigma) were two to three times more likely to report high and very high distress than gay men who reported low minority stress.
In a subsequent study, Meyer (2013) conducted meta-analyses of a variety of studies conducted over the past couple decades on the health of sexual minorities. In this review of the empirical evidence on minority stress, Meyer notes the methodological distinction between within-group studies and between-group studies. In the former, studies examine the within-group processes of minority stress by focusing on the differences within sexual minority groups and their impact on mental health, whereas in the latter researchers have compared the differences in prevalence of mental disorders between sexual minority groups and nonminority groups.
In general, these studies have demonstrated that higher levels of stress have a greater impact on mental health problems in the form of depressive symptoms, substance use, and suicide ideation. Overall, he found that gay men and lesbians are 2.5 times more likely to have had a mental disorder at any point in their lives when compared to heterosexual men and women, with these odds being higher for women. Similar results were found in prevalence of current disorders, although the combined odds ratios for men was not significant and was lower than that for women. Moreover, results found LGBs to have disproportionately higher levels of experiences with prejudice and victimization, including discrimination and violence. LGB youth in particular are even more likely than adults to be victimized by antigay prejudice specifically (Meyer 2013). Other important stressors noted are stigma (including expectations of rejection and discrimination), disclosure of one’s sexual


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identity (i.e., whether one chooses to conceal their sexual orientation or “come out”), and internalized homophobia.
Since Meyer proposed this model and his subsequent studies testing it, many other studies have found empirical support for it with respect to sexual orientation and LGB samples. One such study is from Kelleher (2009) who studied the impact of minority stress on psychological distress in Ireland among 301 youth and young adults who self-identified as LGBTQ+. Using heterosexist experiences, stigma consciousness, and sexual identity distress as the measures for minority stressors in this analysis, Kelleher found all three stressors to be significantly associated with psychological distress even when combining all three stressors into one model. Experiences with heterosexism in particular was the strongest predictor of distress for this sample of LGBTQ youth. These results demonstrate support for minority stress as each minority stressor predicted negative psychological outcomes.
Barnes, Hatzenbuehler, Hamilton, and Keyes (2014) also find support for minority stress by finding that it increases the risk of psychiatric morbidity in a nationally representative sample of US adults. Lick, Durso and Johnson (2013) review the literature on minority stress and physical health in SM individuals. In reviewing the literature up to that point, they argue that these disparities are related specifically to the experience of minority stress that SM individuals must grapple with in their day-to-day lives. In this way, minority stress was concluded to be an important mechanism through which everyday, chronic stressors impact the physical and mental health of sexual minorities.
A more recent study has tested minority stress in the context of physical health among sexual minority individuals. Utilizing Project STRIDE data, Frost, Lehavot, and Meyer (2015) analyzed minority stress and its association with the onset of a physical health


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problem in a sample of LGBs during the one-year follow-up of the longitudinal study using both self-appraised (or subjective) measures and “externally rated” measures of both minority stress and physical health. Externally rated measures of minority stress were measured as “prejudice events” that were rated “externally” by independent judges who looked for prejudice as the basis of the event during qualitative interviews conducted over the course of data collection for the study (see Frost, Lehavot & Meyer 2015 for a more thorough discussion of their methodology). Only externally rated measures of minority stress were found to be associated with the onset of an externally rated physical health problem during the preceding year. Subjective measures of minority stress were not found to be associated with either measure of physical health. These findings led the researchers to posit that perhaps more major minority stressors (i.e., discrete, event-based ones in the form of prejudice or stressful life events) are more important for health than less discrete, minor, everyday ones in the form of microaggressions.
Looking at discrimination, Khan, Ilcisin, and Saxton (2017) found multifactorial discrimination to be strongly linked to multiple mental health outcomes. Discrimination here was associated with an increased odds of depression, an increased odds of a substance use disorder diagnosis, and reduced psychological well-being. Although they argue discrimination as a fundamental cause of health, that it endures so strongly to be associated with these outcomes provides evidence that discrimination is an important stressor among sexual minority individuals. Indeed, as Krieger (2014) describes, discrimination is associated positively with psychological distress, and there is growing evidence that links exposure to discrimination to an increased likelihood of adverse health behaviors. Furthermore, evidence demonstrates that discrimination shapes societal distributions of health and disease (Krieger


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2014). Clearly then, discrimination is an important and critical stressor for understanding SM health and its role in shaping the health disparities between SM and non-SM.
Another study examining discrimination and its relationship with substance use found the prevalence of any past-year substance use disorders to be more than twice as high among LGB adults than heterosexual adults, with substance use being more prevalent among LGB adults who reported any discrimination and the highest among respondents who experienced all three types of discrimination measured (McCabe et al. 2010). This is striking given the fact that two-thirds of the sample of LGB adults experienced at least one type of discrimination in the past year.
Brewster and Tillman (2012) examined sexual orientation and substance use behavior across three dimensions of sexual orientation (self-identity, sexual attraction, and sexual behavior) using data from the National Survey of Family Growth Cycle 6. These researchers reported findings that are broadly consistent with the minority stress model, such as general findings that substance use as measured by tobacco use, illicit drug use, and binge drinking were more prevalent in women and men who self-identified as gay/lesbian or bisexual, or who reported same-gender sexual attraction or behavior, with the caveat that all these differences were significant for women whereas not all the differences were significant for men. Analyses demonstrated that self-identifying as LGB significantly predicted the odds of any substance use in the last year. However, once accounting for all three dimensions of sexual orientation, self-identifying as LGB was no longer significantly associated with higher odds of any substance use. That is, once the measures of sexual attraction and sexual behavior or experiences were considered, self-identifying as LGB no longer predicted the


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odds of substance use, suggesting that it is not identity itself that is necessarily important for linking distress and health in the context of sexual minority health disparities.
Minority stress: A mechanism for sexual minority health disparities
Overall, there is broad empirical support for minority stress as a theoretical framework for viewing health disparities related to sexual minority status. However, most of the work on sexual minority health disparities has not explored minority stress as a potential mechanism by which sexual minority individuals come to have poorer health through a direct test of it. Indeed, a critical gap in the current literature in this area is an exploration of the mechanisms that drive these disparities by sexual minority status. I seek to address this gap by exploring minority stress as one of these potential mechanisms through explicitly hypothesizing and then testing it as a mechanism. Specifically, I examine the theorized stressors of discrimination, stigma, and internalized homophobia as measures of this minority stress. I hypothesize that these stressors create a layer of added stress that sexual minority groups are exposed to and consequently increase their risk for poorer health. In other words, minority stressors will predict these health outcomes, and have the potential to mediate the relationship between sexual minority status and corresponding health outcomes.
I predict that sexual minority individuals will be more likely to have poorer outcomes in their physical and mental health as compared to their heterosexual, non-sexual minority counterparts. Furthermore, these poorer health outcomes will be explained by specific stressors in the form of stigma and discrimination that sexual minority individuals are at increased risk of exposure to because of their sexual minority status. It is also important to explore the differences between sexual minority subgroups. For instance, bisexuality can be


22
overlooked or dismissed as an identity among both heterosexuals as well as in the gay community. Examples of this range from ideas that those who are bisexual are just promiscuous, or that they are in denial about being gay. Those who identify as bisexual therefore must face discrimination from both sides, adding additional stressors that lesbian women and gay men do not necessarily have to contend with. Such a reality could put them at risk for poorer health than their lesbian and gay counterparts. It is essential to explore this reality to understand the stressors and experiences of all SM.
In the current study, I explore the health outcomes of ever having any lifetime physical health condition and ever having any lifetime mental disorder. Accordingly, I propose the following hypotheses:
Between-group comparisons (Sexual minorities versus heterosexuals)
Hypothesis la: Sexual minority individuals are more likely to have been diagnosed with any lifetime physical health condition than their heterosexual counterparts.
Hypothesis lb: Sexual minority individuals are more likely to have been diagnosed with any lifetime mental health disorder than their heterosexual counterparts.
Hypothesis 2a: The odds of ever having been diagnosed with any lifetime physical health condition increase with more feelings of stigmatization and discrimination based on sexual orientation.
Hypothesis 2b: The odds of ever having been diagnosed with any lifetime mental disorder increase with feelings of stigmatization and discrimination based on sexual orientation.
Hypothesis 3a: The relationship between SM status and ever having been diagnosed with any lifetime physical health condition is mediated by feelings of stigmatization and discrimination based on sexual orientation.
Hypothesis 3b: The relationship between SM status and ever having been diagnosed with any lifetime mental disorder is mediated by feelings of stigmatization and discrimination based on sexual orientation.


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Within-group comparisons (Sexual minority sub-group versus gay men)
Hypothesis 4a: Among sexual minorities, lesbian women will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts.
Hypothesis 4b: Among sexual minorities, lesbian women will be more likely to have been diagnosed with any lifetime mental disorder than their gay male counterparts.
Hypothesis 4c: Among sexual minorities, those who identify as bisexual will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts.
Hypothesis 4d: Among sexual minorities, those who identify as bisexual will be more likely to have been diagnosed with any lifetime mental disorder than their gay male counterparts.
Hypothesis 4e: Among sexual minorities, those who identify as queer or something else other than heterosexual (other LGB) will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts.
Hypothesis 4f: Among sexual minorities, those who identify as queer or something else other than heterosexual will be more likely to have been diagnosed with any lifetime mental disorder than their gay male counterparts.


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METHODS
Data
To test my hypotheses, I draw on public-use data from Project STRIDE: Stress, Identity, and Mental Health. Headed by the principal investigators Han H. Meyer, David M. Frost, Rafael Narvaez, and Jessica H. Dietrich, this project was funded by the National Institute of Mental Health. Project STRIDE utilizes a longitudinal research design with participants recruited in over 32 different New York City zip codes. Interviewed at baseline in 2004, then again at a one-year follow-up interview, participants were recruited from five different types of venues using a representative case quota sampling technique and snowball sampling used as an additional recruitment strategy. Although heterosexual participants were recruited at baseline (n=128) as a means of comparing sexual minority participants with heterosexual ones, they were not followed up with in the second interview. Of the total sample size (N=524), 396 participants identified as either lesbian, gay, bisexual, queer, or something else, and 371 of these sexual minority participants were retained at follow-up, for a 94% retention rate. Transgender persons were not recruited for the Project STRIDE study. Only data from the baseline interview are utilized in the present study.
Project STRIDE examines the intersection of minority identities as they relate to sexual orientation, race-ethnicity, and gender. It furthermore investigates the social stressors that affect minority groups, the impact of these stressors on their mental health, and the coping and social support resources they utilize as they confront these stressors (Meyer et al. 2006). It includes an array of different diagnostic interviews and scales to measure these areas. From a participant’s history of illness and presence of mental illness and substance use, to their psychological and social well-being; from self-esteem, to factors dealing with


25
coping and social support; these extensive data offer a wide range of information on the stressors and experiences these participants face in their lives.
Respondents in the study were more likely to be college educated than not, with less than 20% of the total sample having a high school diploma or less. Nearly three-quarters of the total sample was employed. The sample is also quite young, with a mean age of 32.24 years (SD=9.27). I will now discuss the specific variables I draw on from the STRIDE public-use dataset for the measures in the current investigation.
Measures
Sexual Orientation
All three dimensions of sexual orientation (self-identity, sexual behavior, and sexual attraction) were assessed for each respondent in the STRIDE sample. Only self-identity was used for measuring sexual orientation in the current study. Self-identity was chosen to measure sexual orientation because of the significance identity plays in the shaping of one’s life and the salience it can have across different contexts. Self-identity was assessed with the question, “How would you describe your sexual orientation?” Respondents were given a range of answers to choose from, including lesbian, gay, bisexual, queer, homosexual, other LGB, straight, heterosexual, and other straight. I recoded SM respondents as “other LGB” for those who identified as a SM identity that was anything other than lesbian, gay, or bisexual. All respondents who identified as straight, heterosexual, or “other straight” were recoded as heterosexual for the current investigation. Additionally, females who identified as gay were recoded as lesbian.


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Physical Health Outcome
For the main outcome I examine regarding physical health, I utilize data from participants’ history of illness. The STRIDE interview includes a subscale assessing past-year and lifetime prevalence of 22 disorders that are potentially influenced by stress, including hypertension, respiratory diseases, colds and flues, asthma, headaches, and GI track disorders, to name just a few (for a full list of all 22 disorders, please refer to Appendix A found at the end of the text). Two of these 22 disorders (emotional disorders and drug or alcohol disorders) were assessed as mental health outcomes for the current analysis and so not included for analysis of the physical health outcome.
As a crude measure for physical health conditions, I constructed a dichotomous variable based on whether a respondent indicated they had ever been diagnosed with at least one of the remaining 20 health conditions from the history of illness in the STRIDE dataset. Participants responded with either “yes” or “no” to questions asking if they have ever been told by a doctor or other health care professional that they had a given condition. Participants were accordingly coded as either a “1” if they said yes and a “0” if they said no.
Mental Health Outcome
For the other health outcome examined in this study, I assess the presence of any lifetime mental disorder. Lifetime mental disorder presence was measured based on whether participants indicated they had ever been diagnosed with any of at least one of several mental health disorders, including anxiety disorders, mood disorders, substance disorders, eating disorders, and phobic disorders. Two disorders from the history of illness subscale of the STRIDE interview (“any emotional disorder” and “any drug or alcohol disorder”) were also


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included when assessing the presence of any lifetime mental disorder. Participants responded with either “yes” or “no” if they had ever been diagnosed with a disorder in a given disorder category and coded as either a “1” if they ever had and a “0” if they never had been diagnosed with any mental disorder.
General health
To avoid the issue of using mental health or physical health as a confounding factor of the other, which Lick, Durso, and Johnson (2013) highlight, I control for other health factors by controlling for respondents’ general health. General health was a variable previously constructed by the investigators of the STRIDE study and which I utilized in the current investigation.
General health was assessed in the STRIDE sample with the SF-12, a shortened version of the SF-36 that improves upon certain aspects of the original scale (Meyer et al. 2006). This subscale assesses the general physical and mental health, bodily pain, role limitations, social functioning, and vitality of each respondent. All responses were self-reported. Examples of questions on this scale included, “During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular activities as a result of your physical health?” and “During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?” All responses ranged along a 5-point scale from “all of the time” to “none of the time” with responses summed and coded so that higher scores indicated better general health. The final variable is therefore summed scores, with a range of 18.87 - 61.99, a mean of 51.69, and a standard deviation of 9.82.


