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. Author manuscript; available in PMC: 2023 Aug 1.
Published in final edited form as: Sex Res Social Policy. 2020 Mar 4;18(1):112–126. doi: 10.1007/s13178-020-00435-z

First comes marriage, then comes the election: Macro-level event impacts on African-American, Latina/x, and White sexual minority women

Ellen DB Riggle 1, Laurie A Drabble 2, Alicia K Matthews 3, Cindy B Veldhuis 4, Robyn A Nisi 5, Tonda L Hughes 6
PMCID: PMC10393113  NIHMSID: NIHMS1895962  PMID: 37528937

Abstract

Sexual minority women (SMW) may have different experiences of macro-level events, such as changes in marriage laws or election outcomes, related to their multiple identities. African American, Latina/x, and White identities intersect with gender/sex and sexual identity to influence experiences at the intrapersonal, interpersonal, social, and political levels of the socio-ecological environment. Participants include 100 African American, 35 Latina/x, and 164 White SMW (N = 299) in Wave 4 (2017–2019) of a longitudinal study of SMW’s health conducted in the United States (Chicago Health and Life Experiences of Women Study). Responses to nine open-ended survey questions about marriage equality and the 2016 Presidential election were examined. Thematic analysis noted similarities across groups and focused on group differences in four areas: 1) personal well-being (including fear and anxiety about discrimination; risk associated with masculine presentation; and religion as stress and support); 2) interpersonal relationships (including relationships with partners, family, and in a community); 3) societal discrimination and prejudice (including harassment in public spaces and concerns about travel); and 4) civil rights, government harassment, and police-state violence. Emerging differences emphasized the impact of race/ethnicity and the intersection of race/ethnicity and gender on experiences of marriage equality and the 2016 election. Findings suggest that a more nuanced understanding of the experiences of individuals with different racial/racialized identities and the intersection of race/ethnicity with sexual identities is essential to creating culturally competent and effective supports for SMW.

Keywords: 2016 Election, Minority Stress, Same-sex Marriage, Sexual Minority Women, Intersectionality


Sexual minority women (SMW), particularly SMW of color, are culturally and politically stigmatized on the basis of their gender/sex, gender expression (including non-traditional gender expressions), sexual identities, and intersectional identities (e.g., Ghabrial, 2017; Schmitz, Robinson, Tabler, Welch, & Rafaqut, 2019). Structural stigma involves societal, institutional, and cultural policies and norms that negatively impact opportunities and well-being (Hatzenbuehler & Link, 2014). Changes in the social-political environment, such as recent changes in U.S. marriage laws and events during and after the 2016 U.S. Presidential election, may reduce or amplify stigma on the macro, interpersonal, and individual levels (Cook, Purdie-Vaughns, Meyer, & Busch, 2014), contributing to a complex and possibly conflicting context of support and risk to the well-being of SMW (e.g., Wootton et al., 2018). In this context, political events are not discrete occurrences, but unfold in temporal sequence and are cumulative in their impacts.

Decisions by the U.S. Supreme Court related to marriage equality, resulting in marriage recognition for same-sex couples by the federal government in 2013 (United States v. Windsor, 570 U.S. 744) and in all states in 2015 (Obergefell v. Hodges, 576 U.S. _), represent important national-level events in the socio-political environment. The 2016 Presidential election, and subsequent Trump administration actions, was another political event with significant impacts on the lives of individuals in the United States. Changes in relationship recognition laws and recognition of marriages of same-sex couples have had mostly positive impacts on SMW, lesbian, gay, bisexual and transgender (LGBT) people, and same-sex couples (e.g., Everett, Hatzenbuehler, & Hughes, 2016; Tatum, 2016). The 2016 Presidential election, which occurred approximately 16 months after the U.S. Supreme Court decision legalizing marriage equality in all 50 states, has been linked to negative impacts on the well-being of SMW and LGBT people (Brown & Keller, 2018; Gonzalez, Ramirez, & Galupo, 2018; Veldhuis, Drabble, Riggle, Wootton, & Hughes, 2018) and people of color (Hagan, Sladek, Luecken, & Doane, 2018). These events, occurring in succession and in relatively close temporal proximity, resulted in a rapidly changing social and political context for SMW.

