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The relationship between minority stress and biological outcomes: A systematic review

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Abstract

Sexual minority (non-heterosexual) individuals experience higher rates of physical health problems. Minority stress has been the primary explanatory model to account for this disparity. The purpose of this study was to identify in published research empirically established relationships between minority stress processes and biological outcomes and identify avenues for future research. The PubMed database was queried with search terms relevant to minority stress and a comprehensive list of physical and biological outcomes. To be included in the analysis, studies had to examine the relationship between minority stress and a biological outcome among sexual minority individuals. Those meeting inclusion criteria were coded for key variables including methodology used, positive and null results, participant characteristics, and specific minority stress processes and biological outcomes considered. In total, 26 studies met inclusion criteria. Studies tested relationships between specific minority stress processes including prejudice, expectations of prejudice, concealment of sexual orientation, and internalized stigma and multiple biological outcomes, such as overall physical health, immune response, HIV specific outcomes, cardiovascular outcomes, metabolic outcomes, cancer related outcomes, and hormonal outcomes. Studies included both analyses that detected this relationship (42% of analyses) and analyses that did not detect this relationship (58%). There is substantial evidence to support the relationship between minority stress and biological outcomes, yet additional research is needed to identify the measurements and outcomes that have the most rigorous and replicable results.

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References

  • Bauermeister, J. A., Meanley, S., Hickok, A., Pingel, E., VanHemert, W., & Loveluck, J. (2014). Sexuality-related work discrimination and its association with the health of sexual minority emerging and young adult men in the Detroit Metro Area. Sexuality Research and Social Policy, 11, 1–10.

    PubMed  Google Scholar 

  • Boehmer, U., Bowen, D. J., & Bauer, G. R. (2007). Overweight and obesity in sexual-minority women: Evidence from population-based data. American Journal of Public Health, 97, 1134–1140. https://doi.org/10.2105/AJPH.2006.088419

    Article  PubMed  PubMed Central  Google Scholar 

  • Boehmer, U., Glickman, M., Winter, M., & Clark, M. A. (2013). Long-term breast cancer survivors’ symptoms and morbidity: Differences by sexual orientation? Journal of Cancer Survivorship, 7, 203–210.

    PubMed  Google Scholar 

  • Bogart, L. M., Landrine, H., Galvan, F. H., Wagner, G. J., & Klein, D. J. (2013). Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men. AIDS and Behavior, 17, 1431–1441.

    PubMed  PubMed Central  Google Scholar 

  • Brondolo, E., Hausmann, L. R. M., Jhalani, J., Pencille, M., Atencio-Bacayon, J., Kumar, A., et al. (2011). Dimensions of perceived racism and self-reported health: Examination of racial/ethnic differences and potential mediators. Annals of Behavioral Medicine, 42, 14–28. https://doi.org/10.1007/s12160-011-9265-1

    Article  PubMed  PubMed Central  Google Scholar 

  • Chae, D. H., Lincoln, K. D., Adler, N. E., & Syme, S. L. (2010). Do experiences of racial discrimination predict cardiovascular disease among African American Men? The moderating role of internalized negative racial group attitudes. Social Science and Medicine, 71, 1182–1188. https://doi.org/10.1016/j.socscimed.2010.05.045

    Article  PubMed  Google Scholar 

  • Chae, D. H., & Walters, K. L. (2009). Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska Natives. American Journal of Public Health, 99, S144–S151.

    PubMed  PubMed Central  Google Scholar 

  • Chandola, T., Brunner, E., & Marmot, M. (2006). Chronic stress at work and the metabolic syndrome: Prospective study. BMJ, 332, 521–525. https://doi.org/10.1136/bmj.38693.435301.80

    Article  PubMed  PubMed Central  Google Scholar 

  • Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: The cultural assessment of risk for suicide (CARS) measure. Psychological Assessment, 25, 424.

