Sexual minority women are at greater risk of depressive symptoms: the mediation effects of minority stressors

doi:10.21203/rs.3.rs-2075979/v1

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Sexual minority women are at greater risk of depressive symptoms: the mediation effects of minority stressors

https://doi.org/10.21203/rs.3.rs-2075979/v1

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Background

Although, a substantial amount of research has shown that compared with heterosexual counterparts, sexual minority populations are at increased risk of mental health symptoms, there are less public health researches on lesbian and bisexual women, making it hard to draw conclusions about the way to improve health.

Methods

This study examined the association of distal stressors, proximal stressors with depressive symptom. The study sample included 301 sexual minority women in Beijing, with 81.4% identifying as lesbian and 18.6% identifying as bisexual. They responded to self-report measures of sexual minority stress and depressive symptoms. Data were collected from August 2018 to October 2018. The association of minority stressors and depressive symptoms was estimated using the parallel mediation models.

Results

Depressive symptoms were prevalent among sexual minority women (56.1%). The correlations between distal stressors, proximal stressors and depressive symptoms were significant. The parallel mediation model showed that, expectation of rejection rather than sexual orientation concealment and internalized homophobia emerges as a significant mediator between sexual orientation-related stigma and depressive symptoms.

Conclusions

Early intervention addressing sexual orientation-related stigma combined with eliminating expectation of rejection would help prevent depressive symptoms in sexual minority women.

Depressive symptoms

Minority stressors

Parallel mediation model

Sexual minority women

Numerous studies have documented mental health disparities among sexual minorities, which refers to lesbians, gay, bisexual, and transgender (LGBT) individuals [1–4]. Furthermore, a substantial amount of research has shown that compared with heterosexual counterparts, sexual minority populations are at increased risk of depressive, anxiety, bipolar disorders, suicidality, and substance use-related morbidity [4–6]. Several studies indicated that sexual minorities are two to three times more likely than their heterosexual individuals to have suicide attempts [7, 8]. However, there are less public health researches on lesbian and bisexual women, making it hard to draw conclusions about the way to improve health. Thus, understanding the risk factors of mental health among lesbian and bisexual women is important to reduce health disparities.

Chronic exposure to social stress has been recognized to contribute to mental health problems [9, 10]. Sexual minority populations are stigmatized in an environment that privileges heterosexual, resulting in minority stress in their lives [11, 12]. Initially, minority stress was used by Brooks as a term in her study with lesbian women [13]. Researches have shown that minority stress is related to poor mental health in the LGBT population [14, 15]. Minority stress describes stress processes associated with prejudice and stigma which included experiences of prejudice and discrimination, the expectations of rejection, concealment of sexual orientation, internalized homophobia and dealing with these stress experiences. Each type of minority stress can trigger others [16]. For instance, experiences of prejudice or expectations of rejection could influence decisions about whether conceal the sexual orientation.

In addition, Meyer proposed the minority stress model which pointed out a distal–proximal distinction on account of its concern with the influence of external social structures and conditions on individuals [14]. Distal stressors are typically caused by objective events such as harassment or discrimination [14, 17]. While proximal stressors can be defined as personal and subjective, including anticipation of such events (i.e., expectations of rejection and concealment of sexual orientation) and the internalization of external negative societal prejudice (i.e., internalized homophobia) [14].

It was reported that sexual minority women experience increased rates of societal discrimination and violence [18]. Minority stress theory has been the primary explanation for increased rates of mental illness among those groups. However, whether and how minority stress might impact depressive symptom among sexual minority women is uncertain. In this effort, we aimed to (1) assess the influencing factors of depressive symptoms among sexual minority women in China, (2) examine the association of distal stressors (i.e., sexual stigma), proximal stressors (i.e., expectations of rejection, concealment of sexual orientation, internalized homophobia) with depressive symptom, and (3) test the parallel mediation model of sexual stigma to depressive symptoms through expectation of rejection, sexual orientation concealment and internalized homophobia experienced by sexual minority women.