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Discrimination and prejudice
Experiences with discrimination and prejudice in the STIDE interview were assessed with an everyday discrimination subscale that inquired how often experiences with discrimination occurred over a respondents’ lifetime on a 4-point scale (l=often, 4=never). This subscale measured chronic, routine, and less overt experiences of unfair treatment like being treated with less respect or courtesy, being threatened or harassed, and being called names or insulted (Meyer et al. 2006). Questions included, “How often have you been treated with less respect than others?” and “How often have you been called names or insults?”
The subscale was adapted to be applied to all the minority groups in the sample, with respondents asked to identify whether each instance was related to their gender, sexual orientation, race/ethnicity, physical appearance, or other reasons (Meyer et al. 2006). For the current investigation, I utilized a continuous variable in the Project STRIDE public-use dataset that measures total discrimination based on sexual orientation. This variable measured number of instances respondents had indicated that an experience with discrimination was because of their sexual orientation. The variable had a range of 0.00 -8.00, a mean of 1.87, and a standard deviation of 2.05. (For more information regarding this variable, please refer to Appendix B).
Stigma
A previously constructed continuous variable in the STRIDE public-use dataset measuring stigmatization was utilized for the minority stressor of stigma in the current investigation. This variable was measured from a 6-item subscale which inquired about expectations of rejection and discrimination based on one’s sexual identity on a 4-point


29
Likert scale that ranged from “strongly agree” to “strongly disagree”. An example of one question read, “Most people would willingly accept a gay man as a close friend.” All responses were coded by the principal investigators so that higher scores meant more stigma, with all item scores summed then averaged so that each respondent was given a mean total score (Meyer et al. 2006). The variable had a range of 1.00 - 4.00, a mean of 1.92, and a standard deviation of 0.77. (For more information regarding this variable, please refer to Appendix B).
Internalized homophobia
Internalized homophobia was measured with a continuous variable already constructed and made available in the STRIDE public-use dataset. This variable was constructed by the investigators of Project STRIDE using a 9-item subscale that assessed the extent to which sexual minority men and women do not accept their sexual orientation or sexual identity, are uneasy about their same-sex desire, and try to avoid feelings associated with their same-sex desire (Meyer et al. 2006). A sample item included, “How often have you wished you weren't gay?" Responses measured the frequency that respondents experienced such thoughts and feelings in the previous year on a 4-point scale ranging from “often” to “never.” Internalized homophobia was not assessed for heterosexual respondents. For each SM respondent, a mean total score was obtained and coded so that higher scores indicated more internalized homophobia (Meyer et al. 2006). It had a range of 1.00 - 3.50, a mean of 1.20, and a standard deviation of 0.52. (For more information regarding this variable, please refer to Appendix B).


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Other sociodemographic characteristics
Looking at sociodemographic characteristics, race-ethnicity was measured with a single item asking, “Which of the following best describes your racial or ethnic background...” Only individuals who identified as Black, Latino, or white were recruited for the Project STRIDE study. As such, respondents were only given the options White,
Black/African-American, and Latino/Hispanic to describe their racial/ethnic background. Participants who identified as anything other than these, including those who described themselves as multi-racial or bi-racial, were not qualified to participate. (Racial-ethnic identity was also assessed with other questions asking about the participant’s family background including country of origin and national background. However, these measures were not utilized in the current exploration).
Sex was based upon whether a participant indicated they were male or female. Respondents indicated their age with their date of birth. Based on this, respondents were then categorized into different age group intervals (1 - 8), including under 21, over 50, and 4-year age intervals in between these (i.e., 21-25 years old, 26-30 years old, etc.), for a total of 8 age groups and categories.
SES included measures of employment status, household income, and education. Employment status was measured based on whether participants indicated they were employed or not. Income was measured using an ordinal measure of a respondent’s household income (before taxes) in the past 12 months (a continuous variable of household income was not available in the Project STRIDE public-use dataset). A total of 35 intervals were created by the STRIDE researchers in the construction of the ordinal variable. Intervals of $1,000 were utilized up until a total household income of more than $20,000, such that a 1


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indicates a household income in the range of $1 - $999, a 2 in the range of $1,000 - $1,999 and so on. Intervals of $5,000 were used for household incomes in the range of $20,000 -$99,999, with larger intervals used at higher levels up to $1,000,000 or more. Education was defined as whether participants were or were not college educated. A respondent was coded as college educated if they had at least a Bachelor’s degree or higher, while anything less than a Bachelor’s degree was coded as non-college educated.
Analyses
A number of analyses were conducted for the current study. First, proportions were estimated for the physical and mental health outcomes to show the burden of each outcome for each sexual identity category. Descriptive statistics were then conducted to compare every covariate by sexual identity category, first by SM status, then by SM subcategory. Comparisons by levels of each minority stressor were also assessed.
To test the study’s hypotheses, a number of regression analyses were conducted to compare heterosexuals and sexual minorities, then within sexual minority subgroups, for each outcome. Logistic regression was used to predict the odds of having any lifetime physical health condition as well as the odds of having any lifetime mental health disorder. Logistic regression analyses consisted of two sets of models for comparisons between heterosexuals and SM, with the first model including the sociodemographic characteristics and average general health scores of the sample. Then, the specific minority stressors of discrimination and stigma were added in the second model. For the models comparing only sexual minorities, internalized homophobia was also included.


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RESULTS
Table 1 shows the descriptive statistics of the whole sample and by sexual minority status. T-tests reveal that a significantly lower proportion of sexual minority respondents held a Bachelor’s degree or higher, and had significantly higher scores of stigma and sexual orientation-based discrimination, than their heterosexual counterparts. A significantly higher proportion of SM reported ever having any lifetime physical condition (83.33%) versus heterosexuals (71.88%). A higher proportion of SM also reported ever having any lifetime mental disorder (76.51%) compared to heterosexuals (71.09%), although this difference was not large enough to be statistically significant (p<.2178) (not shown in table).
Turning to within-group differences, Table 2 shows descriptive statistics that compare within-group differences among SM sub-groups for all outcomes and covariates of the study. One-way analysis of variance tests reveal significant differences in household income, average general health scores, sexual orientation-based discrimination, and internalized homophobia across SM sub-groups. Bisexual-identified respondents reported the lowest levels of household income and general health, as well as the highest levels of internalized homophobia. In contrast, gay men reported the highest levels of household income and general health. For the outcomes of the study, Chi-square tests of independence demonstrated no significant differences in the proportion of SM respondents reporting any lifetime physical health condition or any lifetime mental disorder across SM sub-groups. While there were no statistically significant differences in reporting lifetime health conditions by SM sub-group within the population, differences within the sample were evident. Lesbian women had the highest proportion among SM of ever having any lifetime mental disorder, and over 90% of other LGB respondents reported having any lifetime physical health condition.


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Table 1. Descriptive statistics of the STRIDE sample, overall and by sexual minority status
Overall sample (N=524) Heterosexuals (n=128) Sexual minorities (n=396) P<
Any lifetime physical
health condition .8053 .7188 .8333 .0044
Any lifetime mental
disorder .7519 .7109 .7651 .2178
Race/ethnicity
Black .2500 .0000 .2500
Latino .2500 .0000 .2500
White .5000 1.000 .5000 .0000
Female .4981 .4922 .5000 .8782
Age 3.81 3.73 3.84 .5534
Household income 21.47 21.67 21.40 .7275
Unemployed .1584 .1484 .1616 .7232
Bachelor’s degree or higher .5324 .7031 .4772 .0000
General health 51.69 52.66 51.38 .2023
Stigma (1-4) 1.91 1.46 2.06 .0000
Sexual orientation-
based discrimination 1.87 0.34 2.37 .0000
(0-8)
Internalized
homophobia (1 -3.5) - - 1.41 -
*P-values represent significance levels in t-tests for differences in means/proportions and Chi-square
tests of independence for differences in frequency distributions for categorical variables


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Table 2. Descriptive statistics of the sexual minority sample, by sub-group
Gay Lesbian Bisexual Other LGB P<
(n=155) (n=134) (n=71) (n=36)
Any lifetime physical
health condition .8065 .8284 .8592 .9167 .3960
Any lifetime mental
disorder .7290 .7985 .7887 .7500 .5280
Race/ethnicity
Black .1237 .1010 .0758 .0303
Latino .1263 .1136 .0682 mn
White .1414 .1237 .0354 .0379 .1750
Female - .5560 .1784 .0871 .0000
Age 3.90 3.94 3.61 3.67 .5768
Household income 22.31 21.68 19.24 20.89 .0387
Unemployed .0505 .0556 .0455 .0101 .0970
Bachelor’s degree or higher .2071 .1641 .0631 .0429 .1040
General health 52.96 51.10 49.36 49.65 .0408
Stigma (1-4) 1.95 2.15 2.12 2.11 .1408
Sexual orientation-based
discrimination (0 - 8) 2.50 2.63 1.61 2.33 .0056
Internalized homophobia (1-3.5) 1.37 1.30 1.79 1.26 .0000
*P-values represent significance levels in one-way ANOVA tests for differences in means for
multinomial categorical variables and Chi-square tests of independence for differences in frequency distributions/proportions for categorical variables


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Comparing health outcomes between sexual minority and heterosexual respondents, odds ratios from logistic regression models of ever having any lifetime physical health condition and any lifetime mental disorder are presented in Tables 3 and 4, respectively. In support of Hypothesis la, Model 1 from Table 3 reveals that SM have significantly higher odds of ever having any lifetime physical health condition (OR=2.19, p< 05) relative to heterosexuals after controlling for race/ethnicity, sex, age, SES, and general health. In other words, the odds of having any lifetime physical health condition is larger among SM than it is among heterosexuals by a factor of 2.19. Consistent with Hypothesis lb, Model 1 in Table 4 reveals that SM are at significantly higher odds of ever having any lifetime mental disorder (OR=2.11, p<05) compared to heterosexuals and controlling for these same covariates. In other words, SM have a 111% increase in odds of any lifetime mental disorder compared to heterosexuals.
Model 2 from both Tables 3 and 4 adds in adjustments for the minority stressors of stigma and sexual orientation-based discrimination. Model 2 demonstrates some support for Hypothesis 2a, where the odds of ever having been diagnosed with any lifetime physical health condition increase with more experiences of discrimination based on sexual orientation (OR=1.13, p<10). However, the odds do not increase with higher feelings of stigma (OR=0.96, p=.831). Once accounting for each of these minority stressors, SM, compared to heterosexuals, no longer have statistically significant higher odds of having any lifetime physical health condition (OR=1.72). This is in support of Hypothesis 3a, although only for discrimination based on sexual orientation. That is, discrimination based on sexual orientation is mediating the relationship between SM status and ever having any lifetime


36
physical health condition. Because stigma is not significant here, it is not mediating this relationship.
A somewhat different picture is revealed in Table 4. Results demonstrate some support for Hypothesis 2b, with the odds of ever having any lifetime mental disorder increasing with increases in feelings of stigma (OR=1.49, p<05), but not with experiences of discrimination based on sexual orientation (OR=1.09). Relative to heterosexuals, the higher odds among SM of ever having any lifetime mental disorder is no longer statistically significant once adjusting for stigma and discrimination based on sexual orientation and controlling for every other covariate (OR=1.57). These results are also in support of Hypothesis 3b, although only for stigma since discrimination based on sexual orientation was not significant here. In other words, the relationship between SM status and ever being diagnosed with at least one lifetime mental disorder is mediated by stigma.
Taken together, these results demonstrate that minority stressors in the form of stigma and discrimination can explain the disparities in health outcomes examined in this investigation. However, it appears to depend upon the health outcome in question because they do not both explain either outcome. Discrimination is the mediator in the physical health outcome, whereas stigma is the mediator in the mental health outcome. Such findings suggest that minority stress is one mechanism that can explicate the health disparities documented between SM and heterosexuals and the poorer health outcomes SM experience. Moreover, it depends upon how minority stress is measured, and which stressor is used, for the significance it has in this relationship.


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Table 3. Logistic regression estimates of odds ratios (OR) predicting any lifetime physical health condition
Model 1 (n=511) OR Model 2 (n=511) OR
Sexual minority 2.19** 1.72
Race-ethnicity
Black 0.97 1.04
Latino 0.55* 0.57
White — —
Female 1.23 1.25
Age 1.16** 2 27**
Household income 0.99 0.99
Unemployed 1.06 1.09
Bachelor’s degree or
higher 0.87 0.86
General health Q <^3**** q <23****
Stigma 0.96
Sexual orientation-based
discrimination 1.13*
(*p< 10, **p< 05, ***p< 01, ****p< 001)


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Table 4. Logistic regression estimates of odds ratios (OR) predicting any lifetime mental disorder
Model 1 (n=511) OR Model 2 (n=511) OR
Sexual minority 2.11** 1.57
Race-ethnicity
Black q 29**** q 24****
Latino 0.65 0.57
White — —
Female 1.36 1.33
Age \ 24** \ 24**
Household income 0.99 0.99
Unemployed 0.75 0.73
Bachelor’s degree or
higher 0.74 0.78
General health 0 95**** 0 95****
Stigma 2 49**
Sexual orientation-based
discrimination 1.09
(*p< 10, **p< 05, ***p< 01, * * * *p< 001)
Turning to within-group comparisons, Tables 5, 6, and 7 present odds ratios from logistic regression models predicting the odds of ever having any lifetime physical health condition and any lifetime mental disorder among just SM. Each table presents odds of one particular sub-group of SM relative to gay men. Table 5 displays theses analyses by comparing lesbian women to gay men and shows that there are no differences in the odds of lesbian women ever having any lifetime physical health condition or lifetime mental disorder relative to gay men once adjusting for every covariate in the analysis. These results do not


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support Hypotheses 4a and 4b. In this sample of gay men and lesbians, discrimination is associated with having a lifetime physical health condition, with each additional instance of sexual orientation-based discrimination associated with a significant increase in odds of ever having any lifetime physical health condition (OR= 1.30, p<01).
Turning to bisexual respondents as compared to gay men in their health outcomes, Table 6 shows that bisexual respondents have no difference in odds of either health outcome once adjusting for every covariate. Therefore, Hypotheses 4c and 4d are not supported. Stigma and internalized homophobia are associated with significant increases in odds of having any lifetime mental disorder among this sample of gay men and bisexual men and women. Every one unit increase in stigma is associated with an increase in odds of any lifetime mental disorder by 68%, while every unit increase in internalized homophobia is associated with a 110% increase in odds of this outcome.
Finally, Table 7 displays results from analyses ran comparing other LGB respondents to gay men. Although within the sample other LGB respondents have an odds of ever having any physical health condition that is 2.68 times the odds of gay men, this was not found to be a statistically significant difference within the population (p<3660, CI=0.32-22.73) (not shown in table). This was likely due to lack of statistical power, with the large difference in confidence intervals certainly suggesting this. Turning to the mental health outcome, there is similarly no significant difference in odds of ever having any lifetime mental disorder among other LGB respondents relative to gay men. Hypotheses 4e and 4f are consequently not supported by these results.