In the socio-political context of post-marriage equality where SMW remain stigmatized, and the racially stigmatizing rhetoric of the 2016 U.S. Presidential campaign and subsequent Trump Administration actions, we used data from Wave 4 (2017 – 2019) of the Chicago Health and Life Experiences of Women Study (CHLEW) to better understand SMW’s perceptions of these two events. Although there is limited research on the impact of each event separately, even less attention has been paid to the combined impact of these events on the well-being of SMW—particularly those with intersecting racial/racialized identities. By asking questions about marriage equality and the 2016 Presidential election, our primary aim was to identify overall themes describing the impact of these events and explore emerging differences among SMW who identified as Black/African American, Latina/x, and White.

Marriage Equality

Changes in state marriage laws since 2003 (when Massachusetts became the first U.S. state to recognize marriages of same-sex couples) have allowed researchers to study the impact of marriage (in)equality. Marriage equality has been found to be associated with higher levels of well-being and health among sexual minority individuals at the state level. For example, sexual minority people living in states with marriage equality reported lower levels of psychological distress, vigilance, and isolation than those living in states without marriage equality (Frost & Fingerhut, 2016; Hatzenbuehler, Keyes, & Hasin, 2009; Wight, LeBlanc, & Badgett, 2013). Ogolsky, Monk, Rice and Oswald (2018) used data collected before and after the Obergefell decision in 2015 to examine changes in well-being of people in same-sex relationships living in four states with different laws on same-sex marriage. Although there were few changes in well-being over time, those who reported higher initial levels of internalized homonegativity, vicarious trauma, or isolation also reported greater improvement in well-being after recognition of same-sex marriage. A limitation of the study was that 86% of the sample identified as White, highlighting the need for research examining the impact of recognition of marriage for same-sex couples on racial/ethnic minority individuals.

In a study using data from the 2000–2016 Centers for Disease Control’s Behavioral Risk Factor Surveillance System (BRFSS) surveys, Carpenter and colleagues (Carpenter, Eppink, Gonzales, & McKay, 2018) found a significant relationship between state-level marriage equality and increased access to insurance and use of health services among men in same-sex households (a proxy for sexual minority status). However, access to marriage did not systematically improve access to health care or health outcomes among women in same-sex households. These findings suggest that the impact of marriage legalization may differ for women and men, and underscores the importance of exploring experiences of SMW, who may be at higher risk for poor health outcomes.

Few studies have examined the impact of relationship recognition and marriage equality on sexual minority people of color. Everett, Hatzenbuehler, and Hughes (2016) found that the passage of civil union legislation in Illinois was associated with positive effects on health, with the greatest benefits for SMW of color who reported lower levels of depression and stigma consciousness after the legislation was enacted. In 2010, Lee (2018) examined lesbian, gay and bisexual people’s perceptions of the impact of same-sex marriage. Although there was no significant difference in perceptions of the potential impact of same-sex marriage between Black and White participants in the sample, results revealed that Black women had more positive perceptions of marriage recognition than Black men. Lee suggested this might be related to the potential for economic stabilizing effects of marriage for Black SMW who face more economic disadvantages than gay men, White individuals, and heterosexual women.

The meaning and perceived impact of same-sex marriage legalization may differ between sexual minority people of color and their White counterparts. Moore (2018) suggested that marriage equality may have created opportunities for connections and communication between LGBT people and their families and communities, and this changed dynamic may have been particularly impactful for LGBT people of color. At the same time, the prioritized focus on legalized marriage for same-sex couples may be perceived less positively among sexual and gender minorities who remain disadvantaged by other social and economic inequities (DeFilippis, 2016). For example, a majority of 102 Black LGBT participants in a qualitative study perceived the centrality of same-sex marriage in the LGBT movement as protecting the economic interests of White lesbian women and gay men, and neglecting Black and Latinx community priorities (McGuffey, 2018). Financial insecurity, barriers to health care access, and employment discrimination remain important concerns for SMW generally, and especially SMW of color (DeFilippis, 2016; Moodie-Mills, 2012).

