Individual

Individual forms of stigma refer to individuals’ cognitive, affective, and behavioral responses to stigma. In this section, we focus on 3 individual-level stigma processes that have received the most empirical attention with LGBT populations: internalized homophobia/transphobia, rejection sensitivity, and concealment.

Internalized homophobia/transphobia refers to the internalization of negative societal attitudes about one’s sexual orientation or gender identity. Such negative self-regard has been associated with poor health outcomes among LGBT individuals. For example, sexual minority adults’ experiences with internalized homophobia are positively associated with alcohol and drug use, HIV risk behaviors, and bulimic behavior. Internalized homophobia among sexual minority male youth is associated prospectively with sexual risk behavior. In addition, internalized transphobia is associated with increased risk of lifetime suicide attempts among transgender adults. Thus, experiences with internalized homophobia and transphobia can arouse negative feelings about one’s own social group, which have been linked to unhealthy behaviors that put LGBT individuals at risk for health problems.

Experiences with stigma and minority stress also make targets sensitive to rejection. Stigma-based rejection sensitivity describes the psychological process through which some individuals learn to anxiously anticipate rejection because of previous experiences with prejudice and discrimination toward their group membership. Sensitivity to possible rejection becomes particularly salient during adolescence, and rejection during this time predicts mental health problems across the lifespan. Adolescents who become aware of a stigmatized personal status during this developmental period and who are particularly sensitive to rejection of their stigma may be particularly likely to develop unhealthy coping strategies to fend off expected rejection in potentially threatening contexts. Most studies on rejection sensitivity among LGBT populations have been conducted with adult samples, but recent studies have shown that young gay and bisexual men high in rejection sensitivity use condoms less often, which is mediated by their diminished condom use self-efficacy. Although rejection sensitivity should also affect the health of LGBT youth, this has not yet been documented empirically.

Experiences with sexual orientation-related stigma can lead sexual and gender minority individuals to engage in concealment behaviors, which refers to hiding their identity to avoid future victimization. Although this can serve as a positive coping strategy in the short term by helping sexual minorities to avoid victimization, it is associated with a host of psychological consequences in the long term, including depressive symptoms, negative affect and anxiety, poor self-esteem and elevated psychiatric symptoms, and psychological strain. Concealment can also harm sexual minority physical health by affecting the care they receive from medical professionals. For example, sexual minority adults have special medical needs that likely go unmet if they conceal their sexual orientation from health care workers. Transgender individuals who cannot or choose not to access gender affirmation procedures, and those who transition later in life after already having developed secondary sex characteristics, may be at increased risk of stigma given their visible gender nonconformity. In fact, the degree to which others can tell whether an individual is transgender has been linked to discrimination and poor mental and physical health outcomes. Delaying the transition process while concealing one’s transgender identity may contribute to psychological distress in adolescents and adults. Concealment by those who have not transitioned can restrict access to transition-related medical services, whereas concealment by those who have transitioned can lead to inappropriate medical care for relevant anatomy.

Interpersonal

Interpersonal forms of stigma refer to prejudice and discrimination as expressed by one person toward another—that is, to interactional processes that occur between the stigmatized and the nonstigmatized. Interpersonal stigma not only includes intentional, overt actions, such as bias-based hate crimes, but also unintentional, covert actions, like microaggressions. Research on interpersonal forms of stigma among LGBT youth has tended to focus on 2 forms: peer victimization and bullying (see Valerie A. Earnshaw and colleagues’ article, “ LGBT Youth and Bullying ,” in this issue) and parental abuse and rejection (see Sabra L. Katz-Wise and colleagues’ article, “ LGBT Youth and Family Acceptance ,” in this issue). Given that these 2 topics are covered in greater detail in other articles in this issue, we will not discuss them here.

Structural

Structural forms of stigma refer to stigma processes that occur above the individual and interpersonal levels of analyses and are defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized.” Compared with research on individual and interpersonal forms of stigma, there has been less empirical work on stigma at the structural level. Nevertheless, an emerging body of evidence highlights the role that structural stigma plays in the production of LGBT health inequalities (for a review, see Hatzenbuehler ). We review several illustrative examples of this research in the following section.

Studies of structural stigma and the health of LGBT youth have followed 2 broad approaches. In the first approach, researchers examine the association between a single indicator of structural stigma and health outcomes among LGBT populations. In an example of this work, researchers obtained data on neighborhood-level LGBT hate crimes involving assaults or assaults with battery from the Boston Police Department that were linked to individual-level data on health and sexual orientation from a population-based sample of Boston adolescents. Sexual minority youth residing in neighborhoods with higher rates of LGBT assault-based hate crimes were significantly more likely to report adverse health outcomes, including suicidal ideation and suicide attempts, bullying, and marijuana use, than were sexual minority youth residing in neighborhoods with lower LGBT assault-based hate crime rates. No associations between LGBT assault-based hate crimes and these adverse health outcomes were found among heterosexual adolescents, indicating that the results were specific to sexual minority respondents. Further, no relationships were observed between overall neighborhood-level violent crimes and these adverse health outcomes among sexual minority adolescents, which provided evidence for the specificity of the results to LGBT assault-based hate crimes.