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Table 5. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Lesbian women compared to gay men
Any lifetime physical health condition (n=280) OR Any lifetime mental disorder (n=280) OR
Lesbian women 0.93 1.22
Race-ethnicity
Black 0.85 q 23****
Latino 0.50* 0.58
White — —
Female 1.00 (omitted) 1.00 (omitted)
Age 1.21* 1.11
Household income 0.98 0.99
Unemployed 2.37 1.31
Bachelor’s degree or
higher 0.99 0.88
General health q 94*** 0.95**
Stigma 0.94 1.32
Sexual orientation-based
discrimination 1.30*** 1.08
Internalized homophobia 1.30 1.17
(*p< 10, **p< 05, ***p< 01, ****p< .001)


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Table 6. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Bisexual respondents compared to gay men
Any lifetime physical health condition (n=221) OR Any lifetime mental disorder (n=221) OR
Bisexual respondents 0.91 0.82
Race-ethnicity
Black 1.16 q 27****
Latino 0.48 0.43*
White — —
Female 1.97 2.85
Age 1.13 1.10
Household income 0.99 1.01
Unemployed 1.52 0.87
Bachelor’s degree or
higher 0.94 0.91
General health 0.95* 0.98
Stigma 1.03 1.68**
Sexual orientation-based
discrimination 1.20* 1.15
Internalized homophobia 1.23 2.10**
(*p< 10, **p< 05, ***p< 01, ****p< 001)


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Table 7. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Other LGB participants compared to gay men
Any lifetime physical health condition (n=163) OR Any lifetime mental disorder (n=185) OR
Other LGB respondents 2.68 0.64
Race-ethnicity
Black 1.15 016****
Latino 0.52 0.56
White — —
Female 0.84 2.06
Age 1.08 1.07
Household income 0.98 1.02
Unemployed 1.00 (omitted) 1.57
Bachelor’s degree or
higher 0.95 0.86
General health 0.98 0.96*
Stigma 1.06 1.70*
Sexual orientation-based
discrimination 1.23* 1.10
Internalized homophobia 1.06 0.84
(*p<.10, **p< 05, ***p< 01, ****p< 001)


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DISCUSSION
Under the minority stress model, the heterosexist and homophobic conditions that exist in society put sexual minorities at differential exposure to stress compared to heterosexual, non-sexual minority individuals (Meyer 1995; 2013). Living in a heterosexist culture that devalues non-heterosexual people and relationships create added stressors for SM that in turn put them at an increased risk for poorer health outcomes. Minority stressors such as stigma, discrimination, and internalized homophobia create feelings of poor self-worth and inadequacy to living up to the dominant, heterosexist norms valued in society. Such realities put SM at increased exposure to stress relative to heterosexuals, which in turn increases their risk for disease and illness.
Findings from the current investigation are consistent with these ideas, with SM (as a whole) being more than twice as likely to have any lifetime physical health condition or any lifetime mental disorder when compared to heterosexuals. Looking at physical health, results here are consistent with other research that has also examined disparities in physical health outcomes (Lick, Durso, & Johnson 2013). For instance, Hsieh and Ruther (2016) look at self-rated health and functional limitations and find that, overall, SM were associated with poorer health when compared to heterosexuals. Furthermore, Jackson et al. (2015) document a greater burden of poor physical health problems among SM men and women relative to heterosexuals as well. Other research similarly documents poorer physical health outcomes among SM (Branstrom et al. 2016; Conron, Mimiaga, & Landers 2010; Farmer et al. 2013; Gonzales, Przedworski, & Smith 2016).
Turning to mental health, the finding that SM respondents are significantly more likely to have any lifetime mental disorder than their heterosexual counterparts is consistent


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with prior research that has examined disparities in mental health outcomes (Hatzenbuelher et al. 2010; Barnes, Hatzenbuehler, Hamilton, & Keyes 2014; Russel & Fish 2016). That SM are more than twice as likely to have had any lifetime mental disorder is also consistent with findings from Meyer (2013) who found SM to be 2.5 times more likely than heterosexuals to have had a mental disorder at any point in their lives. Together, along with further evidence in the present study, it is clear the SM suffer serious health disparities in both physical and mental health outcomes.
The present study went beyond simply examining health outcomes and comparing them between SM and heterosexuals. It also explicitly tested the minority stress framework as a mechanism for explaining these health disparities by assessing specific minority stressors in the form of stigma, discrimination, and (in within-group comparisons) internalized homophobia. This addresses a lack of work investigating mechanisms in sexual minority health disparities—a critical gap in the current literature. Once considering minority stressors of stigma and discrimination based on sexual orientation, there were no longer any significant differences in odds of either health outcome. The more than twice the odds in both health outcomes examined here were thus mediated by feelings of stigmatization and experiences with discrimination based on sexual orientation among this sample of SM. This suggests minority stress is a mechanism that drives the health disparities between SM and heterosexuals; that is, the stress SM must navigate because of their minority status ultimately has a negative impact on their health and well-being.
Stress is regarded as a mechanism by which health disparities are formed, reproduced, and socially patterned (Thoits 2010). The specific stress that is experienced because of an individual’s minority status is socially derived and referred to as minority stress (Meyer


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1995). It can likewise be framed as a mechanism that drives health disparities; in this case, SM health disparities. The logic follows as such: being a sexual minority leads to differential exposure to stress as a result of the heterosexist conditions in society that lead to stigmatization, experiences with discrimination, and feelings of internalized homophobia, which in turn harm well-being and have a negative impact on health. In this way SM experience poorer health outcomes in comparison to their heterosexual counterparts.
Turning to the stress process model (Pearlin 1989; Aneshensel 2015) is useful for conceptualizing how these stressors come to have an effect on health in the long-run. For one, stress in and of itself is important in the context of health because it comes to have effects on health when it goes beyond an individual’s ability to cope or respond to it (Adler & Stewart 2010). This is even more true when stress is severe and/or chronic. Minority stress can be considered chronic to the extent that SM individuals perceive and/or experience negative feelings, emotions, or situations associated with their sexual minority status. As such, the perceptions, experiences, and chronic reality of minority stress will likely vary among SM because their levels of stigma, internalized homophobia, and experiences with discrimination also vary. Future research should therefore determine whether discrimination and stigma differentially affect odds of health diagnoses since this was not assessed in the current study. Doing so would extend research on within-group differences between SM and document how minority stress and the processes by which it affects health differently across different sub-groups of SM. For instance, whether or not different stressors of minority stress moderate this relationship.
One way to consider how stress influences health, particularly in the realm of physical health, is in the biological pathways. Kubzansky, Seeman, & Glymour (2014)


46
review much of the literature on these biological pathways. When stressors are perceived to exceed one’s ability to cope or respond, stress and negative responses that impact one’s affect result. This initiates a biological stress response. When such stress responses repeatedly occur due to chronic or recurring stress, it can activate the autoimmune nervous system and neuroendocrine system to respond to the situation at hand. Thus, even the perception of a stressor as going beyond a capacity to cope can alter the physiology of the body, which in turn can negatively influence biological systems. Similarly, these researchers document the strong support linking chronic stress with poorer immune functioning and a dysregulated inflammatory response (Kubzansky, Seeman, & Glymour 2014). This research illuminates how stress “gets under the skin” and affects different systems in the body that then expose individuals to higher risk for disease and illness. The implications of this for minority stress are all too clear.
Given the stressors that SM routinely experience because of their sexual minority status, it is not implausible that, over time, repeated activation of the body’s stress response resulting from these stressors will take a toll on the body and ultimately impact their health status. This avenue of exploration offers new ways to illuminate the processes by which stress impacts health, particularly in the context of sexual minority health. Although some research has explored this avenue [such as in the case of immune functioning and markers of inflammation in SM (Everett, Rosario, McLaughlin & Austin (2014))], more research on the biological pathways that specifically examines SM is warranted.
Although SM did differ significantly in their levels of general health (bisexual and other LGB respondents reported the poorest general health overall), no differences were found in health outcomes when conducting within-group comparisons; that is, comparing


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different sub-groups of SM. Lesbian women, bisexual men and women, and other LGB respondents were no more likely than gay men to have ever had any lifetime physical health condition or any lifetime mental disorder. There is evidence to believe that bisexual and other SM people suffer from poorer health compared to their gay and lesbian counterparts. For example, Gorman and colleagues (2015) assessed self-rated health and found that bisexual men and women reported significantly poorer health than their heterosexual and gay and lesbian counterparts. Furthermore, gay men and lesbian women reported better health than heterosexual men and women. In another case, Farmer and friends (2013) compare cardiovascular risk between SM men and heterosexual men and document that bisexual men had an increased cardiovascular risk compared to heterosexual men, while gay men and men who reported same-sex partners had no increased risk. Such findings raise questions on the vulnerability of bisexual and other queer-identified individuals. It is critical to explore the nuance between different categories of SM as they are not a monolithic group, and, although sharing minority sexual identities, have very different lived experiences.
One likely explanation for finding no differences between SM sub-groups is a lack of statistical power due to small sample sizes, particularly among the comparisons with gay men and other LGB respondents. That other LGB respondents were nearly three times as likely to have any lifetime physical health condition than gay men in the sample certainly points to this explanation. Alternatively, it may well be that among this sample there are in fact no differences in these health outcomes between SM sub-groups as compared to gay men in the sample. This could be a result of how the outcomes were measured. Using different outcomes may have resulted in different findings that do find significant difference among SM. That said, given how the outcomes were measured here, the current findings may be a result of


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SM being equally as likely of having any lifetime physical health condition or lifetime mental disorder. In this way, there are no disparities because SM sub-groups are at no increased risk from each other of either outcome as they were measured in this investigation.
Another potential explanation for this finding is that Project STRIDE participants were only recruited from the New York City area and is therefore not nationally representative. In the two studies cited above that document poorer health among bisexual adults compared to lesbian and gay adults, these results were found from population-based datasets that allowed for more statistical power as well as comparisons across sexual orientation-by-gender groups that the STRIDE sample did not. Still, the STRIDE sample included the ability to assess measures of minority stress important for the current study. These other datasets did not have such an ability.
This study is not without its limitations. For one, the STRIDE project did not sample heterosexual Black and Latino participants. As such, it cannot be ruled out that the Black and Latino SM here do not differ in their health outcomes and other sociodemographic characteristics from their heterosexual, racial-minority counterparts. Furthermore, because heterosexuals were 100% white, differences in outcomes attributed to sexual minority status could include racial impacts as well. Also, the STRIDE sample did not recruit participants who were not Black, Latino, or white, and as such is missing all other racial-ethnic groups, including those who are multiracial. Another limitation is the relatively small sample size, especially once the sexual minority sample is broken down into sub-groups. Finally, the STRIDE sample is not population-based and is consequently not nationally representative, thus limiting the generalizability of the findings here.


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Still, most nationally representative datasets continue to not include questions about sexual orientation for any dimension, and certainly do not include measures of these minority stressors. As such, the STRIDE dataset is an important one because of its relatively large sample of SM individuals, and the fact its interview schedule incorporates subscales for measuring the particular stressors theorized to be important by the minority stress framework. Research that is able to incorporate nationally representative data with data on these stressors is warranted to continue to build our knowledge of the processes by which minority stress shapes the health and well-being of sexual minorities. Moreover, it would extend the current investigation and further test minority stress as a mechanism driving SM health disparities.


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CONCLUSION
The results from the current investigation further establish the poorer health of SM. It also extends previous research on sexual minority health by finding evidence of minority stress (in the form of stigma and sexual orientation-based discrimination) explaining the health disparities between SM and heterosexuals. Such evidence points to the utility of minority stress as a framework for understanding the poorer health among SM as a group and the processes that drive this reality. But beyond this, these results also offer valuable information that can be used to inform policy and practice.
For one, because it is the heterosexist and homophobic conditions within society that fundamentally create this additional (social) stress that SM must contend with and navigate, policies and programs that address these conditions are critical for responding to the poorer health profiles of SM. One way to do this is to change current educational curricula and policies in schools that continue to be heterosexist and discriminatory against SM.
Significant proportions of sexual minority youth report feeling unsafe at their schools and experience policies and practices in their schools that are discriminatory (McClain, Thomas, & Yehia 2017). School curricula and policies that are more inclusive and accepting of nonheterosexual identities and relationships would go far in promoting a more open and accepting environment. This is especially important for LGBTQ+ and sexual minority youth, who are especially vulnerable. LGBTQ+ youth are significantly more likely to experience suicidal ideation, engage in self-harm, attempt suicide, and engage in substance abuse/misuse (Russell & Fish 2016). It is paramount that this reality be acknowledged, and steps taken to address it, so that LGBTQ+ youth are able to feel welcome and safe.


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Such policies should also be implemented in other domains, including in the workplace and in health care. Between 15% and 43% of SM individuals have faced discrimination at work, and 56% of SM report experiencing discrimination in health care, with many continuing to avoid seeking care because of the stigma and discrimination they face because of their identity (IOM 2011; McClain, Thomas, & Yehia 2017). As the findings from this study demonstrate, discrimination is a key factor that plays a role in the stress-health relationship. School, work, and health care spaces that respond to discrimination and are proactive in stemming it will provide more inclusive and accepting spaces for nondominant identities and relationships. Moreover, they would go far in promoting safety and productivity as SM feel welcome and less stigmatized in them.
Additionally, the lack of data on sexual orientation and sexual minorities continues to be a challenge (McClain, Thomas, & Yehia 2017). This lack of data impedes research that can be conducted on this population, and so limits the ability to investigate mechanisms and factors that shape and impact sexual minority health. As results from this study demonstrate, minority stress is one prospective mechanism and needs more research to further validate empirically its role in shaping SM health. Robust, high-quality data must therefore be collected on this population so that research can continue to add to our knowledge of SM health disparities and be able to address the challenges that SM face. Consequently, epidemiological and population-based demographic surveys must do more than they currently are by including, by default, questions about sexual orientation in their surveys. Policies that require federal studies, surveys, and research studies that receive federal funds to include questions that ask about sexual orientation would be a key step in addressing this
lack of data.


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In sum, this study demonstrates the critical role discrimination and stigma can play as minority stressors to shape the health and well-being of sexual minorities. Moreover, the findings highlight the substantive and theoretical significance of minority stress as a framework for understanding and explaining sexual minority health and the disparities in health between SM and heterosexuals. It extends prior research and offers future avenues of exploration for this important subject and a marginalized population.