    PubMed  Google Scholar 

  • Cochran, S. D., Ackerman, D., Mays, V. M., & Ross, M. W. (2004). Prevalence of non-medical drug use and dependence among homosexually active men and women in the US population. Addiction, 99, 989–998.

    PubMed  PubMed Central  Google Scholar 

  • Cochran, S. D., & Mays, V. M. (2007). Physical health complaints among lesbians, gay men, and bisexual and homosexually experienced heterosexual individuals: Results from the California Quality of Life Survey. American Journal of Public Health, 97, 2048–2055.

    PubMed  PubMed Central  Google Scholar 

  • Cochran, S. D., Sullivan, J. G., & Mays, V. M. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71, 53.

    PubMed  PubMed Central  Google Scholar 

  • Cohen, S., Janicki-Deverts, D., Doyle, W. J., Miller, G. E., Frank, E., Rabin, B. S., et al. (2012). Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. Proceedings of the National Academy of Sciences, 109, 5995–5999.

    CAS  Google Scholar 

  • Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. The Journal of the American Medical Association, 298, 1685–1687. https://doi.org/10.1001/jama.298.14.1685

    Article  PubMed  CAS  Google Scholar 

  • Cole, S. W., Hawkley, L. C., Arevalo, J. M., Sung, C. Y., Rose, R. M., & Cacioppo, J. T. (2007). Social regulation of gene expression in human leukocytes. Genome Biology, 8, R189.

    PubMed  PubMed Central  Google Scholar 

  • Cole, S. W., Kemeny, M. E., & Taylor, S. E. (1997). Social identity and physical health: Accelerated HIV progression in rejection-sensitive gay men. Journal of Personality and Social Psychology, 72, 320–335. https://doi.org/10.1037/0022-3514.72.2.320

    Article  PubMed  CAS  Google Scholar 

  • Cole, S. W., Kemeny, M. E., Taylor, S. E., & Visscher, B. R. (1996a). Elevated physical health risk among gay men who conceal their homosexual identity. Health Psychology, 15, 243.

    PubMed  CAS  Google Scholar 

  • Cole, S. W., Kemeny, M. E., Taylor, S. E., Visscher, B. R., & Fahey, J. L. (1996b). Accelerated course of human immunodeficiency virus infection in gay men who conceal their homosexual identity. Psychosomatic Medicine, 58, 219–231.

    PubMed  CAS  Google Scholar 

  • Conron, K. J., Mimiaga, M. J., & Landers, S. J. (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100, 1953–1960.

    PubMed  PubMed Central  Google Scholar 

  • Dickerson, S. S., Gable, S. L., Irwin, M. R., Aziz, N., & Kemeny, M. E. (2009). Social-evaluative threat and proinflammatory cytokine regulation an experimental laboratory investigation. Psychological Science, 20, 1237–1244.

    PubMed  PubMed Central  Google Scholar 

  • Dickerson, S. S., & Kemeny, M. E. (2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130, 355.

    PubMed  Google Scholar 

  • Doyle, D. M., & Molix, L. (2016). Minority stress and inflammatory mediators: Covering moderates associations between perceived discrimination and salivary interleukin-6 in gay men. Journal of Behavioral Medicine, 39, 782–792.

    PubMed  PubMed Central  Google Scholar 

  • Flentje, A., Kober, K., Carrico, A. W., Neilands, T. B., Flowers, E., Heck, N. C., et al. (2018). Minority stress and leukocyte gene expression in sexual minority men living with treated HIV infection. Brain, Behavior, and Immunity, 70, 335–345.

    PubMed  PubMed Central  CAS  Google Scholar 

  • Fredriksen-Goldsen, K. I., Kim, H.-J., Shui, C., & Bryan, A. E. B. (2017). Chronic health conditions and key health indicators among lesbian, gay, and bisexual older US adults, 2013–2014. American Journal of Public Health, 107, 1332–1338. https://doi.org/10.2105/AJPH.2017.303922

    Article  PubMed  PubMed Central  Google Scholar 

  • Friedman, M. R., Sang, J. M., Bukowski, L. A., Matthews, D. D., Eaton, L. A., Raymond, H. F., et al. (2018). HIV care continuum disparities among black bisexual men and the mediating effect of psychosocial comorbidities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 77, 451–458.