2016 Presidential Election

Findings from several studies suggest that the 2016 Presidential election and subsequent Trump Administration actions have had a significant negative impact on the health and well-being of LGBT people in the United States. A Gallup poll conducted in December 2016 found that LGBT adults, but not non-LGBT adults, reported a substantial decline in perceptions that they are “thriving” (Gates, 2017). Several other surveys measuring the effects of the 2016 election have found high levels of stress, distress, and concerns about increased violence, hate crimes, and safety among LGBT participants (Brown, & Keller, 2018; Veldhuis, Drabble, Riggle, Wootton, & Hughes, 2018a; Veldhuis, Drabble, Riggle, Wootton, & Hughes, 2018b). In a study using daily diary methods with lesbian women and gay men, Garrison, Doane, and Elliott (2018) compared data from the day before the election and the day after the election. There were significant increases in reports of multiple negative psychological and sexual-identity related outcomes such as depression, anxiety, stress, discrimination, and identity concealment, as well as increases in physical illness and self-reported poor physical health. A retrospective study (Gonzalez, Ramirez, & Galupo, 2018), in which participants rated statements based on their perceptions before and after the 2016 election, found that LGBTQ people reported experiencing higher levels of sexual minority-related distress, vicarious trauma, victimization, vigilance, and rumination after the election.

Findings suggesting increased risks and vulnerabilities following the 2016 election for sexual minority individuals (based on predominately White samples) may also extend to people of color. A survey by the American Psychological Association (American Psychological Association, 2017) found that Blacks (69%), Asians (57%), and Hispanics (56%) were more likely to report the 2016 presidential election outcome as a significant source of stress than non-Hispanic Whites (42%) (sexual identity was not assessed in the survey). Williams and Medlock (2017) suggest that the election and increased racial hostility at all levels of the socio-political environment may negatively impact the mental and physical health of racial minority individuals.

A study of 769 college students conducted two to three months after the 2016 election found that non-Hispanic White students reported significantly less election-related stress than African American, Asian American, and Hispanic/Latino students; heterosexual students reported less stress than sexual minority students; and men reported less stress than women (Hagan, Sladek, Luecken, & Doane, 2018). Although race was not a significant predictor of election-related stress after controlling for sex, political party, religion, and perceived impact of the election on relationships (sexual identity was not included in the multivariate analyses), findings suggest the need for further research on intersectional identities of race/ethnicity and gender/sex.

A qualitative study (Veldhuis et al., 2018b) found that SMW reported distress after the 2016 election due to fears of the rollback of rights (e.g., marriage equality, the Affordable Care Act), and increases in experiences of witnessing and hearing about violence, hate crimes, stigma, and discrimination toward LGBT and other minority groups. LGBT individuals reported concerns about the effects of the election on their relationships, particularly relationships with families-of-origin (Gonzalez, Pulice-Farrow, & Galupo, 2018). Lannutti (2018) examined how fears that the right to marry and other rights for LGBT people (such as adoption-related rights and healthcare benefits) might be rescinded influenced same-sex couples’ decisions about whether to marry after the 2016 election.

Current Study

The political context in which the current study was conducted included on-going court cases and legislative debates on LGBT rights and marriage equality, and Trump Administration actions related to LGBT rights and other issues (such as immigration), many of which disproportionately impacted people of color. For example, the Trump Administration created and enforced policies which made immigration to the United States more difficult, disproportionately impacting people of color, including LGBT Latinx individuals. Police shootings of unarmed Black people and other occurrences of police abuse were covered in the national news during the data collection period, an issue which also disproportionately impacts LGBTS people. For example, the National Coalition of Anti-Violence Programs (2014) reported that “Black survivors of hate violence were 1.3 times more likely to experience police violence than their non-Black counterparts” and LGBT people are more likely to report negative or abusive encounters with the police. Other events, such as the Pulse nightclub massacre which killed 49 people and wounded 53 others during “Latin night” at an LGBT nightclub in Orlando Florida, took place after the U.S. Supreme Court decision legalizing marriage and shortly before the 2016 general election (Ramirez, Gonzalez, & Galupo, 2018).