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APPENDIX A
Full list of 22 disorders covered in participants ’ history of illness.
History of Illness: “Have you ever been told by a doctor or health care professional that you have any of the following conditions.
- Asthma bronchitis or emphysema
- Tuberculosis
- Other lung problems
- Arthritis, rheumatism, or other bone or joint diseases
- Sciatica, lumbago, or recurring backache
- Persistent skin problem (e.g. eczema)
- Thyroid disease
- Hay fever
- Recurring stomach trouble, indigestion, or diarrhea
- Urinary or bladder problems
- Ulcers
- AIDS or HIV infection
- Lupus or other autoimmune disorders
- High blood pressure or hyptertension
- Anxiety, depression, or some other emotional disorder
- Alcohol or drug problems
- Migraine headaches
- Chronic sleeping problems
- Diabetes or high blood sugar


Multiple sclerosis, epilepsy, or other neurological disorders Stroke
Any other health condition


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APPENDIX B
The following is a deeper account of the individual minority stressors explored in the current study. I explain them and include the items used in the Project STRIDE questionnaire to assess them. All variables utilized to measure these minority stressors were previously constructed by the researchers involved with Project STRIDE and made available in the STRIDE public-use dataset. All information was gathered from the STRIDE questionnaire and codebook, as well as from the “Methodology and Technical Notes” document completed by Ilan H. Meyer, David D. Frost, Rafael Narvaez, and Jessica H. Dietrich (2006). Discrimination and prejudice
Discrimination based on sexual orientation was a continuous variable created by the principal investigators to show how many times a respondent indicated an experience with discrimination was based on their sexual orientation. This variable was created based on the everyday discrimination subscale administered with the questionnaire. This subscale had a total of 8 items along a 4-point scale ranging from “often” to “never” inquiring about different types of experiences related to discrimination, including chronic, routine, and less overt experiences of unfair treatment over a respondent’s lifetime (Meyer, Frost, Narvaez, & Dietrich 2006). The items included: How often over your lifetime have you...
...been treated with less courtesy than others?;
...been treated with less respect than others?;
...received poorer services than others in restaurants or stores?;
...experienced people treating you as if you're not smart?;
...experienced people acting as if they are better than you are?;
...experienced people acting as if they are afraid of you?;


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...experienced people acting as if they think you are dishonest?;
...been called names or insulted?
Following each item, respondents were then asked whether this was based on their gender, physical appearance, sexual orientation, race/ethnicity, or something else. For total discrimination based on sexual orientation, researchers tallied each instance in which respondents indicated that the discrimination experienced in each item was because of their sexual orientation. Therefore, given the 8 items administered in the subscale, the total could range from 0-8. This was the final variable utilized for measuring discrimination in the current investigation.
Stigma
Stigma measured the degree to which respondents indicated expectations of rejection and discrimination because of their sexual orientation (Meyer, Frost, Narvaez, & Dietrich 2006). This was administered in the Project STRIDE interview with 6 items along a 4-point scale ranging from “agree strongly” to “disagree strongly.” Responses were summed and averaged by researchers so that each respondent had a mean total score of stigma, with higher mean scores meaning more stigma. The following items were administered for assessing stigma:
- Most employers will not hire a person like you
- Most people believe that a person like you cannot be trusted
- Most people think that a person like you is dangerous and unpredictable.
- Most people think less of a person like you
- Most people look down on people like you
- Most people think people like you are not as intelligent as the average person


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Internalized homophobia
Internalized homophobia was assessed to measure how sexual minority men and women feel about their sexual orientation, including feelings of uneasiness about it, not accepting it, and attempts to avoid feelings related to it (Meyer, Frost, Narvaez, & Dietrich 2006). As such, it was only administered to sexual minority respondents, and was not assessed on heterosexual ones. It was measured with 9 items along a 4-point scale ranging from “often” to “never.” All responses were summed and averaged so that each sexual minority respondent had a total mean score, with higher mean scores meaning more internalized homophobia. The following is a list of the items administered to SM respondents:
- You felt it best to avoid personal or social involvement with other people who are [lesbian/gay/bisexual/other]
- You have tried to stop being attracted to [the same sex]
- If someone offered you the chance to be completely heterosexual this past year, you would have accepted the offer
- You have wished you weren't [lesbian/gay/bisexual/other]
- You have felt alienated from yourself because of being [lesbian/gay/bisexual/other]
- You have wished that you could develop more erotic feelings towards [the opposite sex]
- You have felt that being [lesbian/gay/bisexual/other] is a personal shortcoming
- You would have liked to get professional help in order to change your sexual orientation from [lesbian/gay/bisexual/other] to straight
- You have tried to become more sexually attracted to [the opposite sex]


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MINORITY STRESS AND HEALTH: THE HEALTH DISPARITIES OF SEXUAL MINORITIES by BRENDON G . ATKINS B.A., University of Colorado, 2015 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Sociology Program 2018

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ii This thesis for the Master of Arts degree by Brendon G . Atkins h as been approved for the Sociology Program b y Edelina M. Burciaga, Chair Candan Duran Aydintug Kari Alexander Date: May 12, 2018

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iii Atkins, Brendon G . (M.A., Sociology Program ) Mino rity stress and health: The health disparities of sexual minorities Thesis directed by Assistant Professor Edelina M. Burciaga ABSTRACT Existing and emerging research ha ve documented health disparities between sexual minorities (SM) and heterosexual s . T his research consistently find s that SM experience poorer health outcomes when compared to their heterosexual counterparts . Minority stress is a commonly used theoretical model for understanding and examining this reality. Yet little work has directly tested this model as a mechanism for explaining these disparities in health. The present study addresses this gap by explicitly testing specific minority stressors postulated by the minority stress model to explain the disparities in two health outcomes. Results find that stigma and discrimination can explain the observed disparities in the current investigation and suggest that minority stress is one mechanism that can explicate the documented health disparities between SM and heterosexual individuals. In contrast to expectations of the study, no differences in health outcomes are found among SM in within group compa risons. This form and content of this abstract are approved. I recommend its publication. Approved: Edelina M. Burciaga

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iv TABLE OF CONTENTS I. . . . 1 II. . .. . . . . ... .. .. 4 III. LITERATURE . 7 IV. . .. 2 4 ..... 2 5 31 V. ... .. .. 3 2 VI. . 4 3 VII. .. .. . . 50 VIII. .. . . 5 3 IX. APPENDIX A . .. 5 9 X. 61

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v LIST OF TABLES TABLE 1. Descriptive statistics of the STRIDE sample, overall and by sexual minority 3 2. Descriptive statistics of the sexual minority sample, by sub 4 3. Logistic regression estimates of odds ratios (OR) predicting any lifetime physical 37 4. Logistic regression estimates of odds ratios (OR) predicting any lifetime mental 38 5. Logistic regression estimates of odds ratios (OR) predi cting health outcomes, 4 0 6. Logistic regression estimates of odds ratios (OR) predicting health outcomes, 4 1 7. Logistic regression estimates of odds ratios (OR) predicting health outcomes, 4 2

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1 I NTRODUCTION Sexual minorities /sexual minority (SM) individuals ( folks who identify as something other than heterosexual , who are attracted to those of the same gender , or who engage in sexual behavior with those of the same gender) continue to face severe cultural and structural barriers that prevent this population from achieving any true measure of equity in health or in society (McClain, Thomas, & Yehia 2017) . These barriers and continuing challenges set up SM for poorer health compared to heterosexual individuals. They create toxic, heterosexist environments and situations that continue to stigmatize and discriminate against non heterosexual identities, exposing SM to stressors that in turn harm their health and well being. A large majority of sexual minority people (over two thirds) report discrimination in their personal lives, and between 15% and 43% of SM report having been discriminated against in some form on the job (McClain, Thomas , & Yehia 2017 ; Sears & Mallory 2011) . Hate crimes against members of the LGBT Q+ community 1 continue to be prevalent, with gay men facing higher victimization rates than any other social group overall after transgender individuals (Stotzer 2012). Moreover, r esearch over the past decade has demonstrated that SM suffer serious physical and mental health disparities compared to heterosexual s (Lick, Durso, & Johnson 2013; Russel & Fish 2016). Such realities demonstrate the continued need to study and document the health and well being of sexual minority people . Because physical and mental health together shape our lives in fundamental and important ways, examining 1 I main ly refrain from using the common acronym LGBTQ+ (lesbian, gay, bisexual, transgender, queer) because this acronym includes both sexual and gender minority identities. These are separate identities and different populations, even as there can be overlap with some individuals who embody identities within both. Because in this study I study only sexual minorities, I refrain from using LGBTQ+ except w hen explicitly referring to the larger community that constitutes both sexual and gender minorities, or when research articles examine both populations.

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2 how they look in this population documents the reality of their health for researchers and health practitioners. Although research th at documents this is important, it is also vital to explore the mechanisms that drive the disparities in health between SM and heterosexuals. Examining how or why SM come to have poorer health outcomes highlights an underexamined avenue of research and helps to explain these documented health disparities. This is an important part of the picture because it provides context to this reality and has the capacity to bring forward answers and solutions to the problem of not only SM health , but health disparit ies more generally. Furthermore, i t elucidates some ways in which social inequalities are created and rep ro duced . Minority stress ( Meyer 1995 ; 2013 ) is one proposed explanation for how SM come to have poorer health compared to their heterosexual counterparts. According to minority stress , it is the stressors that SM face , and the hostile, heterosexist environments they are exposed to because of their sexual minority s tatus that heighten their risk for poorer health outcomes. In this way it is the stressors and larger cultural context that drive these disparities , not the being a sexual minority itself. This framework is often invoked in the literature in the context of SM health , and some work has explored it as a n important variable . However, little work has explicitly or directly tested minority stress as a mechanism that explains the poorer health of SM. I address this gap in the current investigati on by testing whether specific minority stressors e xplain the relationship between sexual minority status and poor health. Specifically, I address the following research questions : o How do sexual minority individuals differ from heterosexuals as well as fro m each other in their physical health and mental health (outcomes)?

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3 o Does minority stress (defined as stigma, discrimination, and internalized homophobia) work as a mechanism that can explain these differences? By drawing on a diverse sample of SM and heterosexual individuals, I address these important questions above and explore how minority stress acts as a mechanism that can explain the ways in which these stressors harm sexual minority folks and ultimately af fect their health via poorer health outcomes and higher risk for poor health . I find that SM are over two times as likely to have any lifetime physical health condition or lifetime mental disorder compared to heterosexuals, and that minority stressors in t he form of stigma and discrimination based on sexual orientation can explain th is relationship . Ultimately, I argue that minority stress is a mechanism driving SM health disparities and which can explicate the documented poorer health outcomes of SM.

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4 B ACKGROUND Although I am investigating health disparities in the context of sexual minority status and sexual orientation, I will begin with a brief background of health disparities more generally . In the United States, h ealth disparities have long been documented and discussed in scholarly research. This literature illustrates the complexities and nuances that come with studying them. Much of this work has examined health disparities related to race ethnicity and socioeconomic status (SES) (Adler & Rehkopf 2008; Braveman 2006). I begin by providing a definition of health disparities , then briefly discuss the history of this research. Health disparities do not have an agreed upon definition in the literature. Most conceptualizations of health dispar ities start with bases of social disadvantage that are avoidable (Braveman & Gruskin 2003; Braveman 2006). They result from both biological Stewart 2010). As such , a health disparity is a difference in health status or health outcome between social groups that is unnecessary, avoidable, and unjust. Adler & Rehkopf (2008) review some of the most common types of research in health disparities, which has typically examined disparities related to race ethnicity and disparities related to SES, social class, or socioeconomic resources. Other historical investigations into dispa rities have examined sex and geography. Still other research has looked at both race ethnicity and SES insofar as how they both matter and influence health (Kawachi, Daniels, & Robinson 2005). The extent of health disparities varies by the outcome being o bserved, time, and geographic location within the US (Adler & Rehkopf 2008). Broadly speaking, there are

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5 substantial health disparities by race ethnicity and SES. Blacks under the age of 65 experience higher all cause mortality than non Hispanic Whites und er the age of 65 do, but these differ by the specific cause of death. For instance, data from the National Longitudinal Mortality Study (NLMS) demonstrate that Black men and women experience higher mortality than White men and women f rom homicide, hyperten sive heart disease, and certain types of cancer . However, Black men and women experience lower mortality f rom causes such as suicide and leukemia compared to White men and women . These differences in mortality rates vary across the US and an interaction be tween local socioeconomic factors, race ethnicity, and geography has been documented (Chen et al. 2006; Subramanian et al. 2005). Turning to disparities by SES, an SES health gradient has been demonstrated to exist in the US in which individuals experienc e better health status and health outcomes at each & Stewart 2010). Individuals in the upper classes experience better health outcomes than individuals in the middle class, who in turn experience better health outcomes than individuals in lower classes. Moreover, l ower SES is correlated with an increased risk of nearly every major cause of premature mortality (Glymour, Avendano, & Kawachi 2014). Health disparities rel ated to sex have also been explored and documented. Although women on average live longer than men , and men have been documented to have higher mortality rates, women suffer from elevated rates of morbidity and experience poorer health across a variety of health outcomes. By and large, men suffer more fatal, life threatening conditions such as heart dise ase, cancer, and kidney disease, while women experience more chronic and acute conditions such as migraines, arthritis, upper respiratory infections, and

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6 infectious diseases (Verbrugge 1985; Bird & Rieker 1999; Gorman & Read 2006). Furthermore, women exper ience poorer health than men in self rated health and disability (Read & Gorman 2006). Although this overview is by no means exhaustive, it presents a brief overview of some of the work that has investigated health disparities. This work is important bec ause it I will now discuss some of the work that has investigated health disparities with regard to sexual orientation and sexual minority status . This is another important identity status that impacts health and which continues to be under examined.