Participants and Procedures

This study was conducted from August 2018 to October 2018 in Haidian District, Beijing. The inclusion criteria were individuals who (1) were aged 16 or above; (2) identified as lesbian or bisexual; and (3) were currently living in Beijing. Females who had a mental disorder and couldn’t complete questionnaires individually were excluded from this research. A total of 335 individuals were recruited through snowball sampling; of these, 307 completed the questionnaire (completion rate: 91.6%). Finally, 6 cases missing the outcome variables were excluded from this study. This yielded a final analytic sample of 301 sexual minority women. Electronic questionnaires were sent to participants who agreed to take part in the study. All the data was anonymized to protect the privacy of study participants. Upon completion, participants were compensated ¥ 50 (US$7.84) for their time.

The study was approved by the Ethics Committee of Wuhan University (reference number: 2018YF0100). Prior to data collection, written informed consent was obtained from each participant.

Measures

Demographic Characteristics

Demographic variables including age, ethnicity, education level, marital status, monthly income, and employment status were collected. Participants also provided their sexual orientation (lesbian or bisexual). The personal information was used for descriptive and statistical analyses.

Sexual orientation-related stigma

The original homosexuality stigma scale was developed by Diaz et al. to assess the impact of stigma among sexual minorities man in Latino [19]. The researchers revised the 10 items to make them suitable for the Chinese context [20]. The subscale of perceived sexual stigma consists of 3 items, which include “how often have you heard that homosexuals are not normal?”, “how often have you felt that your homosexuality hurt and embarrassed your family?” and “how often have you had to pretend that you are not homosexual in order to be accepted?”. Response options ranged from 1 (never) to 4 (many times). A total score was calculated for each participant, with higher scores suggesting higher levels of perceived stigma. The scale was expanded to be measured with sexual minority women [21, 22]. The Cronbach’s α was 0.72 for this study.

Expectation of rejection

Expectation of rejection owing to sexual orientation was assessed using six questions [23], including questions such as “When I meet new people, I am afraid they will dislike me in secret for being homosexual.” The scale was originally developed to evaluate stigma related to mental problems [24], and later adapted to sexual minorities [25]. The response scale ranged from 1 (disagree) to 5 (agree). Higher scores reflected higher levels of expectation of rejection. The Cronbach’s α was 0.88 for this study.

Sexual orientation concealment

Participants completed Sexual Orientation Concealment Scale to measure their attempts to hide sexual orientation [26]. The original scale was published by Testa et al. [27], and further adapted by Outland et al. [28], which was appropriate for LGBT population. The scale consists of six items, including items such as “I have concealed my sexual orientation by telling someone that I was heterosexual or denying that I was homosexual.” Each item had five response options, ranging from 1 (never) to 5 (all of the time). Higher scores reflected high levels of sexual orientation concealment. The Cronbach’s α was 0.90 for this study.

Internalized homophobia

The Revised Internalized Homophobia scale (IHP-R) measures the extent to which participants reject their sexual orientation [27]. The IHP-R is composed of five items, example items are “If someone offered me the chance to be completely heterosexual, I would accept the chance” and “I tried to stop being attracted to women in general.” Each item was scored on a four-point Likert scale ranging from 1 (never) to 4 (often). Higher scores indicate high levels of internalized homophobia. This scale has satisfactory construct validity and internal reliability with LGB individuals [29]. The Cronbach’s α was 0.85 for this study.

Depressive Symptoms

Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Rating Scale (CESD-10) [30]. Each item of the CESD-10 was measured on a four-point Likert scale ranging from 0 (rarely) to 3 (all the time). Higher scores (ranged from 0 to 30) representing a higher degree of depressive symptoms during the past-week. Participants who had a total score ≥ 10 were categorized in depressive symptoms group [31]. The scale was highly validated for use in sexual minorities and indicated adequate validity and reliability [32]. The Cronbach’s α was 0.89 for this study.