    PubMed  Google Scholar 

  • Frost, D. M., Lehavot, K., & Meyer, I. H. (2015). Minority stress and physical health among sexual minority individuals. Journal of Behavioral Medicine, 38, 1–8.

    PubMed  Google Scholar 

  • Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56, 97–109.

    PubMed  PubMed Central  Google Scholar 

  • Gaab, J., Rohleder, N., Nater, U. M., & Ehlert, U. (2005). Psychological determinants of the cortisol stress response: The role of anticipatory cognitive appraisal. Psychoneuroendocrinology, 30, 599–610.

    PubMed  CAS  Google Scholar 

  • Gamarel, K. E., Neilands, T. B., Dilworth, S. E., Taylor, J. M., & Johnson, M. O. (2015). Smoking, internalized heterosexism, and HIV disease management among male couples. AIDS Care, 27, 649–654.

    PubMed  CAS  Google Scholar 

  • Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135, 707.

    PubMed  PubMed Central  Google Scholar 

  • Hatzenbuehler, M. L., & McLaughlin, K. A. (2014). Structural stigma and hypothalamic–pituitary–adrenocortical axis reactivity in lesbian, gay, and bisexual young adults. Annals of Behavioral Medicine, 47, 39–47.

    PubMed  PubMed Central  Google Scholar 

  • Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460.

    Google Scholar 

  • Hengge, U. R., Reimann, G., Schäfer, A., & Goos, M. (2003). HIV-positive men differ in immunologic but not catecholamine response to an acute psychological stressor. Psychoneuroendocrinology, 28, 643–656.

    PubMed  CAS  Google Scholar 

  • Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353–375.

    PubMed  Google Scholar 

  • Higgins, J., & Green, S. (2011). Cochrane handbook for systematic reviews of interventions version 5.10. Retrieved November, 2018, from The Cochrane Collaboration website: http://handbook.cochrane.org/

  • Huebner, D. M., & Davis, M. C. (2005). Gay and bisexual men who disclose their sexual orientations in the workplace have higher workday levels of salivary cortisol and negative affect. Annals of Behavioral Medicine, 30, 260–267.

    PubMed  Google Scholar 

  • Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, D.C.: The National Academies Press.

    Google Scholar 

  • Johns, M. M., Lowry, R., Demissie, Z., & Robin, L. (2017). Harassment and mental distress among adolescent female students by sexual identity and BMI or perceived weight status. Obesity, 25, 1421–1427.

    PubMed  Google Scholar 

  • Juster, R.-P., Smith, N. G., Ouellet, É., Sindi, S., & Lupien, S. J. (2013). Sexual orientation and disclosure in relation to psychiatric symptoms, diurnal cortisol, and allostatic load. Psychosomatic Medicine, 75, 103–116.

    PubMed  Google Scholar 

  • Kabagambe, E. K., Judd, S. E., Howard, V. J., Zakai, N. A., Jenny, N. S., Hsieh, M., et al. (2011). Inflammation biomarkers and risk of all-cause mortality in the reasons for geographic and racial differences in stroke cohort. American Journal of Epidemiology, 174, 284–292. https://doi.org/10.1093/aje/kwr085

    Article  PubMed  PubMed Central  Google Scholar 

  • Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

    Google Scholar 

  • Li, P., Huang, Y., Guo, L., Wang, W., Xi, C., Lei, Y., et al. (2017). Is sexual minority status associated with poor sleep quality among adolescents? Analysis of a national cross-sectional survey in Chinese adolescents. British Medical Journal Open, 7, e017067.