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7 LITERATURE REVIEW Sexual minority health disparities A growing body of research has analyzed health disparities as they relate to sexual orientation or sexual minority (SM) individuals. This body of research has examined both mental health disparities and physical health disparities, although often not simultaneously. In practice, this literature has only examined one while either ignoring the other or using one as a confounding factor of the other ( Lick, Durso, & Johnson 2013) . Findings have largely provided empirical support that sexual minorities as a group experience poorer health relative to heterosexuals, but these findings vary based on the outcome(s) being examined, the data or datasets used, the methodologies being employed, and how variables are measured. Furthermore, studies vary depending on whether they are looking at between group variation (sexual minority vs. heterosexual/non minority) or within group variation (comparing betwee n sexual minority subgroups) (Meyer 2013). Advantages of looking at between group differences include the ability to see how SM as a group differ from heterosexuals and to then document those differences; however, this means that the differences in health among SM are masked and not accounted for. By extension , looking at within group differences allow the ability to see how SM differ in their health from each other, but then ignore how those differences compare with heterosexuals. As such, examining both t ypes of differences give researchers wide range in documenting the myriad differences in health between and within these distinct social groups. How sexual orientation or sexual minority status is measured similarly varies from study to study and has been shown to matter greatly to the findings. For instance, sexual orientation includes different dimensions : self identification /identity , sexual attraction, and

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8 sexual behavior or sexual partners. These domains have important theoretical and methodological si gnificance, and some studies point to the inability of using these interchangeably (Brewster & Tillman 2012). Some studies use only self identification and characterize those who self identify as gay, lesbian, and bisexual into separate categories . O thers divide the sample into those who are 100% heterosexual and those who are not 100% heterosexual status . F or instance, when heterosexual. In these cases sexual minority individuals are all those who either self identify as lesbian, gay, bisexual, something else , or are not 100% heterosexual . Other cases define sexual orientation based on those who report same sex attraction or having had a same sex . In the sections that follow I summarize some main findings from myriad studies that have utilized various datasets to examine different types of health outcomes and comparison groups. I begin with research that has investigated sexual minority dispariti es i n mental health, before turning to work on SM disparities in physical health. Sexual minority disparities in mental health Disparities in mental health by sexual minority status have been documented across many different samples and outcomes. These samples range from smaller, localized ones (Meyer, Dietrich, & Schwarz 2008; Odonnel, Meyer, & Schwarz 2011) to nationally representative ones (Hatzenbuelher et al. 2010; Barnes, Hatzenbuehler, Hamilton, & Keyes 2014 ; Gonzales, Przedworski, & Smith 2 016 ; Scotte, Lasiuk, & Norris 2016 ) . These studies examine different mental health outcomes, including suicidality, substance abuse / misuse, specific mental disorders like depression, and prevalence rates across multiple psychiatric

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9 mental disorders. Some of these studies demonstrate the need to look at how other social factors play a role in shaping these disparities. For instance, Hatzenbuehler and colleagues (2010) find that institutional discrimination in the form of constitutional amendments banning sa me sex marriage shape the prevalence rates in psychiatric disorders of lesbian, gay, and bisexual (LGB) individuals . These researchers found higher prevalence rates among LGB individuals in states with amendments compared to states without, and that rates increas ed in states with such amendments. This points to how a heterosexist, anti gay environment can contribute to SM health disparities. Barnes, Hatzenbuehler, Hamilton, & Keyes (2014) find a moderating role by education. Although LGB respondents with and heterosexuals, the odds of psychiatric disorders were consistently higher among LGB respondents wi the protective effect of having a Other studies have compared sub groups of SM and demonstrate the need to look at within group differences of SM indi viduals. For instance, Meyer, Dietrich, and Schwarz (2008) assessed the lifetime prevalence of mental disorders and suicide attempts among a diverse sample of sexual minority respondents . They f ou nd that Black SM reported significantly fewer mental disorde rs, while Latino SM compared similar rates, compared to white SM. However, both Black and Latino SM reported a greater number of suicide attempts compared to their white counterparts. T hese researchers speculate that the early age of suicide attempts may h ave coincided with coming out about their sexuality and is therefore among Black SM , Latino SM, and other SM of color . Indeed, Battle and Ashley (2008) have

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10 pointed to th e greater reluctance among Black SM to come out, especially to their parents . This suggests i s also a n important stressor. Odonnel, Meyer, and Schwarz (2011 ) f ou nd results consistent with these findings. Minority race/ethnicity was found to be associated with a significantly increased risk of suicide attempts in youth. Taken t ogether, this work demonstrates the need for work to look at within group differences among SM individuals. Finally, in an important review on mental health in LGBTQ + and sexual minority populations ( LGBTQ + youth in particular ), Russell and Fish (2016) document the overwhelming evidence of mental health disparities by SM status . These researchers emphasize adolescence a because mental disorders show onset during and directly following this stage . S tudies examining adolescents trace the origins of SM mental health disparities to these years and have found disproportionate rates of mental disorders a mong LGBTQ + youth. Furthermore, t hese researchers find that data from population based studies illustrate overwhelming evidence that LGBTQ+ and SM individuals are at greater risk for poor mental health across developmental stages, with disparities both in symptoms and distress. In particular, elevated rates of depression, mood disorders, PTSD, alcohol and substance use / abuse, suicidal ideation , suicidal behavior, suicide attempts, and psychiatric comorbidity have all been documented among SM individuals ac ross many studies. Importantly, these researchers find that SM youth are approximately 3 times as likely to report suicidality, and statistically more likely to report and experience depressive symptoms compared to heterosexual youth. Bisexual youth are at an especially greater risk for poor mental health when compar ed to their heterosexual and lesbian/gay counterparts (Russell &

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11 Fish 2016; Marshal et al. 2011). Although great work on its own, this work does not directly test minority stress as a mechanism driving these poorer health outcomes. I address this gap in th e current study to explore minority stress as one possible mechanism t hat can explicate these previous findings. Sexual minority disparities in physical health An emerging body of work has similarly examined SM health in the context of physical health. Ma ny of these studies draw on nationally representative, population based data such as the National Health and Nutrition Examination Survey and the National Health Interview Study . As with mental health disparities, these studies vary in the types of physical health outcomes they examine. Outcomes range from self rated health ( Conron, Mimiaga, & Landers 2010 ; Gorman et al. 2015 ; Hsieh & Ruther 2016 ) , to functional limi t ations ( Hsie h & Ruther 2016 ; Jackson et al. 2016 ) ; from risk factors for cardiovascular disease (CVD) ( Conron, Mimiaga, & Landers 2010 ; Farmer et al. 2013; Farmer, Jabson, Bucholz, & Bowen 2013 ; Jackson et al. 2016 ), to sexually transmitted infections ( Operario et al. 2015 ); and from immune functioning ( Everett, Rosario, McLaughlin & Austin 201 4 ), to mortality (Cochran & Mays 2011). Lick, Durso, and Johnson (2013) document the growing body of literature focused on SM individuals in the context of physical health disparities. In reviewing this research, they f ou nd lesbian, gay, and bisexual (LGB) individuals to be at risk of a wide array of physical health problems, including poorer overall health , poor self rated health , a higher number of acute physical symptoms (such as the common cold or headaches) , a higher number of

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12 chronic conditions (like cancer and cardiovascular diseas e), a ctivity limitations , disability , and even mortality. In general, these studies have fou nd SM to have a distinct disadvantage in physica l health compared to their heterosexual counterparts. For example, J ackson and colleagues (2016 ) compare d SM and heterosexuals in the prevalence of health outcomes , health behaviors , and health care services use. Lesbian women were more likely to be obese, to have suffered a stroke, and to have a functional limitation compared to heterosexual women. Gay men were more likely to have hypertension and heart disease compared to heterosexua l men, and SM men overall were more likely to have a functional limitation. Operario et al. (2015) document ed evidence that SM in the US experience disparities in different types of health outcomes (e.g. sexual health, health behaviors, etc.) that ultimate ly can contribute to morbidity and preventable mortality. I n another study, Branstrom, Hatzenbuehler, Pachankis, & Link (2016) f ou nd LGB men and women to have a higher odds of high preventable disease morbidity (but not in low pre ve ntable diseases) than their heterosexual counterparts . (Preventable is defined as preventable through individual behaviors or medical intervention.) This remained after controlling for psychological distress and smoking. However , d ifferences do emerge when comparing by SM sub g roup and by sex. For instance, Farmer et al. ( 2013 ) f ou nd that SM men taken as a whole had no significant differences in CVD risk compared to heterosexual men after adjusting for education and history of hard drug use. O nce examining SM men sub groups, bisexual men had an increased CVD risk compared to heterosexual men, whereas gay men and men who reported same sex partners had no increased CVD risk. The increased risk in bisexual men was not attributable to differences in demographic charac teristics or negative health

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13 behaviors. Meanwhile, in a subsequent study examining CVD risk among SM women, Farmer, Jabson, Bucholz, and Bowen ( 2013 ) found that SM women were at a significantly increased CVD risk relative to heterosexual women, and this r emained after controlling for smoking and alcohol use. The authors suggest that they found a significantly increased CVD risk in SM women but not in SM men in the other study potentially because of the lower proportion of bisexually identified SM men than bisexually identified SM women . Alternatively, they reasoned that SM status may affect CVD risk differently for men and women. Similarly, Gorman, Denney, Dowdy, and Medeiros (2015) f ou nd that bisexual men and women to be at a distinct disadvantage in health status compared to heterosexual and SM men and women. Bisexual men and women reported significantly poorer self rated health than their heterosexual and gay/lesbian counterparts. Importantly , gay men and lesbian women reported better health than heterosexual men and women. This may well have been due to the advantage in SES that gay men and lesbian women reported relative to their heterosexual and bisexual counterparts. The authors conclude b y emphasizing the need for separating out the subgroups within sexual minority populations, as combining them conflates the health status of gay/lesbian and bisexual individuals. T hese findings demonstrate how critically important it is to look at differen ces within sexual minority categories, as combining them into one broad category masks important differences among SM . As such, I make a point of looking at differences within SM in the current study.

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14 Stress and the impact of stress on health Stress is an important factor with regard to health and has been recognized as a mechanism by which health disparities are formed and continue to affect population health (Thoits 2010). Perhaps the most important reason for this is because of the different ial exposure to stress that individuals in different social locations experience. Social groups sit at different social locations in the social hierarchy on the bases social statuses such as race ethnicity, gender, SES, sexual orientation, and so on. As a result, some statuses are at a disadvantage relative to others and are exposed to more stress as a result of this social location, whether it be from access to resources, financial distress, or experiences with discrimination and prejudice, among many othe 2010, pp.13). An important and influential model to explain this process by which stress affects health (including physical health and mental health) is the stress process model and the contributions of Pearlin to this model (Aneshensel 2015; Pearlin 1989). It posits the construct structure on stressors and by extension the structural origins of them. It conceptualizes these structural origins as having three components: systems of stratification (SES, race, etc.), social institutions and the arrangement of statuses and roles, and interpersonal relationships (Aneshensel 2015). These components mold and shape the stressors that social groups and individuals are exposed to, and, coupled with life events and circumstances that people living. In particular, this stress process model calls attention to the interconnections that exist

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15 between stressors and social and personal resources. In sum, it is the social patterning of exposure to these stressors and the concentration of them in specific segments or strata of society that contribute importantly to the concentration of disparities in the same segments. Minority stress One commonly utilized and helpful model for understanding disparities as they re late to sexual orientation in particular and sexual minority status more generally is minority stress. Proposed by and expanded on by Ilan Meyer (1995 ; 2013 ), minority stress is a model that can help understand the health disparities observed in LGBTQ+ and sexual minority populations. Derived from a variety of social and theoretical orientations that view stress as the conflict between individuals and their experiences in society ( Merton 1968; Pearlin 1989) , minority stress fundamentally can be described as psychosocial stress that is a consequence of minority status. As such, it is not exclusive to LGBTQ or sexual minority populations and can be extended to other minority social groups such as racial and ethnic minority groups (Meyer 1995). At issue is the the social conditions that exist , and the location in which SM are situated in them. potential mechanisms by which this process funct ions: internalized homophobia, stigma, and experiences with discrimination and prejudice . Each of these are different kinds of psychosocial stressors but can be conceptualized as minority ones due to their relation to an stressors are concerned with the negative societal attitudes and the stigma SM individuals must contend with in their lives. Internalized homophobia has been shown to be a significant correlate of mental health (Meyer 2013 ) . Discrimination is

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16 another significant stressor that many sexual minority individuals are exposed to. For example, in one study 75% of the LGB sample reported at least one occurrence of discrimination due to their sexual orientation, while 19% of the sample reported an occur rence attributed to gender nonconformity (Gordon and Meyer 2007). Discrimination is a critical stressor in the context of minority stress and in understanding health disparities. For instance, there is strong evidence in a variety of disciplines that past and present forms of discrimination contribute to contemporary racial ethnic inequities in income, wealth, and education, as well as evidence that it shapes societal distributions of health and disease (Krieger 2014). Understanding the role of discriminat ion in the stress health relationship is critical for explaining health disparities and the social forces that drive and shape them. This is especially true for sexual minority health disparities where SM individuals are at risk of exposure to multiple for ms of interpersonal and institutional discrimination, from individual acts of homophobia to the systemic realities of state sanctioned heterosexism. Yet little work has explicitly tested this explanatory model that drives the process by which SM individual s come to experience poorer health outcomes. I aim to address this gap by hypothesizing and testing minority stress as one of these mechanisms in the current investigation. In proposing this minority stress model, Meyer (1995) went on to test it with speci fic hypotheses that minority stress would posit. Meyer utilized three separate measures based on the three minority stressors mentioned above to analyze how well they would predict psychological distress outcomes (Dohrenwend et al. 1980). Results demonstra ted that each minority stressor predicted all of the psychological distress outcomes when they were considered simultaneously, indicating that each stressor is independently associated with

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17 distress. Moreover, gay men who reported high minority stress (def ined as gay men who had reported any discrimination, violence events, or who had scores above the sample mean of internalized homophobia or stigma) were two to three times more likely to report high and very high distress than gay men who reported low mino rity stress. In a subsequent study, Meyer (20 1 3) conducted meta analyses of a variety of studies conducted over the past couple decades on the health of sexual minorities. In this review of the empirical evidence on minority stress , Meyer notes the methodo logical distinction between within group studies and between group studies. In the former, studies examine the within group processes of minority stress by focusing on the differences within sexual minority groups and their impact on mental health, whereas in the latter researchers have compared the differences in prevalence of mental disorders between sexual minority groups and nonminority groups. In general, these studies have demonstrated that higher levels of stress have a greater impact on mental heal th problems in the form of depressive symptoms, substance use, and suicide ideation. Overall, he found that gay men and lesbians are 2.5 times more likely to have had a mental disorder at any point in their lives when compared to heterosexual men and women , with these odds being higher for women. Similar results were found in prevalence of current disorders, although the combined odds ratios for men was not significant and was lower than that for women. Moreover, results found LGBs to have disproportionatel y higher levels of experiences with prejudice and victimization, including discrimination and violence. LGB youth in particular are even more likely than adults to be victimized by antigay prejudice specifically (Meyer 20 1 3). Other important stressors note d

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18 internalized homophobia. Since Meyer proposed this model and his subsequent studies testing it, many other studies have found empirical support for it with respect to sexual orientation and LGB samples. One such study is from Kelleher (2009) who studied the impact of minority stress on psychological distress in Ireland among 301 youth and young adults who self identified as LGBTQ + . Using heterosexist experiences, stigma consciousness, and sexual identity distress as the measures for minority stressors in this analysis, Kelleher found all three stressors to be significan tly associated with psychological distress even when combining all three stressors into one model. Experiences with heterosexism in particular was the strongest predictor of distress for this sample of LGBTQ youth. These results demonstrate support for min ority stress as each minority stressor predict ed negative psychological outcomes . Barnes, Hatzenbuehler, Hamilton, and Keyes (2014) also find support for minority stress by finding that it increases the risk of psychiatric morbidity in a nationally representative sample of US adults. Lick, Durso and Johnson (2013) review the literature on minority stress and physical health in SM individuals. In reviewing the literature up to that point, they argue that these disparities are related specifically to the experience of minority stress that SM individuals must grapple with in their day to da y lives. In this way, minority stress was concluded to be an important mechanism through which everyday, chronic stressors impact the physical and mental health of sexual minorities. A more recent study has tested minority stress in the context of physica l health among sexual minority individuals. Utilizing Project STRIDE data, Frost, Lehavot, and Meyer (2015) analyzed minority stress and its association with the onset of a physical health