Literature to date has focused on the discrete events of marriage equality or the 2016 election. To add to understanding of how macro-level political events impact SMW with racial minority/racialized identities, SMW who were part of a longitudinal study of SMW’s health (Wave 4 of the CHLEW study) were asked to respond to questions about marriage legalization and the 2016 election. Sexual minority women of color are under-represented in LGBT research and the LGBT literature generally (e.g., Coulter, Kenst, & Bowen, 2014). Given disparities and racialized politics, it is important to understand the impacts of political events on specific racial/racialized groups to avoid overgeneralizing to “people of color,” especially among SMW. The current study used narrative thematic analysis to understand the impact of these events, within the socio-political context, by comparing grouped narratives for Black/African American, Latina/x, and White SMW.

Method

Participants

Data are from the fourth wave (2017–19) of the CHLEW study, a 20-year longitudinal study of SMW’s health. The baseline sample was recruited in the greater Chicago (IL, USA) Metropolitan area using a broad range of recruitment strategies (e.g., listservs, local media, flyers in bookstores and businesses) to solicit participation by English-speaking lesbian identified women age 18 and over. The baseline (Wave 1) sample included 436 lesbian and 11 bisexual women. Follow-up interviews were conducted in 2003–05 (Wave 2) and in 2010–12 (Wave 3). In Wave 3, a supplemental sample of younger women (ages 18–25), Black/African American and Hispanic/Latina/x women, and bisexual-identified women was recruited (n = 370). All participants when initially recruited identified as “women.” However, there is a range of gender expression, including feminine, masculine, and non-binary/gender non-conforming.

Data for the current study are from Wave 4 and include responses to open-ended questions in a separate online survey. The online Qualtrics-based survey was designed to understand study participants’ perceptions regarding the national legalization of same-sex marriage and the 2016 Presidential election. Data analysis focused on responses to nine open-ended questions of the subgroup of participants (n = 308) who completed the survey between April 2017 and July 2018.

We obtained demographic information (age and race/ethnicity) from the separate Wave 4 interview data. Of the 308 participants who completed the online survey during the study timeframe, 100 identified as African American (or Black), 35 as Latina/x (or Hispanic), 164 as White, and 9 indicated other or multiple racial/ethnic identities. The nine participants who indicated multiple or other racial identities were excluded from the analysis, resulting in a final sample of N = 299.

Participants ranged in age from 24- to 80-years old. Latina/x participants were younger than African American and White participants (mean age 44 versus 50 years), slightly less likely to identify as lesbian and more likely to endorse “other” sexual identity, more likely to live in Illinois, and most likely to be single. African American participants were least likely to have a professional degree. The mean household income for Latina/x and African American participants was $30,000-$34,999, substantially less than White participants’ mean household income of $75,000-$99,999. White participants were most likely to have obtained a graduate or professional degree, and more likely (more than one-third) to have moved away from Chicago (IL) or out of Illinois where they were initially recruited for the study. White participants were more likely to be married and least likely to be single/dating (see Table 1 for demographic information).

Table 1.

Sample demographics for African American, Latina/x, and White participants

African American/Black (n = 100) Latina/x/Hispanic (n = 35) White (n = 164)
Mean Age in Years (SD); Range 50(12); 26–76 44(13); 26–61 50(14); 24–80
Sexual Orientation/Identity (%)
 Lesbian 71 (71%) 23 (66%) 123 (75%)
 Bisexual 18 (18%) 4 (11%) 24 (15%)
 Other 11 (11%) 8 (23%) 17 (10%)
Gender Identity (%)
 Female 97 (97%) 32 (91%) 152 (93%)
 Trans 0 0 4 (2%)
 Other 3 (3%) 3 (9%) 8 (5%)
Residence (%)
 Illinois 84 (84%) 32 (91%) 105 (64%)
 Other state 16 (16%) 3 (9%) 59 (36%)
Residence (%)
 Chicago or other large city 65 (65%) 24 (69%) 85 (52%)
 Suburbs 25 (25%) 5 (14%) 41 (25%)
 Other 10 (10%) 6 (17%) 38 (23%)
Relationship Status (%)
 Married 17 (17%) 4 (11%) 63 (38%)
 Committed with partner 32 (32%) 10 (29%) 56 (34%)
 Dating or Single 50 (50%) 21 (60%) 45 (27%)
Education Level (%)
 High School 14 (14%) 6 (17%) 3 (2%)
 Some College 36 (36%) 11 (31%) 23 (14%)
 College BA/BS 26 (26%) 8 (23%) 41 (25%)
 Professional degree 19 (19%) 10 (29%) 94 (57%)
Mean Household Income Range $30,000 to $34,999 $30,000 to $34,999 $75,000 to $99,999