    Google Scholar 

  • Lick, D. J., Durso, L. E., & Johnson, K. L. (2013). Minority stress and physical health among sexual minorities. Perspectives on Psychological Science, 8, 521–548. https://doi.org/10.1177/1745691613497965

    Article  PubMed  Google Scholar 

  • Livingston, N., Flentje, A., Heck, N. C., Szalda-Petree, A., & Cochran, B. N. (2017). Ecological momentary assessment of daily prejudice experiences and nicotine, alcohol, and drug use among sexual and gender minority individuals. Journal of Consulting and Clinical Psychology, 85, 1131–1143.

    PubMed  PubMed Central  Google Scholar 

  • Manigault, A. W., Figueroa, W. S., Hollenbeck, C. R., Mendlein, A. E., Woody, A., Hamilton, K. R., et al. (2018). When family matters most: A test of the association between sexual minority identity disclosure context and diurnal cortisol in sexual minority young adults. Psychosomatic Medicine, 80, 717–723.

    PubMed  CAS  Google Scholar 

  • Martin-Storey, A., Prickett, K. C., & Crosnoe, R. (2018). Disparities in sleep duration and restedness among same and different sex couples: Findings from the American time use survey. Sleep, 41, 1–11.

    Google Scholar 

  • Mason, T. B. (2016). Binge eating and overweight and obesity among young adult lesbians. LGBT Health, 3, 472–476.

    PubMed  Google Scholar 

  • Mason, T. B., & Lewis, R. J. (2015). Minority stress, depression, relationship quality, and alcohol use: Associations with overweight and obesity among partnered young adult lesbians. LGBT Health, 2, 333–340.

    PubMed  PubMed Central  Google Scholar 

  • McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T., & Boyd, C. J. (2010). The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100, 1946–1952.

    PubMed  PubMed Central  Google Scholar 

  • McEwen, B. S. (2004). Protection and damage from acute and chronic stress: Allostasis and allostatic overload and relevance to the pathophysiology of psychiatric disorders. Annals of the New York Academy of Sciences, 1032, 1–7. https://doi.org/10.1196/annals.1314.001

    Article  PubMed  Google Scholar 

  • McEwen, B. S., Eiland, L., Hunter, R. G., & Miller, M. M. (2012). Stress and anxiety: Structural plasticity and epigenetic regulation as a consequence of stress. Neuropharmacology, 62, 3–12. https://doi.org/10.1016/j.neuropharm.2011.07.014

    Article  PubMed  CAS  Google Scholar 

  • Mereish, E. H. (2014). The weight of discrimination: The relationship between heterosexist discrimination and obesity among lesbian women. Psychology of Sexual Orientation and Gender Diversity, 1, 356.

    Google Scholar 

  • Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. https://doi.org/10.2307/2137286

    Article  PubMed  CAS  Google Scholar 

  • Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674.

    PubMed  PubMed Central  Google Scholar 

  • Miller, G., Rohleder, N., & Cole, S. W. (2009). Chronic interpersonal stress predicts activation of pro-and anti-inflammatory signaling pathways six months later. Psychosomatic Medicine, 71, 57.

    PubMed  Google Scholar 

  • Miller, G. E., Cohen, S., & Ritchey, A. K. (2002). Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model. Health Psychology, 21, 531.

    PubMed  Google Scholar 

  • Miller, G. E., & Cole, S. W. (2012). Clustering of depression and inflammation in adolescents previously exposed to childhood adversity. Biological Psychiatry, 72, 34–40.

    PubMed  PubMed Central  Google Scholar 

  • Mohr, J., & Fassinger, R. (2000). Measuring dimensions of lesbian and gay male experience. Measurement and Evaluation in Counseling and Development, 33, 66–90.

    Google Scholar 

  • NIMHD. (2016). Director’s message for October 6, 2016. Retrieved September 14, 2018, from NIMHD website: https://www.nimhd.nih.gov/about/directors-corner/messages/message_10-06-16.html

  • Norcini Pala, A., Hart, R. P., & Steca, P. (2015). Minority stress, depression and HIV-progression biomarkers: An exploratory study on a sample of Italian HIV-positive gay and bisexual men. Journal of Gay & Lesbian Mental Health, 19, 244–260.