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19 problem in a sample of LGBs during the one year follow up of the lo ngitudinal study using both self minority stress and physical health. Externally rated measures of minority stress were y independent judges who looked for prejudice as the basis of the event during qualitative interviews conducted over the course of data collection for the study (see Frost, Lehavot & Meyer 2015 for a more thorough discussion of their methodology). Only ext ernally rated measures of minority stress were found to be associated with the onset of an externally rated physical health problem during the preceding year. Subjective measures of minority stress were not found to be associated with either measure of phy sical health. These findings led the researchers to posit that perhaps more major minority stressors (i.e., discrete, event based ones in the form of prejudice or stressful life events) are more important for health than less discrete, minor, everyday ones in the form of microaggressions. Looking at discrimination, Khan, Ilcisin, and Saxton (2017) found multifactorial discrimination to be strongly linked to multiple mental health outcomes. Discrimination here was associated with an increased odds of depres sion, an increased odds of a substance use disorder diagnosis, and reduced psychological well being. Although they argue discrimination as a fundamental cause of health, that it endures so strongly to be associated with these outcomes provides evidence tha t discrimination is an important stressor among sexual minority individuals. Indeed, as Krieger (2014) describes, discrimination is associated positively with psychological distress, and there is growing evidence that links exposure to discrimination to an increased likelihood of adverse health behaviors. Furthermore, evidence demonstrates that discrimination shapes societal distributions of health and disease (Krieger

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20 2014). Clearly then, discrimination is an important and critical stressor for understandi ng SM health and its role in shaping the health disparities between SM and non SM. Another study examining discrimination and its relationship with substance use found the prevalence of any past year substance use disorders to be more than twice as high am ong LGB adults than heterosexual adults, with substance use being more prevalent among LGB adults who reported any discrimination and the highest among respondents who experienced all three types of discrimination measured (McCabe et al. 2010). This is str iking given the fact that two thirds of the sample of LGB adults experienced at least one type of discrimination in the past year. Brewster and Tillman (2012) examined sexual orientation and substance use behavior across three dimensions of sexual orientat ion (self identity, sexual attraction, and sexual behavior) using data from the National Survey of Family Growth Cycle 6. These researchers reported findings that are broadly consistent with the minority stress model, such as general findings that substanc e use as measured by tobacco use, illicit drug use, and binge drinking were more prevalent in women and men who self identified as gay/lesbian or bisexual, or who reported same gender sexual attraction or behavior, with the caveat that all these difference s were significant for women whereas not all the differences were significant for men. Analyses demonstrated that self identifying as LGB significantly predicted the odds of any substance use in the last year. However, once accounting for all three dimensi ons of sexual orientation, self identifying as LGB was no longer significantly associated with higher odds of any substance use. That is, once the measures of sexual attraction and sexual behavior or experiences were considered, self identifying as LGB no longer predicted the

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21 odds of substance use, suggesting that it is not identity itself that is necessarily important for linking distress and health in the context of sexual minority health disparities. Minority stress : A mechanism for sexual minority health disparities Overall, there is broad empirical support for minority stress as a theoretical framework for viewing health disparities related to sexual minority status. However, most of the work on sexual minority health disparities has not explored minority stress as a potential mechanism by which sexual minority individuals come to have poorer health through a direct test of it. Indeed, a critical gap in the current literature in this area is an exploration of the mechanisms that drive these dispari ties by sexual minority status. I seek to address this gap by exploring minority stress as one of these potential mechanisms through explicitly hypothesizing and then testing it as a mechanism . Specifically, I examine the theorized stressors of discriminat ion, stigma, and internalized homophobia as measures of this minority stress. I hypothesize that t hese stressors create a layer of added stress that sexual minority groups are exposed to and consequently increase their risk for poorer health. In other word s, minority stressors will predict these health outcomes, and have the potential to mediate the relationship between sexual minority status and corresponding health outcomes. I predict that sexual minority individuals will be more likely to have poorer out comes in their physical and mental health as compared to their heterosexual, non sexual minority counterparts. Furthermore, these poorer health outcomes will be explained by specific stressors in the form of stigma and discrimination that sexual minority i ndividuals are at increased risk of exposure to because of their sexual minority s tatus. It is also important to explore the differences between sexual minority subgroups. For instance , bisexuality can be

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22 overlooked or dismissed as an identity among both h eterosexuals as well as in the gay community. Examples of this range from ideas that those who are bisexual are just pr omiscuous, or that they are in denial about being gay. Those who identify as bisexual therefore must face discrimination from both sides , adding additional stressors that lesbian women and gay men do not necessarily have to contend with. Such a reality could put them at risk for poorer health than their lesbian and gay counterparts. It is essential to explore this reality to understand the stressors and experiences of all SM. In the current study, I explore the health outcomes of ever having any lifetime physical health condition and ever having any lifetime mental disorder. Accordingly, I propose the following hypotheses: Between group comparisons (Sexual minorities versus heterosexuals ) H ypothesis 1a: Sexual minority individuals are more likely to have been diagnosed with any lifetime physical health condition than their heterosexual counterparts . H ypothesis 1b: Sexual minority indivi duals are more likely to have been diagnosed with any lifetime mental health disorder than their heterosexual counterparts. H ypothesis 2a: The odds of ever having been diagnosed with any lifetime physical health condition increase with more feelings of stigmatization and discrimination based on sexual orientation. H ypothesis 2b: The odds of ever having been diagnosed with any lifetime mental disorder increase with feelings of stigmatization and discrimination based on sexual orientation. H ypothesis 3a: The relationship between SM status and ever having been diagnosed with a ny lifetime physical health condition is mediated by feelings of stigmatization and discrimination based on sexual orientation. H ypothesis 3b: The relationship between SM status and ever having been diagnosed with a ny lifetime mental disorder is mediated by feelings of stigmatization and discrimination based on sexual orientation.

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23 Within group comparisons (S exual minority sub group versus gay men) H ypothesis 4a: Among sexual minorities, lesbian women will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts. H ypothesis 4b: Among sexual minorities, lesbian women will be more likely to have been diag nosed with any lifetime mental disorder than their gay male counterparts. H ypothesis 4c: Among sexual minorities, those who identify as bisexual will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts. H ypothesis 4d: Among sexual minorities, those who identify as bisexual will be more likely to have been diagnosed with any lifetime mental disorder than their gay male counterparts. H ypothesis 4e: Among sexual minorities, those who identify as queer or something else other than heterosexual (other LGB) will be more likely to have been diagnosed with any lifetime physical health condition than their gay male counterparts. H ypothesis 4f: Among sexual minorities, those who identify as queer or something else other than heterosexual will be more likely to have been diagnosed with any lifetime mental disorder than their gay male counterparts.

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24 M ETHODS Data To test my hypothese s , I draw on public use data from Project STRIDE: Stress, Identity, and Mental Health. Headed by the princip al investigators Ilan H. Meyer, David M. Frost, Rafael Narvaez , and Jessica H. Dietrich, this project was funded by the Nati onal Institute of Mental Health. Project STRIDE utilizes a longitudinal research design with participants recruited in over 32 different New York City zip codes. Interviewed at baseline in 2004 , then again at a one year follow up interview, participants were recruited from five different types of venues using a representative case quota sampling technique and snowball sampling used as an additional recruitment strategy. Although heterosexual participants were recruited at baseline (n=128) as a means of comparing sexual minority participan ts with heterosexual ones, they were not followed up with in the second interview. Of the total sample size (N=524), 396 participants identified as either lesbian, gay, bisexual, queer, or something else, and 371 of these sexual minority participants were retained at follow up, for a 94% retention rate. Transgender persons were not recruited for the Project STRIDE study. Only data from the baseline interview are utilized in the present study . Project STRIDE examines the intersection of minority identities a s they relate to sexual orientation, race ethnicity, and gender. It furthermore investigates the social stressors that affect minority groups, the impact of these stressors on their mental health, and the coping and social support resources they utilize as they confront these stressors (Meyer et al. 2006) . It includes an array of different diagnostic interviews and scales to measure these illness and substance use, to their psychological and social well being; from self esteem , to factors dealing with

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25 coping and social support ; these extensive data offer a wide range of information on the stressors and experiences these participants face in their lives. Respondents in the study were more likely to be college educated than not, with less than 20% of the total sample having a high school diploma or less. Nearly three quarters of the total sample was employed. The sample is also quite young, with a mean age of 32.24 years (SD=9.27). I will no w discuss the specific variables I draw on from the STRIDE public use dataset for the measures in the current investigation. Measures Sexual Orientation All three dimensions of sexual orientation (self identity, sexual behavior, and sexual attraction) were assessed for each respondent in the STRIDE sample. O nly self identity was used for measuring sexual orientation in the current study . Self identity was chosen to measure sexual orientation because of the significance identity plays in the shaping of life and the salience it can have across different contexts. Self identity was assessed with the range of answers to choose from, including lesbian, gay, bisexual, quee r , homosexual, other LGB, straight, heterosexual, and other straight. I recoded SM for those who identified as a SM identity that was anything other than lesbian, gay, or recoded as heterosexual for the current investigation. Additionally, females who identified as gay were rec oded as lesbian.

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26 Physical Health Outcome For the main outcome I examine regarding physical health, I utilize data from sub scale assessing past year and lifetime prevalence of 22 disorders that are potentially influenced by stress, including hypertension, respiratory diseases, colds and flues, asthma, headaches, and GI track disorders, to name just a few (for a full list of all 22 disorders, please refer to Appendix A found at the end of the text ) . Two of these 22 disorders (emotional disorders and drug or alcohol disorders) were assessed as mental health outcomes for the current analysis and so not included for analys i s of the physical health outcome. As a crude measure for physical heal th conditions, I constructed a dichotomous variable based on whether a respondent indicated they had ever been diagnosed with at least one of the remaining 20 health conditions from the history of illness in the STRIDE dataset. Participants responded with told by a doctor or other health care professional that they had a given condition. Participants Mental He alth Outcome For the other health outcome examined in this study , I assess the presence of any lifetime mental disorder. Lifetime mental disorder presence was measured based on whether participants indicated they had ever been diagnosed with any of at le ast one of several mental health disorders, including anxiety disorders, mood disorders, substance disorders, eating disorders, and phobic disorders. Two disorders from the history of illness sub scale of the STRIDE interview ( any emotional disorder and any drug or alcohol disorder ) were also

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27 included when assessing the presence of any lifetime mental disorder. Participants responded had ever been diagnosed with a disorder in a given disorder category and coded as either ever had they never had been diagnosed with any mental disorder . General health To avoid the issue of using mental health or physical health as a confounding factor of the other , which Lick, Durso, and Johnson (2013) highlight , I control for other health factors by controlling for General health was a variable previously constructed by the investigators of the STRIDE study and which I utilized in the current investigation. General health was assessed in the STRIDE sample with the SF 12, a shortened version of the SF 36 that improves upon certain aspects of the original scale (Meyer et al. 2006). This sub scale assesses the general physical and mental health, bodily pain, role limitations, s ocial functioning, and vitality of each respondent. All responses were self of the time have you had any of the following problems with your work or other regular ac time has your physical health or emotional problems interfered with your social activities 5 indicated better general health. The final variable is therefore summed scores, with a range of 18.87 61.99 , a mean of 51.69, and a standard deviation of 9.82 .

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28 Discrimination and prejudice Experiences with discrimination and prejudice in the STIDE interview were assessed with an everyday discrimination sub scale that inquired how often experiences with discrimination occurred over a respondents point scale (1=often, 4=never). This sub scale measured chronic, routine, and less overt experiences of unfair treatment like being treated with less respect or courtesy, being threatened or harassed, and being called names or insulted (Me The sub scale was adapted to be applied to all the minority groups in the sample, with respondents asked to identify whether each instance was related to their gender, sexual orientation, race/ethnicity, physical appearance, or other reasons (Meyer et al. 2006). For the current investigation, I utilized a continuous variable in the Project STRIDE public use dataset that measures total discrimination based on sexual orientation. This variable measured number of instances respondents had indicated that an experience with discrimination was because of their sexual orientation. The variable had a range of 0 .00 8 .00 , a mean of 1.87 , and a standard deviation of 2.05. (For more information regarding this variable, please refer to Appendix B). Stigma A previously constructed continuous variable in the STRIDE pu blic use dataset measuring stigmatization was utilized for the minority stressor of stigma in the current investigation. This variable was measured from a 6 item sub scale which inquired about point

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29 responses were coded by the principal investigators so that higher scores meant more stigma, with all item scores summed then averaged so that each respondent was given a mean total score (Meyer et al. 2006). The variable ha d a range of 1.00 4.00, a mean of 1.92, and a standard deviation of 0.77. (For more information regarding this variable, please refer to Appendix B) . Internalized homophobia Internalized homophobia was measured with a continuous variable already constructed and made available in the STRIDE public use dataset. This variable was constructed by the investigators of Project STRIDE using a 9 item sub scale that assessed the extent to which sexual minority men and wome n do not accept their sexual orientation or sexual identity, are uneasy about their same sex desire, and try to avoid feelings associated with their same you wished you weren't gay?" R esponses measured the frequency that respondents experienced such thoughts and feelings in the previous year on a 4 point scale ranging from for heterosexual respondents. For each SM respondent, a mean total score was obtained and coded so that higher scores indicated more internalized homophobia (Meyer et al. 2006). It had a range of 1.0 0 3.5 0 , a mean of 1.20, and a standard deviation of 0.52. (For more information regarding this variable, plea se refer to Appendix B).