Procedure

A link to the online survey was included in an email confirmation of participants’ interview appointment date and time for Wave 4 of the CHLEW study. We included a reminder to complete the online survey at the end of the phone interview. In addition, reminders were periodically sent to participants who had completed the phone interview but not the online survey. Participants (n = 25) who did not have access to the internet or preferred not to complete the survey online were administered the survey by phone.

Participants read and provided informed consent prior to beginning the on-line survey. The procedure and survey were approved by the institutional review board at the University of Illinois-Chicago.

Open-ended Questions

Participants were asked to respond to open-ended questions about their perceptions and experiences after the U.S. Supreme Court ruled state refusal to recognize the marriages of same-sex couples unconstitutional. These questions asked participants to share their experiences of how marriage equality had impacted them: 1) personally (the way they felt about themselves and their sexual/gender identity, including any effects on physical health and well-being); 2) in disclosure and expression of their sexual and gender identity; 3) in relationships with intimate partners; 4) in relationships with others (family, friends, neighbors, co-workers); and 5) in encounters with prejudice or discrimination. The survey also asked a series of questions about the 2016 election and the impact of the Trump administration: 6) the impact of the Trump administration on their own sense of safety, and sense of safety and well-being of others; 7) the impact of policies on their relationships with family and others; 8) the impact of actual or proposed laws and policies on their perceptions of their future; and 9) their thoughts about the current political and social environment in the United States.

Analysis

Responses to all open-ended questions were included as one case for each participant. Cases were sorted by race/ethnicity. The first and second authors read all responses from African American participants as one group narrative, Latina/x participants as a second group narrative, and White participants as a third group narrative. During the separate initial reading, notes were made by the two authors to indicate preliminary thematic meanings, noting similarities and differences across individual responses within groups. A modified constant comparison approach was used to create a narrative summary for each group (Braun & Clarke, 2006). Similar meanings across more than one theme or sub-themes are acceptable within thematic coding schemes (Clarke & Braun, 2013; see also Hill, Knox, Thompson, Williams, Hess, & Ladany, 2005).

The two authors compared and discussed their notes to reach consensus on a group narrative for each of the three groups. Consensus was reached for the themes for each group and a narrative that included the diversity of responses within each group. The thematic narratives were then compared across groups and narrative notes highlighted similarities and differences across the groups. The third author then read the thematic summaries, original data, and narrative notes as a check on data adequacy, perspective management in analysis, groundedness, contextualization of the data, and coherence of the results (see Levitt et al., 2018 for a discussion of fidelity and utility in qualitative research). Discussion of differences in interpretation and possible analytic biases led to consensus on the narratives with a specific focus on differences among the groups. A final reading of the cases was performed to confirm the results.

The authors include five individuals who identify as White and one who identifies as African American. Five of the authors have lived in the greater Chicago area or Illinois. Individual authors identify as lesbian, bisexual, queer, and heterosexual; cisgender, non-binary, and gender non-conforming. The authors cross-checked with each other to examine possible biases in the examination and understanding of narratives provided by participants, including reflexive discussions and peer debriefing (Creswell & Poth, 2017).

Results

There were many narrative similarities across the groups, but differences (the primary focus of the present study) emerged within four thematic areas. Group differences presented thematically at different socio-ecological levels – individual, interpersonal, societal, and political (macro). Four thematic areas were organized using this framework and sub-themes illustrate different concerns within each level. Sub-themes sometimes reflected similar concerns that were present across two or more levels but had meaning or impact specific to participants’ lived experience at that level of the analysis.

