John E. Pachankis

The Psychological Implications of Concealing a Stigma: A Cognitive-Affective-Behavioral Model

Many assume that individuals with a hidden stigma escape the difficulties faced by individuals with a visible stigma. However, recent research has shown that individuals with a concealable stigma also face considerable stressors and psychological challenges. The ambiguity of social situations combined with the threat of potential discovery makes possessing a concealable stigma a difficult predicament for many individuals. The increasing amount of research on concealable stigmas necessitates a cohesive model for integrating relevant findings. This article offers a cognitive-affective-behavioral process model for understanding the psychological implications of concealing a stigma. It ends with discussion of potential points of intervention in the model as well as potential future routes for investigation of the model.

Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions

RATIONALE Transgender people in the United States experience widespread prejudice, discrimination, violence, and other forms of stigma. OBJECTIVE This critical review aims to integrate the literature on stigma towards transgender people in the U.S. RESULTS This review demonstrates that transgender stigma limits opportunities and access to resources in a number of critical domains (e.g., employment, healthcare), persistently affecting the physical and mental health of transgender people. The applied social ecological model employed here elucidates that transgender stigma operates at multiple levels (i.e., individual, interpersonal, structural) to impact health. Stigma prevention and coping interventions hold promise for reducing stigma and its adverse health-related effects in transgender populations. CONCLUSION Additional research is needed to document the causal relationship between stigma and adverse health as well as the mediators and moderators of stigma in US transgender populations. Multi-level interventions to prevent stigma towards transgender people are warranted.

LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach

OBJECTIVES We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. METHOD Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. RESULTS Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. CONCLUSION This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual mens co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record

CLINICAL ISSUES IN WORKING WITH LESBIAN, GAY, AND BISEXUAL CLIENTS

This article discusses some of the key clinical issues for therapists to consider when working with lesbian, gay, and bisexual (LGB) clients. After a discussion of the biases that can influence psychotherapy, guidelines are given for conducting LGB-affirmative therapy that avoids these biases. Issues that therapists need to be familiar with in working with LGB clients include LGB identity development; couple relationships and parenting; LGB individuals as members of families; the unique stressors faced by individuals who are underrepresented in the LGB research literature (e.g., older LGB individuals, ethnic minorities, religious LGB individuals, bisexual individuals); and legal and workplace issues. An examination of the published literature is offered with particular emphasis given to the available empirical research. Lesbian, gay, and bisexual (LGB) women and men utilize therapy at rates higher than the general population (Bell & Weinberg, 1978; Liddle, 1996; Morgan, 1992; National Lesbian and Gay Health Foundation, 1988), and nearly all therapists report seeing at least one LGB client in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Yet, the mental health professions have historically demonstrated heterocentric and homophobic beliefs, prejudices, and practices against LGB individuals, placing the burden of distress on the client and his or her possession of an illness (Goldfried, 2001). Indeed, some professionals continue to promote cures for homosexuality (Nicolosi & Nicolosi, 2002). Even when homosexuality is not viewed as pathological, mental health professionals need to consider the distress that antihomosexual bias can cause LGB individuals. Disregarding such factors may lead to erroneous and unfortunate attributions of the sources of distress in an LGB person who is seeking therapy. There is a dearth of systematic research on the unique therapy experiences of LGB individuals. Although theoretical work on the nature, etiology, and consequences of LGB identities abounds, little exists in the way of empirical studies on these issues. Thus, it comes as no surprise that when working with LGB clients, we as therapists are often inadequately equipped in our training to handle issues that are unique to LGB individuals (Phillips & Fischer, 1998). As a consequence, LGB clients have a right not only to be skeptical of our competence in handling their LGB-related issues but also to expect that we gain proficiency in handling any such issues that may arise in the therapeutic context. Although guidelines for conducting psychotherapy with LGB clients exist (American Psychological Association, 2000), there is a need for work that explicates these guidelines with the intent of making them more useful for clinicians. Important issues in the lives of LGB clients include LGB identity development, romantic relationships, family relationships, and parenting. There are a number of additional issues and considerations that are important to consider when working with certain members of this population (e.g., specific issues of concern to bisexual, ethnic minority, and older LGB individuals). The primary purpose of this article is to provide an overview of many of the issues we need to know about as therapists when working with LGB clients. As will be seen, some of these issues are based on clinical impressions and some on research findings. We first consider the ways that heterocentrism and homophobia affect LGB individuals and some of the potential therapeutic biases that may arise when working with LGB clients. Toward the goal of encouraging an LGB-affirmative approach to therapy, several of the specific issues confronting our LGB clients are then discussed.

Religious Climate and Health Risk Behaviors in Sexual Minority Youths: A Population-Based Study

OBJECTIVES We examined whether the health risk behaviors of lesbian, gay, and bisexual (LGB) youths are determined in part by the religious composition of the communities in which they live. METHODS Data were collected from 31,852 high school students, including 1413 LGB students, who participated in the Oregon Healthy Teens survey in 2006 through 2008. Supportive religious climate was operationalized according to the proportion of individuals (of the total number of religious adherents) who adhere to a religion supporting homosexuality. Comprehensive data on religious climate were derived from 85 denominational groups in 34 Oregon counties. RESULTS Among LGB youths, living in a county with a religious climate that was supportive of homosexuality was associated with significantly fewer alcohol abuse symptoms (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40, 0.85) and fewer sexual partners (OR = 0.77; 95% CI = 0.60, 0.99). The effect of religious climate on health behaviors was stronger among LGB than heterosexual youths. Results remained robust after adjustment for multiple confounding factors. CONCLUSIONS The religious climate surrounding LGB youths may serve as a determinant of their health risk behaviors.

Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey

Objective:Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however. Design:Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N = 174 209). Methods:Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes. Results:MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes. Conclusion:Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSMs public visibility, it also reduces MSMs ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

Expressive writing for gay-related stress: psychosocial benefits and mechanisms underlying improvement.

OBJECTIVE This study tested the effectiveness of an expressive writing intervention for gay men on outcomes related to psychosocial functioning. METHOD Seventy-seven gay male college students (mean age = 20.19 years, SD = 1.99) were randomly assigned to write for 20 min a day for 3 consecutive days about either (a) the most stressful or traumatic gay-related event in their lives or (b) a neutral topic. We tested an exposure-based hypothesis of written emotional expression by asking half of the participants who were assigned to write about gay-related stress to read their previous days narrative before writing, whereas the other half did not. Posttest and 3-month follow-up outcomes were assessed with common measures of overall psychological distress, depression, physical health symptoms, and positive and negative affect. Gay-specific social functioning was assessed with measures of gay-related rejection sensitivity, gay-specific self-esteem, and items regarding openness and comfort with ones sexual orientation. RESULTS Participants who wrote about gay-related stress, regardless of whether they read their previous days writing, reported significantly greater openness with their sexual orientation 3 months following writing than participants who wrote about a neutral topic, F(1, 74) = 6.66, p < .05, eta(2) = .08. Additional analyses examined the impact of emotional engagement in the writing, severity of the expressed topic, previous disclosure of writing topic, tendency to conceal, and level of perceived social support on mental health outcomes. CONCLUSIONS The findings suggest that an expressive writing task targeting gay-related stress can improve gay mens psychosocial functioning, especially openness with sexual orientation. The intervention seems to be particularly beneficial for those men who write about more severe topics and for those with lower levels of social support. The findings suggest future tests of expressive writing tasks for different aspects of stigma-related stress.

A minority stress--emotion regulation model of sexual compulsivity among highly sexually active gay and bisexual men.

OBJECTIVE Sexual compulsivity represents a significant public health concern among gay and bisexual men, given its co-occurrence with other mental health problems and HIV infection. The purpose of this study was to examine a model of sexual compulsivity based on minority stress theory and emotion regulation models of mental health among gay and bisexual men. METHOD Gay and bisexual men in New York City reporting at least nine past-90-day sexual partners (n = 374) completed measures of distal minority stressors (i.e., boyhood gender nonconformity and peer rejection, adulthood perceived discrimination), hypothesized proximal minority stress mediators (i.e., rejection sensitivity, internalized homonegativity), hypothesized universal mediators (i.e., emotion dysregulation, depression, and anxiety), and sexual compulsivity. RESULTS The hypothesized model fit the data well (RMSEA = 0.05, CFI = 0.98, TLI = 0.95, SRMR = 0.03). Distal minority stress processes (e.g., adulthood discrimination) were generally found to confer risk for both proximal minority stressors (e.g., internalized homonegativity) and emotion dysregulation. Proximal minority stressors and emotion dysregulation, in turn, generally predicted sexual compulsivity both directly and indirectly through anxiety and depression. CONCLUSIONS The final model suggests that gay-specific (e.g., internalized homonegativity) and universal (e.g., emotion dysregulation) processes represent potential treatment targets to attenuate the impact of minority stress on gay and bisexual mens sexual health. Tests of interventions that address these targets to treat sexual compulsivity among gay and bisexual men represent a promising future research endeavor.

The Social Development of Contingent Self-Worth in Sexual Minority Young Men: An Empirical Investigation of the “Best Little Boy in the World” Hypothesis

Young sexual minority men might cope with early stigma by strongly investing in achievement-related success. Sexual minority men (n = 136) reported deriving their self-worth from academics (d = 0.33), appearance (d = 0.33), and competition (d = 0.35) more so than heterosexual men (n = 56). Length of early sexual orientation concealment predicted investment in these domains (β = 0.19, 0.22, 0.24) and an objective measure of stigma predicted the degree to which young sexual minority men sought self-worth through competition (β = 0.26). A nine-day experience sampling approach confirmed that investment in achievement-related domains exacts negative health consequences for young sexual minority men.

Stigma and Minority Stress as Social Determinants of Health Among Lesbian, Gay, Bisexual, and Transgender Youth: Research Evidence and Clinical Implications.

In this article, we review theory and evidence on stigma and minority stress as social/structural determinants of health among lesbian, gay, bisexual, and transgender (LGBT) youth. We discuss different forms of stigma at individual (eg, identity concealment), interpersonal (eg, victimization), and structural (eg, laws and social norms) levels, as well as the mechanisms linking stigma to adverse health outcomes among LGBT youth. Finally, we discuss clinical (eg, cognitive behavioral therapy) and public health (eg, antibullying policies) interventions that effectively target stigma-inducing mechanisms to improve the health of LGBT youth.