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30 Other sociodemographic characteristics Looking at sociodemographic characteristics, race ethnicity was measured with a ls who identified as Black, Latino, or white were recruited for the Project STRIDE study. As such, respondents were only given the options White, Black/African American, and Latino/Hispanic to describe their racial/ethnic background. Participants who ident ified as anything other than these, including those who described themselves as multi racial or bi racial, were not qualified to participate. (Racial ethnic background in cluding country of origin and national background. However, these measures were not utilized in the current exploration ). Sex was based upon whether a participant indicated they were male or female. Respondents indicated their age with their date of birth. Based on this, respondents were then categorized into different age group intervals (1 8), including under 21, over 50, and 4 year age intervals in between these (i.e., 21 25 years old, 26 30 years old, etc.), for a total of 8 age groups and categories. SES included measures of employment status, household income, and education. Employment status was measured based on whether participants indicated they were employed or not. Income was measured using household income (before taxes) in the past 12 months (a continuous variable of household income was not available in the Project STRIDE public use dataset) . A total of 35 intervals were created by the STRIDE researche rs in the construction of the ordinal variable. Intervals of $1,000 were utilized up until a total household income of more than $20,000, such that a 1

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31 indicates a household income in the range of $1 $999, a 2 in the range of $1,000 $1,999 and so on. I ntervals of $5,000 were used for household incomes in the range of $20,000 $99,999, with larger intervals used at higher levels up to $1,000,000 or more. Education was defined as whether participants were or were not college educated. A respondent was co ded college educated. Analyses A number of analyses were conducted for the current study. First, proportions were estima ted for the physical and mental health outcomes to show the burden of each outcome for each sexual identity category. Descriptive statistics were then conducted to compare every covariate by sexual identity category , first by SM status, then by SM subcate gory . Comparisons by levels of each minority stressor were also assessed. compare heterosexuals and sexual minorities, then within sexual minority subgroups, for each outcome . Logistic regression was used to predict the odds of having any lifetime physical health condition as well as the odds of having any lifetime mental health disorder. Logistic regression analyses consisted of two sets of models for comparisons between hete rosexuals and SM, with the first model including the sociodemographic characteristics and average general health scores of the sample. Then, the specific minority stressors of discrimination and stigma were added in the second model. For the models compari ng only sexual minorities, internalized homophobia was also included.

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32 R ESULTS Table 1 shows the descriptive statistics of the whole sample and by sexual minority status. T tests reveal that a significantly lower proportion of sexual minority respondents held , and had significantly higher scores of stigma and sexual orientation based discrimination, than their heterosexual counterparts. A significantly higher proportion of SM reported ever having any lifetime physi cal condition (83.33%) versus heterosexuals (71.88%). A higher proportion of SM also reported ever having any lifetime mental disorder (76.51%) compared to heterosexuals (71.09%), although this difference was not large enough to be statistically significan t (p<.2178) (not shown in table) . Turning to within group differences, Table 2 shows descriptive statistics that compare within group differences among SM sub groups for all outcomes and covariates of the study. One way analysis of varianc e tests reveal s ignificant differences in household income, average general health scores, sexual orientation based discrimination, and internalized homophobia across SM sub groups. Bisexual identified respondents reported the lowest levels of household income and general health, as well as the highest levels of internalized homophobia. In contrast, gay men reported the highest levels of household income and general health. For the outcomes of the study, Chi square tests of independence demonstrated no significant differen ces in the proportion of SM respondents reporting any lifetime physical health condition or any lifetime mental disorder across SM sub groups. While there were no statistically significant differences in reporting lifetime health conditions by SM sub group within the population, differences within the sample were evident. Lesbian women had the highest proportion among SM of ever having any lifetime mental disorder , and over 90% of other LGB respondents reported having any lifetime physical health condition .

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33 Table 1. Descriptive statistics of the STRIDE sample, overall and by sexual minority status * P values represent significance levels in t tests for differences in means/proportions and Chi square tests of independence for differences in frequency distributions for categorical variables Overall sample (N=524) Heterosexuals (n=128) Sexual minorities (n=396) p< Any lifetime physical health condition .8053 .7188 .8333 .0044 Any lifetime mental disorder .7519 .7109 .7651 .2178 Race/ethnicity Black Latino White .2500 .2500 .5000 .0000 .0000 1.000 .2500 .2500 . 5000 .0000 Female .4981 .4922 .5000 .8782 Age 3.81 3.73 3.84 .5534 Household income 21.47 21.67 21.40 .7275 Unemployed .1584 .1484 .1616 .7232 higher .5324 .7031 .4772 .0000 General health 51.69 52.66 51.38 .2023 Stigma (1 4) 1.91 1.46 2.06 .0000 Sexual orientation based discrimination (0 8) 1.87 0.34 2.37 .0000 Internalized homophobia (1 3.5) --1.41 -

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34 Table 2. Descriptive statistics of the sexual minority sample, by sub group Gay (n=155) Lesbian (n=134) Bisexual (n=71) Other LGB (n=36) p< Any lifetime physical health condition .8065 .8284 .8592 .9167 .3960 Any lifetime mental disorder .7290 .7985 .7887 .7500 .5280 Race/ethnicity Black Latino White .1237 .1263 .1414 .1010 .1136 .1237 .0758 .0682 .0354 .0303 .0227 .0379 .1750 Female -.5560 .1784 .0871 .0000 Age 3.90 3.94 3.61 3.67 .5768 Household income 22.31 21.68 19.24 20.89 .0387 Unemployed .0505 .0556 .0455 .0101 .0970 higher .2071 .1641 .0631 .0429 .1040 General health 52.96 51.10 49.36 49.65 .0408 Stigma (1 4) 1.95 2.15 2.12 2.11 .1408 Sexual orientation based discrimination (0 8) 2.50 2.63 1.61 2.33 .0056 Internalized homophobia (1 3.5) 1.37 1.30 1.79 1.26 .0000 * P values represent significance levels in one way ANOVA tests for differences in means for multinomial categorical variables and Chi square tests of independence for differences in frequency distributions/proportions for categorical variables

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35 Comparing health outcome s between sexual minority and heterosexual respondents, odds ratios from logistic regression models of ever having any lifetime physical health cond ition and any lifetime mental disorder are presented in Tables 3 and 4 , respectively. In support of Hypothesis 1a, Model 1 from Table 3 reveals that SM have significantly higher odds of ever having any lifetime physical health condition (OR=2.19, p<.05) re lative to heterosexuals after controlling for race/ethnicity, sex, age, SES, and general health. In other words, the odds of having any lifetime physical health condition is larger among SM than it is among heterosexuals by a factor of 2.19. Consistent with Hypothesis 1b, Model 1 in Table 4 reveals that SM are at significantly higher odds of ever having any lifetime mental disorder (OR=2.11, p<.05) compared to heterosexuals and controlling for these same covariates. In other words, SM have a 111% increase in odds of any lifetime mental disorder compared to heterosexuals. Model 2 from both Tables 3 and 4 adds in adjustments for the minority stressors of stigma and sexual orientation based discrimination. Model 2 demonstrates some support for H ypothesis 2a, where the odds of ever having been diagnosed with any lifetime physical health condition increase with more experiences of discrimination based on sexual orientation (OR=1.13, p<.10). However, the odds do not increase with higher feelings of stigma (OR=0.96, p=.831). Once accounting for each of these minority stressors, SM, compared to heterosexuals, no longer have statistically significant higher odds of having any lifetime physical health condition (OR=1.72). This is in support of Hypothesis 3a , although only for discrimination based on sexual orientation. That is, discrimination based on sexual orientation is mediating the relationship between SM status and ever having any lifetime

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36 physical health condition. Because stigma is not significant here, it is not mediating this relationship. A somewhat different picture is revealed in Table 4. Results demonstrate some support for H ypothesis 2b, with the odds of ever having any lifetime mental disorder increasing with increases in feelings of stigma (OR=1.49, p<.05) , but not with experiences of discrimination based on sexual orientation (OR=1.09). Relative to heterosexuals, the higher odds among SM of ever having any lifetime mental disorder is no longer statistically significant once adjusting for stigma and discrimination based on sexual orientation and controlling for every other covariate (OR=1.57) . These results are also in support of Hypothesis 3b, although only for stigma since discrimination based on sexual orientation was not significan t here. In other words , the relationship between SM status and ever being diagnosed with at least one lifetime mental disorder is mediated by stigma. Taken together, these results demonstrate that minority stressors in the form of stigma and discriminatio n can explain the disparities in health outcomes examined in this investigation. However, it appears to depend upon the health outcome in question because they do not both explain either outcome. Discrimination is the mediator in the physical health outcom e, whereas stigma is the mediator in the mental health outcome. Such findings suggest that minority stress is one mechanism that can explicate the health disparities documented between SM and heterosexuals and the poorer health outcomes SM experience. Mor eover, it depends upon how minority stress is measured, and which stressor is used , for the significance it has in this relationship.

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37 Table 3. Logistic regression estimates of odds ratios (OR) predicting any lifetime physical health condition Model 1 (n=511) OR Model 2 (n=511) OR Sexual minority 2.19** 1.72 Race ethnicity Black Latino White 0.97 0.55* -1.04 0.57 -Female 1.23 1.25 Age 1.16** 1.17** Household income 0.99 0.99 Unemployed 1.06 1.09 r higher 0.87 0.86 General health 0.93**** 0.93**** Stigma 0.96 Sexual orientation based discrimination 1.13* (*p<.10, **p<.05, ***p<.01, ****p<.001)

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38 Table 4. Logistic regression estimates of odds ratios (OR) predicting any lifetime mental disorder Model 1 (n=511) OR Model 2 (n=511) OR Sexual minority 2.11** 1.57 Race ethnicity Black Latino White 0.29**** 0.65 -0.24**** 0.57 -Female 1.36 1.33 Age 1.14** 1.14** Household income 0.99 0.99 Unemployed 0.75 0.73 higher 0.74 0.78 General health 0.95**** 0.95**** Stigma 1.49** Sexual orientation based discrimination 1.09 (*p<.10, **p<.05, ***p<.01, ****p<.001) Turning to within group comparisons, Tables 5, 6, and 7 present odds ratios from logistic regression models predicting the odds of ever having any lifetime physical health condition and any lifetime mental disorder among just SM. Each table presents odds o f one particular sub group of SM relative to gay men. Table 5 displays theses analyses by comparing lesbian women to gay men and shows that there are no difference s in the odds of lesbian women ever having any lifetime physical health condition or lifetime mental disorder relative to gay men once adjusting for every covariate in the analysis. These results do not

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39 support Hypotheses 4a and 4b. In this sample of gay men and lesbians, discrimination is associated with having a lifetime physical health conditio n, with each additional instance of sexual orientation based discrimination associated with a significant increase in odds of ever having any lifetime physical health condition (OR= 1.30, p<.01 ) . Turning to bisexual respondents as compared to gay men in t heir health outcomes, Table 6 shows that bisexual respondents have no difference in odds of either health outcome once adjusting for every covariate . Therefore, Hypotheses 4c and 4d are not supported. Stigma and internalized homophobia are associated with significant increases in odds of having any lifetime mental disorder among this sample of gay men and bisexual men and women . Every one unit increase in stigma is associated with an increase in odds of any lifetime mental disorder by 68%, while every unit increase in internalized homophobia is associated with a 110% increase in odds of this outcome. Finally, Table 7 displays results from analyses ran comparing other LGB respondents to gay men. Although within the sample other LGB respondents have an odds of ever having any physical health condition that is 2.68 times the odds of gay men, this was not found to be a statistically significant difference within the population (p<.3660, CI= 0 .32 22.73) (not shown in table) . This was likely due to lack of statistical power, with the large difference in confidence intervals certainly suggesting this. Turning to the mental health outcome, there is similarly no significant difference in odds of ever having any lifetime mental disorder among other LGB responden ts relative to gay men. Hypotheses 4e and 4f are consequently not supported by these results.

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40 Table 5. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Lesbian women compared to gay men Any lifetime physical health condition (n=280) OR Any lifetime mental disorder (n=280) OR Lesbian women 0.93 1.22 Race ethnicity Black Latino White 0.85 0.50* -0.23**** 0.58 -Female 1.00 (omitted) 1.00 (omitted) Age 1.21* 1.11 Household income 0.98 0.99 Unemployed 2.37 1.31 higher 0.99 0.88 General health 0.94*** 0.95** Stigma 0.94 1.32 Sexual orientation based discrimination 1.30*** 1.08 Internalized homophobia 1.30 1.17 (*p<.10, **p<.05, ***p<.01, ****p<.001)

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41 Table 6. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Bisexual respondents compared to gay men Any lifetime physical health condition (n=221) OR Any lifetime mental disorder (n=221) OR Bisexual respondents 0.91 0.82 Race ethnicity Black Latino White 1.16 0.48 -0.17**** 0.43* -Female 1.97 2.85 Age 1.13 1.10 Household income 0.99 1.01 Unemployed 1.52 0.87 higher 0.94 0.91 General health 0.95* 0.98 Stigma 1.03 1.68** Sexual orientation based discrimination 1.20* 1.15 Internalized homophobia 1.23 2.10** (*p<.10, **p<.05, ***p<.01, ****p<.001)

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42 Table 7. Logistic regression estimates of odds ratios (OR) predicting health outcomes, Other LGB participants compared to gay men Any lifetime physical health condition (n=163) OR Any lifetime mental disorder (n=185) OR Other LGB respondents 2.68 0.64 Race ethnicity Black Latino White 1.15 0.52 -0.16**** 0.56 -Female 0.84 2.06 Age 1.08 1.07 Household income 0.98 1.02 Unemployed 1.00 (omitted) 1.57 higher 0.95 0.86 General health 0.98 0.96* Stigma 1.06 1.70* Sexual orientation based discrimination 1.23* 1.10 Internalized homophobia 1.06 0.84 (*p<.10, **p<.05, ***p<.01, ****p<.001)

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43 DISCUSSION Under the minority stress model, the heterosexist and homophobic conditions that exist in society put sexual minorities at differential exposure to stress compared to heterosexual, non sexual minority individuals (Meyer 1995; 2013) . Living in a heterosexist culture that devalues non heterosexual people and relationships create added stressors for SM that in turn put them at an increased risk for poorer health outcomes. M inority s tressors such as stigma , discrimination, and internaliz ed homophobia create feelings of poor self worth and inadequacy to living up to the dominant, heterosexist norms valued in society. Such realities put SM at increased exposure to stress relative to heterosexuals, which in turn increases their risk for disease and illness . Findings from the current investigation are consistent with these ideas, with SM ( as a whole ) being more than twice as likely to have any lifetime physical health condition or any lifetime mental disorder when compared to het erosexual s . Looking at physical health, results here are consistent with other research that has also examined disparities in physical health outcomes (Lick, Durso, & Johnson 2013). For instance, Hsieh and Ruther (2016) look at self rated health and functi onal limitations and find that, overall, SM were associated with poorer health when compared to heterosexuals . Furthermore, Jackson et al. (2015) document a greater burden of poor physical health problems among SM men and women relative to heterosexuals as well . Other research similarly documents poorer physical health outcomes among SM (Branstrom et al. 2016; Conron, Mimiaga, & Landers 2010; Farmer et al. 2013; Gonzales, Przedworski, & Smith 2016). Turning to mental health, th e finding that SM respondents are significantly more likely to have any lifetime mental disorder than their heterosexual counterparts is consistent