Differences among groups often reflected a coherent narrative of the cumulative effects of responses to the succession of events— marriage equality then the election. Some differences, however, focused specifically on the election outcome. The four primary thematic areas were: 1) personal well-being; 2) conflicts and interactions in interpersonal relationships and with extended social networks; 3) societal discrimination and prejudice; and 4) civil rights, government harassment, and police-state violence.

The most common narrative arc among participants in all groups was an expression of feeling happy about marriage equality (either in general or specific to their own marriage), mixed with general fear and anxiety after the election. For example, narratives across groups often reflected a contrast between descriptions of increased security and access to legal and health benefits as a result of marriage legalization and profound concerns about potential loss of rights and supports (such as health care insurance) after the election. Some participants in each of the groups stated that they perceived no impact of marriage equality on their lives (most of these participants had married prior to the U.S. Supreme Court decision, had been open about their sexual orientation and in a relationship for decades, or were not currently in a relationship), but also reported significant negative impact following the election. Only a few participants described perceiving little or no impact of either marriage equality or the election.

The four thematic areas presented below are illustrated with quotes from participants to enhance groundedness.

Personal Well-Being

A common narrative theme was feelings of greater well-being, visibility, and legitimacy of relationships after marriage equality. This was followed by feelings of decreased well-being (including increased fear and anxiety), including for some feeling the need to “hide” or be less visible after the election. However, there were differences in the content of the narrative themes across groups.

Fear and decreased well-being.

African American participants reported increased fears about their safety after the election, including within their own neighborhoods. A 39-year-old African American bisexual woman living in Chicago noted, “I feel significantly less safe since the election,” and a 60-year-old African American lesbian woman wrote, “I live in Chicago, I am VERY concerned about my safety and well-being.” These feelings were mostly unrelated to marriage equality (except in cases where participants felt “visible” because of gender non-conforming or masculine appearance, or the masculine appearance of their partner, and at risk for “backlash” prejudice after marriage equality, as discussed below) and were often linked to descriptions of the larger context of ongoing racism, segregation, lack of economic opportunity, and discrimination experienced by African Americans. Fears were exacerbated following the election outcome by the perception that the Trump administration condones violence and hatred toward African American individuals and the African American community. For example, one African American participant summarized her feeling after the election as, “I have never felt safe, though I do feel less safe than before [the election].” Another African American lesbian woman (age 62) explained,

I am emotionally cognizant of being extra watchful in public of anyone who looks like he might want to harm us. I do believe this has more to do with the Trump administration than the passing of marriage equality. Trump has made it okay to act out one’s hatred of other. As a lesbian and African American, I am watchful when in public. My anxiety is often high when I consider how policies and laws are being used to advance bigoted beliefs and behaviors.

Latina/x participants also reported a significant decrease in perceptions of personal safety, often in direct connection to the prejudicial actions of others and the government. A 35-year-old Latina/x lesbian woman offered,

Immediately after the election I felt an increased fear for my safety and safety of others within the LGBTQ community and my personal circle. My community and I started looking into Self Defense classes. I think I’m much more aware of my surroundings than ever before especially around male, white heterosexuals.

Some Latina/x SMW reported “passing” as White and/or heterosexual/straight and thus feeling less at risk than others of being harassed or attacked because of their Latinx identity. Others reported fear for their safety because of Trump’s rhetoric legitimizing anti-Latinx hate. A 56-year-old lesbian woman wrote. I don’t feel safe as a woman,

I don’t feel safe as a Hispanic, and I am a citizen. I don’t feel safe being a lesbian. I have already seen how people have reacted - they are showing their true colors…. I have noticed that people now are more open in expressing their feelings against people and not even in a manner about their sexuality but also because I’m Hispanic and you can see that more openly.

Some White participants also reported increased fear for their personal safety after the election. Narratives offered by White participants often began with feeling increased well-being and social support because of marriage equality, but then focused on decreases in well-being and more negative emotions experienced after the election. A 32-year-old White lesbian woman discussed her fear and anxiety after the election. The main type of prejudice I experience is street harassment. I’ve been experiencing a lot of anxiety,

I have witnessed and heard about more aggressive, blatant, and public discrimination against openly LGBT people I know. I no longer feel safe or comfortable at family gatherings. I am much more concerned about my safety when I am out in public. I am afraid to go out alone at night due to the overall increase in violence and harassment that I have witnessed or heard about.