Statistical analyses

All statistical analyses were conducted with the SPSS 26. Significance was set at p ≤ 0.05. The differences in depressive symptoms among demographic characteristics were examined with Chi²-tests, t-tests, and one-way ANOVA. Pearson correlation analyses were used to investigate the correlations between sexual orientation stigma, expectation of rejection, sexual orientation concealment, internalized homophobia, and depressive symptoms. Multiple linear regression analyses were performed to examine the association between stigma and minority stress and depressive symptoms.

In order to test whether sexual orientation stigma has indirect effects on depressive symptoms and to define the effect of expectation of rejection, sexual orientation concealment and internalized homophobia in this interrelation, the SPSS PROCESS macro by Hayes was applied. The parallel mediation models (PROCESS Model 4) of sexual orientation stigma to depressive symptoms through expectation of rejection, sexual orientation concealment and internalized homophobia were explored respectively, where the most predominant mediator would be found. In the parallel mediation models, all the variables we analyzed were scored by sum value. The bootstrap analyses with 5000 samples and bias-corrected 95% bootstrap confidence interval (CI) were used to estimate the parameters. If the CI does not include zero, we concluded that the parameters are statistically significant.

Participants

The socio-demographic and sexual orientation of participants and the corresponding distribution of depressive symptoms are shown in Table 1. A total of 301 participants were included in the study. The participants’ mean age was 28.2 (SD = 5.5) years. The prevalence of depressive symptoms was significantly different among employment status, ethnic and age groups (P < 0.01). Among participants who aged 30 and above, there was a significantly higher proportion of depressive symptoms. Compared with minority ethnic groups and participants living with female friend, the Han people and participants living alone reported higher prevalence of depressive symptoms. Independent samples t-tests and the ANOVA results showed that age, education level, employment status and living conditions were significantly associated with the score of depressive symptoms.

Table 1

Sociodemographic characteristics of sample respondents with depressive symptoms.
Study variables	N(%)	Depressive symptoms		Depressive scores
Study variables	N(%)	n(%)		M ± SD	t/F
Age			10.008^*		3.076*
≤ 20	44(14.6)	21(47.7)		10.80 ± 7.15
21–25	116(38.5)	70(60.3)		12.12 ± 7.76
26–30	97(32.2)	46(47.4)		10.26 ± 6.41
>30	44(14.6)	32(72.7)		14.00 ± 7.85
Ethnicity			5.747^*		-0.866
Han ethnicity	283(94.0)	154(54.4)		11.51 ± 7.38
Other ethnicity	18(6.0)	15(83.3)		13.06 ± 6.88
Marital status			0.133		0.543
Unmarried	271(90.0)	153(56.3)		11.58 ± 7.29
Married	21(7.0)	11(52.4)		10.86 ± 7.74
Divorced	9(3.0)	5(55.6)		13.89 ± 8.72
Education Level			1.770		3.759*
High school or below	50(16.6)	31(62.0)		12.44 ± 7.75
College/Bachelor	223(74.1)	125(56.1)		11.86 ± 7.34
Master’s or above	28(9.3)	13(46.4)		8.07 ± 5.72
Residence			0.013		0.216
Rural	51(16.9)	29(56.9)		11.80 ± 6.68
Urban	250(83.1)	140(56.0)		11.56 ± 7.49
Employment status			4.539		5.518**
Students	72(23.9)	38(52.8)		11.10 ± 7.22
Full-time job	201(66.8)	110(54.7)		11.18 ± 7.16
Part-time job/Other	28(9.3)	21(75.0)		15.93 ± 7.87
Current living situation			18.221^***		5.178**
Living with family	93(30.9)	55(59.1)		12.31 ± 7.82
Living with female friends	67(22.3)	24(35.8)		8.85 ± 5.93
Live in dormitory	71(23.6)	40(56.3)		11.41 ± 7.37
Living alone	70(23.3)	50(71.4)		13.49 ± 7.27
Monthly income level			4.771		1.068
≤ 3000	78(25.9)	48(61.5)		12.08 ± 7.50
3001–6000	120(39.9)	72(60.0)		12.10 ± 7.27
6001–9000	64(21.3)	31(48.4)		11.11 ± 7.40
>9000	39(13.0)	18(46.2)		9.92 ± 7.19
Sexual orientation			1.056		0.981
Lesbian	245(81.4)	141(57.6)		11.80 ± 7.43
Bisexual	56(18.6)	28(50.0)		10.73 ± 6.96
Note: ^p<0.05, ^p<0.01, ^** p<0.001. N, number of participants, M, mean. SD, standard deviation.