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44 with prior research that has examined disparities in mental health outcomes (Hatzenbuelher et al. 2010; Barnes, Hatzenbuehl er, Hamilton, & Keyes 2014 ; Russel & Fish 2016). That SM are more than twice as likely to have had any lifetime mental disorder is also consistent with findings from Meyer (2013) who found SM to be 2.5 times more likely than heterosexuals to have had a men tal disorder at any point in their lives. Together, along with further evidence in the present study, it is clear the SM suffer serious health disparities in both physical and mental health outcomes . The present study went beyond simply examining health outcomes and comparing them between SM and heterosexuals. It also explicitly tested the minority stress framework as a mechanism for explaining these health disparities by assessing specific minority stressors in the fo rm of stigma, discrimination, and (in within group comparisons) internalized homophobia. This addresse s a lack of work investigating mechanisms in sexual minority health disparities a critical gap in the current literature . Once considering minority stressors of stigma and discrimination based on sexual orientati on , there w ere no longer any significant difference s in odds of either health outcome . The more than twice the odds in both health outcomes examined here were thus me diated by feelings of stigmatization and experiences with discrimination based on sexual orientation among th is sample of SM. This suggests minority stress is a mechanism that drives the health disparities between SM and heterosexuals ; that is, the stress SM must navigate because of their minority status ultimately has a negative impact on their health and well being. Stress is regarded as a mechanism by which health disparities are formed, reproduced, and socially patterned (Thoits 2010). The spec ific stress that is experienced because of an socially derived and referred to as minority stress (Meyer

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45 1995). It can likewise be framed as a mechanism that drives health disparities; in this case, SM health disparities. Th e logic follows as such: being a sexual minority leads to differential exposure to stress as a result of the heterosexist conditions in society that lead to stigmatization, experiences with discrimination, and feelings of internalized homophobia, which in turn harm well being and have a negative impact on health. In this way SM experience poorer health outcomes in comparison to their heterosexual counterparts. Turning to the stress process model (Pearlin 1989 ; Aneshensel 2015 ) is useful for conceptualizing how these stressors come to have an effect on health in the long run. For one , stress in and of itself is important in the context of health because it comes to have ler & Stewart 2010) . T his is even more true when stress is severe and/or chronic. Minority stress can be considered chronic to the extent that SM individuals perceive and/or experience negative feelings, emotions, or situations associated with their sexual minority status. As such, the perceptions, experiences, and chronic reality of minority stress will likely vary among SM because their levels of stigma, internalized homophobia, and experiences with discrimination also vary. Future research should t herefore determine whether discrimination and stigma differentially affect odds of health diagnoses since this was not assessed in the current study. Doing so would extend research on within group differences between SM and document how minority stress and the process es by which it affects health differently across different sub groups of SM . F or instance, whether or not different stressors of minority stress moderate this relationship. One way to consider how stress influences health , particularly in the realm of physical health , is in the biological pathways. Kubzansky, Seeman, & Glymour ( 2014 )

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46 review much of the literature on these biological pathways. When stressors are perceived to exceed affect result . This initiate s a biological stress response . When such stress responses repeatedly occur due to chronic or recurring stress, it can activate the autoimmune nervous system and neuroendocrine system to respond to the situati on at hand. Thus, even the perception of a stressor as going beyond a capacity to cope can alter the physiology of the body , which in turn can negatively influence biological systems . Similarly, these researchers document the strong support linking chronic stress with poorer immune functioning and a dysregulated inflammatory response ( Kubzansky, Seeman, & Glymour 2014 ). This research illuminates how and affects different systems in the body that then expose individuals to higher risk for disease and illness. T he implications of th is for minority stress are all too clear. Given the stressors that SM routinely experience because of their sexual minority st atus, it is not implausible t hat resulting from these stressors will take a toll on the body and ultimately impact their health status . This avenue of exploration offers new ways to illuminate the processes by which stress impacts health , particularly in the context of sexual minority health . Although some research has explored this avenue [ such as in the case of immune functioning and markers of inflammation in SM ( Everett, Rosario, McLaughlin & Austin ( 201 4 ) )], more research on the biological pathways that specifically examines SM is warranted . A lthough SM did differ significantly in their levels of general health (bisexual and other LGB respondents reported the poorest general health overall ), no differences were found in health outcome s when conducting within group comparisons ; t hat is, comparing

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47 different sub groups of SM. Lesbian women, bisexual men and women, and other LGB respondents were no more likely than gay men to have ever had any lifetime physical health condition or any lifetime mental disorder. There is evidence to believe that bisexual and other SM people suffer from poorer health compared to their gay and lesbian counterparts. For example , Gorman and colleagues ( 2015) assessed self rated health and found that bisexual men and women reported significantly poorer health than their heterosexual and gay and lesbian counterparts. Furthermore, gay men and lesbian women reported better health than heterosexual men and women. In another case, Farmer and friends (2013) compare cardiovascular risk between SM men and heterosexual men and document that bisexual men had an increased cardiovascular risk compared to heterosexual men, whi le gay men and men who reported same sex partners had no increased risk. Such findings raise questions on the vulnerability of bisexual and other queer identified indi vi duals. It is critical to explore the nuance between different categories of SM as they are not a monolithic group, and, although sharing minority sexual identities, have very different lived experiences. One likely explanation for finding no differences between SM sub groups is a lack of statistical power due to small sample sizes , particula rly among the comparisons with gay men and other LGB respondents. That other LGB respondents were nearly three times as likely to have any lifetime physical health condition than gay men in the sample certainly points to this explanation. Alternatively, it may well be that among this sample there are in fact no differences in these health outcomes between SM sub groups as compared to gay men in the sample. This could be a result of how the outcomes were measured. Using different outcomes may have resulted i n different findings that do find significant difference among SM . That said, given how the outcomes were measured here, the current findings may be a result of

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48 SM being equally as likely of having any lifetime physical health condition or lifetime mental disorder. In this way, there are no disparities because SM sub groups are at no increased risk from each other of either outcome as they were measured in th is investigation. Another potential explanation for this finding is that P roject STRIDE participants were only recruited from the New York City area and is therefore not nationally representative. In the two studies cited above that document poorer health among bisexual adults compared to lesbian and gay adults, these results were found from population based datasets that allowed for more statistical power as well as comparisons across sexual orientation by gender groups that the STRIDE sample did not. Still, the STRIDE sample included the ability to assess measures of minority stress important for the current study . T hese other datasets did not have such an ability . This study is not without its limit ations. For one, the STRIDE project did not sample heterosexual Black and Latino participants. As such, it cannot be ruled out that the Black and Latino SM here do not differ in their health outcomes and other sociodemographic characteristics from their heterosexual, racial minority counterparts. Furthermore, b ecause h eterosexuals were 100% white, differences in outcomes attributed to sexual minority status could include racial impacts as well. Also , the STRIDE sample did not recruit participants who were not Black, Latino, or white, and as such is missing all other racial ethnic groups , including those who are multiracial. Another limitation is th e relatively small sample size, especially once the sexual minori ty sample is broken down into sub groups . F inally , the STRIDE sample is not population based and is consequently not nationally representative , thus limiting the generalizability of the finding s here .

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49 Still, most nationally representative datasets continue to not include questions about sexual orientation for any dimension, and certainly do not include measures of these minority stressors. As such, the STRIDE dataset is an important one because of its r elatively large sample of SM indiv i duals , and the fact its interview schedule incorporates sub scales for measuring the particular stressors theorized to be important by the minority stress framework. Research that is able to incorporate nationally represen tative data with data on these stressors is warranted to continue to build our knowledge of the processes by which minority stress shapes the health and well being of sexual minorities . Moreover, it would extend the current investigation and further test minority stress as a mechanism driving SM health disparities.

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50 C ONCLUSION The results from the current investigation further establish the poorer health of SM. It also extends previous research o n sexual minority health by finding evidence of minority stress ( in the form of stigma and sexual orientation based discrimination ) explaining the health disparities between SM and heterosexuals. Such evidence points to the utility of minority stress as a framework for understanding the poorer health am ong SM as a group and the processes that drive this reality. But beyond this, these results also offer valuable information that can be used to inform policy and practice. For one, because it is the heterosexist and homophobic conditions within society th at fundamentally create this additional ( social ) stress that SM must contend with and navigate, policies and programs that address these conditions are critical for responding to the poorer health profiles of SM. One way to do this is to change current educational curricula and policies in schools that continue to be heterosexist and discriminatory against SM . Significant proportions of sexual minority youth report feeling unsafe at their schools and experienc e pol icies and practices in their schools that are discriminatory (McClain, Thomas, & Yehia 2017). School curricula and policies that are more inclusive and accepting of non heterosexual identities and relationships would go far in promoting a more open and acc epting environment. This is especially important for LGBTQ+ and sexual minority youth , who are especially vulnerabl e. LGBTQ+ youth are significantly more likely to experience suicidal ideation, engage in self harm, attempt suicide, and engage in substance abuse/misuse (Russell & Fish 2016). It is paramount that this reality be acknowledged, and steps taken to address it , so that LGBTQ+ youth are able to feel welcome and safe.

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51 Such policies should also be implemented in other domains, including in the workplace and in health care. Between 15% and 43% of SM indiv i duals have faced discrimination at work, and 56% of SM report experiencing discrimination in health care, w ith many continuing to avoid seeking care because of the stigma and discrimination they face because of their identity (IOM 2011; McClain, Thomas, & Yehia 2017) . As the findings from this study demonstrate, discrimination is a key factor that plays a role in the stress health relationship. School , w ork , and health care spaces that respond to discrimination and are proactive in stemming i t will provide more inclusive and accepting spaces for non dominant identities and relationships . Moreover, they would go far in promoting safety and productivity as SM feel welcome and less stigmatized in the m . Additionally , the lack of data on sexual orientation and sexual minorities continues to be a challenge (McClain, Thomas, & Yehia 2017). This lack of data impedes research that can be conducted on this population, and so limits the ability to investigate mechanisms and factors that shape and impact sexual minority health. As results from this study demonstrate, minority stress is one prospective mechanism a nd needs more research to further validate empirically its role in shaping SM health. R obust, high quality data must therefore be collected on this population so that research can continue to add to our knowledge of SM health disparities and be able to add ress the challenges that SM face. Consequently, epidemiological and population based demographic surveys must do more than they currently are by includ ing , by default , questions about sexual orientation in their surveys . Policies that require federal studi es , surveys, and research studies that receive federal funds to include questions that ask about sexual orientation would be a key step in addressing this lack of data.

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52 In sum, this study demonstrates the critical role discrimination and stigma can play as minority stressors to shape the health and well being of sexual minorities. Moreover, the findings highlight the substantive and theoretical significance of minority stress as a framework for understanding and explaining sexual minority health and the disparities in health between SM and heterosexuals. It extends prior research and offers future avenues of exploration for this important subject and a marginalized population.

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59 A PPENDIX A Full list of . professional that you Asthma bronchitis or emphysema Tuberculosis Other lung problems Arthritis, rheumatism, or other bone or joint diseases Sciatica, lumbago, or recurring backache Persistent skin problem (e.g. eczema) Thyroid disease Hay fever Recurring stomach trouble, indigestion, or diarrhea Urinary or bladder problems Ulcers AIDS or HIV infection Lupus or other autoimmune disorders High blood pressure or hyptertension Anxiety, depression, or some other emotional disorder Al cohol or drug problems Migraine headaches Chronic sleeping problems Diabetes or high blood sugar

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60 Multiple sclerosis, epilepsy, or other neurological disorders Stroke Any other health condition

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61 APPENDIX B The following is a deeper account of the individual minority stressors explored in the current study. I explain them and include the items used in the Project STRIDE questionnaire to assess them. All variables utilized to measure these minority stressors w ere previously constructed by the researchers involved with Project STRIDE and made available in the STRIDE public use dataset. All information was gathered from the STRIDE questionnaire and codebook, as well as from the ethodology and T echnical N otes d ocument completed by Ilan H. Meyer, David D. Frost, Rafael Narvaez, and Jessica H. Dietrich (2006). Discrimination and prejudice Discrimination based on sexual orientation was a continuous variable created by the principal investigators to show how many times a respondent indicated an experience with discrimination was based on their sexual orientation. This variable was created based on the everyday discrimination subscale administered with the questionnaire. This subscale had a total of 8 items along a 4 point scale ranging from often to never inquiring about different types of experiences related to discrimination, including chronic, routine, and less overt experiences of unfair treatment (Meyer, Frost, Narvaez, & Dietrich 2006). The items included: How often over your lifetime have you ...been treated with less courtesy than others ? ; ...been treated with less respect than others? ; ...rec eived poorer service s than others in restaurants or stores? ; ...experienced peopl e treating you as if you're not smart? ; ...experienced people ac ting as if they are better than you are? ; ...experienced people acting as if they are afraid of you? ;

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62 ...experienced people acting as if they think you are dishonest? ; ...been called names or insulted? Following each item, respondents were then asked whether this was based on their gender, physical appearance, sexual orientation, race/ethnicity, or somet hing else. For total discrimination based on sexual orientation, researchers tallied each instance in which respondents indicated that the discrimination experienced in each item was because of their sexual orientation. Therefore, given the 8 items adminis tered in the subscale, the total could range from 0 8. This was the final variable utilized for measuring discrimination in the current investigation. Stigma Stigma measured the degree to which respondents indicated expectations of rejection and discrim ination because of their sexual orientation (Meyer, Frost, Narvaez, & Dietrich 2006) . This was administered in the Project STRIDE interview with 6 items along a 4 point Responses were summed and averaged by r esearchers so that each respondent had a mean total score of stigma, with higher mean scores meaning more stigma. The following items were administered for assess ing stigma: Most employers will not hire a person like you Most people believe that a person like you cannot be trusted Most people think that a person like you is dangerous and unpredictable. Most people think less of a person like you Most people look down on people like you Most people think people like yo u are not as intelligent as the average person

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63 Internalized homophobia Internalized homophobia was assessed to measure how sexual minority men and women feel about their sexual orientation, including feelings of uneasiness about it, not accepting it, and attempts to avoid feelings related to it (Meyer, Frost, Narvaez, & Dietrich 2006). As such, it was only administered to sexual minority respondents, and was not assessed on heterosexual ones . It was measured with 9 items along a 4 point scale ranging All responses were summed and averaged so that each sexual minority respondent had a total mean score, with higher mean scores meaning more internalized homophobia. The f ollowing is a list of the items administered to SM respondents: You felt it best to avoid personal or social involvement with other people who are [lesbian/gay/bisexual/other] You have tried to stop being attracted to [ the same sex ] If someone offered you the chance to be completely heterosexual this past year, you would have accepted the offer You have wished you weren't [lesbian/gay/bisexual/other] You have felt alienated from yourself because of being [lesbian/gay/bisexual/other] You have wished that you could develop more erotic feelings towards [the opposite sex] You have felt that being [lesbian/gay/bisexual/other] is a personal shortcoming You would have liked to get professional help in order to change your sexual orientation from [lesbian/gay/bisexu al/other] to straight You have tried to become more sexually attracted to [the opposite sex]