3 - (OP13) How Heterosexist Stigma Gets Under the Skin: Quantifying the Effects of Stigma on Sexual Minority Mental Health Disparities in a Longitudinal Multilevel Socioecological Model

Background: Sexual minority communities in the US are disproportionately impacted by mental health-related distress compared to heterosexual counterparts. Heterosexist stigma is a well-documented predictor of sexual minority psychological disparities, but it has rarely been studied within theoretically congruent and quantitatively sophisticated models that include its manifestations across environmental, interpersonal, and intrapersonal contexts. We employed a novel quantitative model consistent with the socioecological model to simultaneously examine multiple competing pathways by which psychological disparities attributable to stigma may emerge.

Methods: We leveraged a nationally representative, longitudinal cohort of sexual minority adults (Generations; N = 1518, 2015-2019) nested in all nine US census divisions. We utilized an objective measure of regional structural stigma in year 1 (Movement Advancement Project policy tallies), and validated participant measures of interpersonal stigma in year 2 (Everyday Discrimination Scale), internalized stigma in year 3 (Internalized Homophobia-Revised), and psychological distress in year 4 (Kessler-6). We estimated a longitudinal multilevel mediation model that included parameters for direct/main effects for all stigma sources, within- and between-region effects of mediating stigma mechanisms, indirect effects, random slopes, and cross-level interactions. This novel model specification is necessary to facilitate the decomposition of effects attributable to theoretically relevant but potentially competing stigma processes.

Results: Structural stigma predicted interpersonal stigma a year later (B = 3.16, p = 0.002). Interpersonal stigma predicted internalized stigma a year later (B = 4.71, p < 0.001). Interpersonal (B = 3.58, p < 0.001) and internalized stigma (B = 2.36, p = 0.018) predicted worse psychological distress one to two years later, controlling for structural stigma; structural stigma did not directly predict distress three years later, controlling for more proximal stigma sources (p = 0.764). Interpersonal and internalized stigma did not sequentially mediate the effects of structural stigma on distress (p = 0.079). However, the effects of internalized stigma were stronger in regions with higher structural stigma (B = 2.10, p = 0.036).

Conclusion: Drawing on a novel quantitative model for estimating the embodiment of stigma and foundational theoretical work on how heterosexist stigma “gets under the skin,” we demonstrated that interpersonal and internalized stigma can have persistent negative effects on the mental health of sexual minority persons, even after accounting for structural sources of stigma. The data demonstrate the benefits of statistically probing all theoretically relevant pathways to clarify the causal mechanisms by which stigma can take effect. Consistent with the socioecological model, we found that context affects the strength of these relationships. This indicates that higher-stigma regions should be prioritized for intervention delivery, and that interventions to mitigate disparities may work best when situated at the appropriate level and can address stigma-related processes via specific causal pathways.