    Google Scholar 

  • O’Cleirigh, C., Ironson, G., Antoni, M., Fletcher, M. A., McGuffey, L., Balbin, E., et al. (2003). Emotional expression and depth processing of trauma and their relation to long-term survival in patients with HIV/AIDS. Journal of Psychosomatic Research, 54, 225–235. https://doi.org/10.1016/S0022-3999(02)00524-X

    Article  PubMed  Google Scholar 

  • Pachankis, J. E., & Goldfried, M. R. (2006). Social anxiety in young gay men. Journal of Anxiety Disorders, 20, 996–1015. https://doi.org/10.1016/j.janxdis.2006.01.001

    Article  PubMed  Google Scholar 

  • Page, M. J., McKenzie, J. E., & Higgins, J. P. (2018). Tools for assessing risk of reporting biases in studies and syntheses of studies: A systematic review. British Medical Journal Open, 8, e019703.

    Google Scholar 

  • Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., et al. (2015). Racism as a determinant of health: A systematic review and meta-analysis. PLoS ONE, 10, e0138511. https://doi.org/10.1371/journal.pone.0138511

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Parra, L. A., Benibgui, M., Helm, J. L., & Hastings, P. D. (2016). Minority stress predicts depression in lesbian, gay, and bisexual emerging adults via elevated diurnal cortisol. Emerging Adulthood, 4, 365–372.

    Google Scholar 

  • Slavich, G. M., & Cole, S. W. (2013). The emerging field of human social genomics. Clinical Psychological Science, 1, 331–348.

    PubMed  PubMed Central  Google Scholar 

  • Stall, R., Paul, J. P., Greenwood, G., Pollack, L. M., Bein, E., Crosby, G. M., et al. (2001). Alcohol use, drug use and alcohol-related problems among men who have sex with men: The Urban Men’s Health Study. Addiction, 96, 1589–1601.

    PubMed  CAS  Google Scholar 

  • Szymanski, D. M. (2006). Does internalized heterosexism moderate the link between heterosexist events and lesbians’ psychological distress? Sex Roles, 54, 227–234.

    Google Scholar 

  • Temoshok, L. R., Waldstein, S. R., Wald, R. L., Garzino-Demo, A., Synowski, S. J., Sun, L., et al. (2008). Type C coping, alexithymia, and heart rate reactivity are associated independently and differentially with specific immune mechanisms linked to HIV progression. Brain, Behavior, and Immunity, 22, 781–792. https://doi.org/10.1016/j.bbi.2008.02.003

    Article  PubMed  CAS  Google Scholar 

  • Ullrich, P. M., Lutgendorf, S. K., & Stapleton, J. T. (2003). Concealment of homosexual identity, social support and CD4 cell count among HIV-seropositive gay men. Journal of Psychosomatic Research, 54, 205–212.

    PubMed  Google Scholar 

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Acknowledgements

Dr. Flentje’s work on this paper was supported by the National Institute on Drug Abuse (K23DA039800). This paper does not reflect the views of the National Institutes of Health.

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Authors and Affiliations

  1. Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, CA, USA

    Annesa Flentje

  2. Alliance Health Project, Department of Psychiatry, School of Medicine, University of California, San Francisco, San Francisco, CA, USA

    Annesa Flentje

  3. Putnam County Hospital, Greencastle, IN, USA

    Nicholas C. Heck

  4. Department of Psychology, The University of Montana, Missoula, MT, USA

    James Michael Brennan

  5. The Williams Institute, School of Law, University of California, Los Angeles, Los Angeles, CA, USA

    Ilan H. Meyer

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  1. Annesa Flentje
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Flentje, A., Heck, N.C., Brennan, J.M. et al. The relationship between minority stress and biological outcomes: A systematic review. J Behav Med 43, 673–694 (2020). https://doi.org/10.1007/s10865-019-00120-6

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