Preliminary analyses

Results from linear regression models testing the associations between sexual orientation-related stigma, rejection expectation, sexual orientation concealment, internalized homophobia and depressive symptoms are summarized in Table 2. After adjusting for demographics, higher sexual orientation-related stigma predicted higher scores in depressive symptoms (β = 0.254, p <0.001). Accounting for demographics and sexual orientation-related stigma, rejection expectation was a significant predictor of depressive symptoms (β = 0.177, p <0.05). In addition, the regression result also indicates that education level (p < 0.05), employment status (p < 0.01) and living conditions (p < 0.001) were associated with depressive symptoms. Furthermore, the effects of sexual orientation concealment and internalized homophobia on depressive symptoms were not statistically significant.

Table 2

Effect of demographics and sexual minority stress on depressive symptoms.
	Model 1		Model 2
	β	t	β	t
Demographics
Age
≤ 20	1		1
21–25	0.112	1.205	0.062	0.667
26–30	0.008	0.076	-0.024	-0.224
>30	0.159	1.855	0.107	1.233
Ethnicity
Han ethnicity	1		1
Other ethnicity	0.058	1.068	0.069	1.289
Marital status
Unmarried	1		1
Married	-0.061	-1.100	-0.061	-1.131
Divorced	0.039	0.707	0.008	0.146
Education Level
High school or below	1		1
College/Bachelor	0.020	0.285	-0.020	-0.295
Master’s or above	-0.134	-1.892	-0.166	-2.356^*
Employment status
Full-time job	1		1
Students	-0.250	-2.304^*	-0.256	-2.397^*
Part-time job/Other	-0.230	-2.513^*	-0.243	-2.675^**
Current living situation
Living alone	1		1
Living with family	-0.105	-1.455	-0.100	-1.404
Living with female friends	-0.250	-3.671^***	-0.228	-3.379^***
Live in dormitory	-0.095	-1.193	-0.107	-1.362
Monthly income level
≤ 3000	1		1
3001–6000	-0.068	-0.801	-0.064	-0.774
6001–9000	-0.093	-1.130	-0.072	-0.894
>9000	-0.141	-1.849	-0.128	-1.702
Sexual minority stress
Distal stressors
Sexual orientation-related stigma	0.254	4.636^***	0.137	2.189^*
Proximal stressors
Rejection expectation			0.177	2.299^*
Identity concealment			0.097	1.183
Internalized homophobia			-0.038	-0.619
Note: Model 1 was adjusted for all demographics variables and distal stressors. Model 2 was adjusted for variables in model 1 and proximal stressors. ^p<0.05, ^p<0.01, ^** p<0.001.

Bivariate correlations

The correlations between sexual orientation-related stigma, rejection expectation, sexual orientation concealment, internalized homophobia and depressive symptoms are presented in Table 3. Sexual orientation-related stigma was positively correlated with rejection expectation (r = 0.485, P < 0.01), sexual orientation concealment (r = 0.462, P < 0.01), internalized homophobia (r = 0.283, P < 0.01), and depressive symptoms (r = 0.259, P < 0.01). Rejection expectation was positively correlated with sexual orientation concealment (r = 0.655, P < 0.01), internalized homophobia (r = 0.369, P < 0.01), and depressive symptoms (r = 0.313, P < 0.01). Sexual orientation concealment was positively correlated with internalized homophobia (r = 0.453, P < 0.01), and depressive symptoms (r = 0.261, P < 0.01). Internalized homophobia was positively correlated with depressive symptoms (r = 0.120, P < 0.05).