In the second methodological approach, researchers create a composite index of structural stigma that includes multiple components (rather than examining single indicators of structural stigma), and then examine whether this index predicts adverse health outcomes among LGBT youth. For instance, Hatzenbuehler (2011) created an index of structural stigma surrounding sexual minorities that included 4 different components: density of same-sex couples, proportion of gay–straight alliances per public high school, 5 policies related to sexual orientation discrimination (eg, same-sex marriage laws, antidiscrimination statutes), and aggregated public opinion toward homosexuality. Several studies have shown that this composite variable of structural stigma is associated with adverse health outcomes among LGBT youth. In 1 cross-sectional study, the risk of attempting suicide in the past 12 months was 20% greater among LGB youth living in counties with higher levels of structural stigma compared with those living in counties with lower levels of structural stigma. In longitudinal studies, researchers have shown that sexual minority youth living in low structural stigma states are less likely to smoke over time than sexual minority youth in high structural stigma states ; moreover, sexual orientation disparities in marijuana use and other illicit drug use are significantly smaller in low structural stigma states than in high structural stigma states.

Vigilance

Experiences with stigma and minority stressors can alter cognitive processes in ways that impact health. A substantial body of research has shown that experiences with stigma make minority individuals vigilant of their social environment to anticipate and avoid stigmatizing encounters. Studies in the general population have supported a link between perceptual vigilance and cardiovascular functioning, demonstrating heightened systolic and diastolic blood pressure among participants who were vigilant to negative social messages. Further, experiences with stigma make sexual minority individuals vigilant to threats in their social environment, which in turn is associated with adverse mental health outcomes, such as depressive symptoms.

Rumination

Emotion regulation is defined as the “conscious and nonconscious strategies [people] use to increase, maintain, or decrease one or more components of an emotional response.” Repeated encounters with stigma and minority stressors may lead LGB individuals to ruminate, which is a maladaptive emotion regulation strategy characterized by repeated focus on the causes and symptoms of distress. Prospective studies have revealed that individuals with a high degree of life stress develop increasingly ruminative tendencies. Specific to sexual minority populations, Hatzenbuehler and colleagues have found that LGB adolescents and adults tend to ruminate more than their heterosexual counterparts. Further, ruminative tendencies have been specifically linked to minority stress in particular. Sexual minority young adults were especially likely to ruminate on days when they encountered stigma-related stressors related to their sexual orientation, and such rumination was associated with psychological distress.

Loneliness

Stigma and minority stressors may increase feelings of loneliness among LGBT individuals, which in turn can affect interpersonal relationships. Loneliness is common among members of stigmatized groups, and it may be especially so for sexual and gender minorities, who frequently encounter rejection from family members and friends. In addition, fears of future rejection and negative evaluation lead individuals with concealable stigmas (eg, homosexuality) to avoid entering into close relationships for fear of others’ discovering their stigma, which over time leads to more loneliness, introversion, psychological distress, and social anxiety.

Physiologic Mechanisms Related to Stress Response

Finally, physiologic factors are another way in which stigma and minority stressors “get under the skin” to affect health. Research on the ways in which minority stressors affect physiologic functioning among LGBT people is still in its relative infancy; however, recent evidence has begun to uncover some of these physiologic mechanisms. Most of this work has focused on alterations in activity of the hypothalamic–pituitary–adrenal (HPA) axis, which is the focus of our review.

Stigma and minority stress may impact regulation of the steroid hormone cortisol, which is released by the HPA axis in response to stressors that are socially threatening. Over time, chronic stress can lead to dysregulation of the HPA axis, which is associated with a host of negative health outcomes, including cardiovascular disease and diabetes. A great deal of work in the general population has established links between social stress, HPA functioning, and health (see ), and preliminary evidence suggests that stigma affects HPA axis functioning among sexual minority individuals specifically. For example, researchers recruited 74 LGB young adults who were raised in 24 different states as adolescents. These states differed widely in terms of structural stigma, which was coded based on a composite measure of structural stigma. To examine how prior exposure to structural stigma during adolescence affected subsequent physiologic stress response, participants completed a well-validated laboratory stressor, the Trier Social Stress Test, and neuroendocrine measures were collected. LGB young adults who were raised in high structural stigma states as adolescents evidenced a blunted cortisol response following the Trier Social Stress Test compared with those from low structural stigma states. This pattern of blunted cortisol response has been documented in other groups that have experienced chronic stressors, including children exposed to childhood maltreatment and individuals diagnosed with posttraumatic stress disorder. These results therefore suggest that the stress of growing up in social environments that target gays and lesbians for social exclusion may exert biological effects that are similar to other chronic life stressors.