Structural, interpersonal, and individual factors influencing sexual orientation-based disparities in mental health : a socio-ecological perspective on sexual minority stigma

Background: Compared to heterosexual individuals, sexual minorities (e.g., those identifying as gay, lesbian, or bisexual) are at higher risk of several mental health problems, including suicidality, substance abuse, depression, and anxiety. Research has attributed much of these elevated risks to unique and chronic stress experiences, so-called minority stress, relating to the stigma and prejudice that many sexual minorities face. Less is known about how sexual minority stigma may function as a multilevel socio-ecological system that includes stigma-related risk factors at various levels, such as the structural (e.g., negative population attitudes and discriminatory laws and policies), interpersonal (e.g., victimization and harassment), and individual level (e.g., internalization of negative societal attitudes and concealment of sexual identity), to drive poor mental health among sexual minorities. Such a socio-ecological system of sexual minority stigma may feature unique characteristics and components, including 1) a chronosystem in which stigma-related factors may vary and exert effects across time, space, and the life course, 2) cross-level effects in which stigma-related factors at one level may give rise to stigma at another level, and 3) mechanisms that explain how stigma-related factors may compromise sexual minorities’ mental health. Purpose and aims: The purpose of this Doctor of Philosophy (Ph.D.) thesis was to contribute to the advancement of sexual minorities’ mental health equity by furthering the scientific knowledge on the mechanisms underlying sexual orientation-based disparities in mental health. The Ph.D. thesis aimed to do so by 1) advancing theoretical thinking through combing the existing frameworks of minority stress and psychological mediation with socioecological theory, 2) examining mental health disparities by sexual orientation, and 3) testing different elements of a proposed socio-ecology of sexual minority stigma framework. Methods: Cross-sectional individual-level data were used from surveys sent out to sexual minorities living in Sweden, across Europe, and/or with migration backgrounds. The first two of the presented studies used probability-based sampling techniques to identify representative population-based samples, while the other two studies used convenience samples of sexual minorities who lived in, or have moved from, various countries, diverse in structural climates. Data for the latter two studies were combined with objective indicators of structural forms of stigma present in these countries. In all studies, mediation and/or moderation analyses were employed to examine the explanatory or buffering, respectively, mechanisms underlying the associations between stigma-related factors and sexual minority mental health or wellbeing. Results: In the low-stigma context of Sweden, sexual minorities were at an 2.7-6.8 higher odds for suicidality, 1.3-2.3 higher odds for depression, and 1.4 higher odds for substance abuse, compared with heterosexual individuals. In Sweden, just about one third of sexual minorities reported being completely open about their sexual orientation. Regarding crosslevel effects, exposure to structural forms of stigma throughout the life course were associated with reduced adulthood wellbeing among sexual minorities open about their sexual orientation at school, partially mediated through increased negative interpersonal experiences, such as school bullying and subsequent adulthood victimization. Further, exposure to high levels of structural stigma were associated with reduced mental health among sexual minority male migrants, mediated through higher risks of negative individual stigma-related coping patterns, such as rejection sensitivity and internalized homophobia, with the maladaptive patterns increasing with duration of exposure. Yet, upon exposure to lower structural stigma, these patterns were found to decrease with time. Sexual identity concealment was not found to mediate the association between structural stigma and mental health. Similarly, sexual orientation openness was only positively associated with depression when sexual minorities’ social support was lacking. Conclusions and recommendations: While several stigma-related factors have previously been identified as direct risk factors for poor mental health among sexual minorities, this Ph.D. thesis further explored, and found support for, sexual minority stigma as a socioecological system surrounding sexual minorities, which includes a chronosystem, cross-level effects, and mechanisms linking stigma-related factors to poor mental health. That is, sexual minorities’ mental health and wellbeing might be shaped by the structural climates they live in and have been exposed to, such that those contexts may promote harmful interpersonal stigma-related experiences throughout the life course and may gradually give rise to detrimental individual-level stigma-based coping mechanisms. To improve health equity between sexual minorities and heterosexual individuals, policymakers should focus on eliminating sexual minority stigma in its various forms – whether explicit or subtle, whether intentional or inadvertent, whether structural or interpersonal – from today’s societies. Meanwhile, clinicians may help empower sexual minorities finding purpose within and outside prominent social structures and help break sexual minorities’ harmful coping patterns instilled by stigma through affirmative therapy. Further research is needed to confirm these initial efforts to frame and examine sexual minority stigma as a socio-ecological system.