Table 3

Descriptive statistics and intercorrelations of the variables.
	Range	Mean (SD)	1	2	3	4	5
1.Sexual orientation-related stigma	10–40	15.71(4.05)	1
2.Rejection expectation	6–30	14.35(5.88)	0.485^**	1
3.Identity concealment	6–30	14.18(6.01)	0.462^**	0.655^**	1
4.Internalized homophobia	5–23	7.63(3.59)	0.283^**	0.369^**	0.453^**	1
5.Depressive symptoms	0–30	11.60(7.35)	0.259^**	0.313^**	0.261^**	0.120^*	1
Note: ^p<0.05, ^*p<0.01. SD, standard deviation.

Parallel mediation model

The total effect of sexual orientation-related stigma on depressive symptoms was significant (c = 0.136, 95%CI: 0.012, 0.260) (Fig. 1). The indirect effects of sexual orientation-related stigma on depressive symptoms were conducted using a bootstrapping analysis (Table 4). When rejection expectation was modeled as a mediator, the path coefficients of sexual orientation-related stigma on depressive symptoms revealed that rejection expectation had a significant mediating effect (a1 × b1 = 0.098, 95%CI: 0.021, 0.197). However, the mediating effect of sexual orientation concealment and internalized homophobia were not statistically significant. The parallel mediation model indicates that sexual orientation-related stigma might not only directly affect depressive symptoms but could also exert a significant indirect effect on depressive symptoms via rejection expectation. This result shows that about two-fifths of the total effect of sexual orientation-related stigma on depressive symptoms are an indirect effect through rejection expectation.

Table 4

Bootstrap test of significance of mediation effect
	Effect	Boot SE	95%CI		Relative effect
	Effect	Boot SE	LLCI	ULCI	Relative effect
Total effect	0.270	0.056	0.160	0.379
Direct effect	0.136	0.063	0.012	0.260	50.31%
Total indirect effect	0.134	0.040	0.064	0.217	49.69%
Indirect effect (X^a→Rejection expectation→Y^b)	0.098	0.044	0.021	0.197	36.30%
Indirect effect (X→Identity concealment→Y)	0.052	0.038	-0.025	0.127
Indirect effect (X→Internalized homophobia→Y)	-0.016	0.018	-0.054	0.020
Note: ^a X, sexual orientation-related stigma; ^b Y, depressive symptoms. SE, standard errors, CI, confidence intervals. LLCI, lower-level confidence intervals. ULCI, upper-level confidence intervals.

The current study has multiple aims: the first aim is to assess the influencing factors of depressive symptoms among sexual minority women; the second is to examine the association of distal stressors (i.e., sexual stigma), proximal stressors (i.e., expectations of rejection, concealment of sexual orientation, internalized homophobia) with depressive symptom; the final aim is to determine the influence of sexual stigma on depressive symptoms by considering how expectation of rejection, sexual orientation concealment and internalized homophobia mediate this relationship. Although the associations between sexual stigma and mental health are well established, there is a dearth of research on the underlying mechanisms that impact sexual stigma on mental health.

The present study demonstrated that the prevalence of depressive symptoms was 56.1% among sexual minority women, which was higher than the general female (36.9%) in China [33]. Bostwick reported that the prevalence of depressive symptoms was 38.1% for lesbians and 25.1% for bisexual in the United States [34]. In contrast with similar studies conducted in Australia, our data showed a higher CESD-10 scores than that found by Brown et al [35]. These discrepancies might be due to different measurement tools and different population sample. The presence of depressive symptoms was found to be linked with the age and living conditions of sexual minority women. Older sexual minority women had greater depressive symptoms rate. This could partly be explained by the emphasis on the continuity of bloodlines in the Chinese culture, and older women had more pressure on having children.

We found that sexual minority women living alone tend to have depressive symptoms. This may be related to the association of social support with mental health. To some extent, living with parents or friends means being accepted and supported. It has been reported repeatedly that peer support and family satisfaction was associated with depressive symptoms [36, 37]. Our study found that depressive symptoms were prevalent among sexual minority women, suggesting a strong need for mental health interventions.

The whole sample shows a significant positive association between sexual stigma and depressive symptoms. Indeed, as proposed by the minority stress model [14], discrimination and societal stigma are strong determinants of mental well-being and affective symptoms in sexual minority populations, resulting in an elevated baseline risk of mental health symptoms among both bisexual populations and their gay and lesbian peers [38]. However, some authors have suggested that individual-level sexual stigma is not associated with depressive symptoms, although there is significant variation in the association between individual stigma and depressive symptoms across clusters [39].

On the hypothesized mediated effects by proximal stressors, the findings provided support in that the association between sexual stigma and depressive symptoms was mediated by expectation of rejection, while depressive symptoms were not mediated by sexual orientation concealment and internalized homophobia. We test sexual minority women with higher levels of sexual stigma experienced more expectation of rejection, which in turn was associated with depressive symptoms. As suggested by Randolph, affective symptoms and mental health disparities among sexual minorities could also be explained by sexual orientation concealment [40]. Our findings indicated that the effects of sexual stigma on depressive symptoms are partially mediated by expectation of rejection.

There are several strengths in the present study. In particular, the focus on sexual minority women adds to the existing literature on sexual stigma and depressive symptoms by providing evidence to support the mediating effect of proximal stressors on the association between sexual stigma and depressive symptoms.

However, it also has several limitations to report. A major limitation is that this study was investigated within a particular geographic (Beijing). In addition, like most sexual minority research, our study adopted non-probability sampling. Thus, we cannot generalize to the entire sexual minority women. Furthermore, given the cross-sectional design, causal links between sexual stigma, expectation of rejection, sexual orientation concealment, internalized homophobia and depressive symptoms cannot be inferred. Although the present study was based on the empirical research on LGBT mental health, a reverse causality is also plausible because poor mental well-being may lead to internal struggles with sexual stigma. Thus, longitudinal study is needed to estimate the impact of sexual stigma on the development of depressive symptoms among sexual minority women. Finally, this study relied on self-report measures of sexual minority stress and depressive symptoms, these data may be impacted by reporting bias and social desirability.

Although the result from single research is far from conclusive, the present study provided novel evidence about the potential mediational pathways in which distal stressors influences depressive symptoms among sexual minority women, indirectly through proximal stressors. Our findings have practical implication for policy makers to understand how sexual minority stress are linked to depressive symptoms, which could provide useful insights for potential interventions. Furthermore, well-designed longitudinal studies should be conducted to estimate the longitudinal influences of sexual minority stress on depressive symptoms among sexual minorities.

LGBT: Lesbians, gay, bisexual, and transgender; US: United States; CI: Confidence interval; SD: Standard deviation; CESD: Center for epidemiologic studies depression; SE, Standard errors; CI, Confidence intervals; LLCI, Lower-level confidence intervals; ULCI, Upper-level confidence intervals.

Acknowledgements

We would like to show our gratitude to all the participants for their involvement in this survey.

Authors' Contributions

J.L.: Conceptualization, formal analysis, methodology, and writing—original draft designed. C.X.: Formal analysis methodology and writing—review and editing. M.Z.: Writing—review and editing. L.Y.: Writing—review and editing. D.L.: Writing—review and editing. X.L.: Writing—review and editing. B.Y.: Writing—review and editing. H.Y.: Supervision, conceptualization and writing—review and editing. All authors approved the final version of the article for submission.

Funding

This study was funded by the National Natural Science Foundation of China (Grant No.: 81673196).

Availability of Data and Materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Wuhan University (reference number: 2018YF0100). The study has been conducted in accordance with the Declaration of Helsinki. Prior to data collection, written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

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Sexual minority women are at greater risk of depressive symptoms: the mediation effects of minority stressors

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Method

Participants and Procedures

Measures

Demographic Characteristics

Sexual orientation-related stigma

Expectation of rejection

Sexual orientation concealment

Internalized homophobia

Depressive Symptoms

Statistical analyses

Results

Participants

Preliminary analyses

Bivariate correlations

Parallel mediation model

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

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