Some White SMW expressed concerns for their safety unrelated to their race and acknowledged their privileged status as a White person. Several participants also expressed concerns about partners and friends who had non-White racial/ethnic identities and other minority groups being at risk. A 43-year-old White lesbian woman shared,

Although I am a white upper/middle class woman with loads of privileges, I question my safety more now, and I know my wife, who is an Asian American immigrant and more masculine-presenting, feels much less safe. … I worry about my friends of color especially (including my wife) and about LGBTQ people who are more vulnerable than I am. I worry about LGBTQ people and people of color and immigrants and Muslims being harassed, discriminated against, and feeling delegitimized.

Masculine presentation.

One theme related to perceptions of risk was gender non-conforming presentation, specifically “masculine” presenting participants or those with masculine presenting partners. Masculine gender presentation was perceived to be a risk after the marriage equality decision as a result of sexual identity or a same-sex relationship being more visible because of public awareness. There was a perception that marriage equality made same-sex couples and lesbian women more visible in public, and this visibility was exacerbated by racist and homophobic rhetoric of the 2016 election. Perceptions of risk seemed to increase after the election with rhetoric legitimizing of hate crimes against LGBT people. One Latina/x lesbian woman reported that she was questioned at times in public restrooms even though she did not consider herself to be “masculine.” Several White participants wrote that they dressed as “soft butch” or were otherwise visibly masculine presenting and were harassed in public restrooms. A 55-year-old White lesbian woman noted that after the election, “I do get questioned about bathroom use sometimes, as I present pretty masculine. This seems to happen more often now.”

The issue of masculine presentation was especially salient for African American women because of stereotypes of Black men as predatory. Masculine presenting African American women perceived they were more visible as a sexual minority person and thus more vulnerable to both racial and sexual minority prejudice, or were seen as Black men. Masculine presenting African American women reported that they were sometimes mis-gendered as Black men and thus seen as a “threat,” especially by White people. For example, a 54-year-old lesbian woman who lives with her partner in a committed relationship, shared her experience:

I think I have experienced instances of prejudice because of my gender presentation (masculine) and race (African American). When combined I have experienced the particular jeopardy of being seen as a predatory black male. When out socially with my wife, I’ve been read as a black man married to a white woman, and that has brought a few negative reactions (negative looks in passing from presumably straight people who had issue with racial mixing and derogatory remarks from other gay and lesbian people who thought we were trespassing while in LGBT spaces). I feel less safe; more stressed; and disappointed socially that the current backwards - looking administration was elected. My past experiences at the intersections of race, sex and gender make me feel as if I and people like me are in the cross-hairs.

Religion as a source of support or stress.

African American participants were more likely to discuss their faith in God or religion as part of their worldview and a source of strength following the 2016 election. A 62-year-old African American bisexual woman suggested “praying more and trusting in God” as a way of coping with the impact of the election. A 50-year-old African American lesbian woman offered,

Thank God, I have a God of Understanding to Trust in!! Now, as this current president rushes to tear down all positive laws that were in place prior to him getting in office, it takes away sense of safety, I place all my future in the hands of God! [My] belief in Jesus the Christ, has brought me to a place of calmness, because I know, whatever happens, God knows all about it!

Religion or spirituality was sometimes described by White participants as a source of prejudice and stress, and sometimes as a source of support for doing social good and pursuing social justice. For example, a 68-year-old White lesbian woman reported, “I am concerned that religions and religious people are being given carte blanche to discriminate against LGBTQ individuals. And this is being called religious freedom.” Other participants found support in their church community for engaging in social justice. A 64-year-old White lesbian woman commented,

I feel empowered by the church I attend. I do not think of myself as a religious or even a spiritual person, but I am very thankful that I have such a community in my life. My church is currently housing an immigrant family. A member of that family has been detained in Texas and has been forcibly separated from her family.

Interpersonal Relationships and Extended Social Network Interactions

Experiencing conflict—about marriage equality and the election—in interpersonal relationships with close family and friends, or interactions with individuals in extended social networks such as co-workers, or people in the community, was a common theme across all groups. However, there were some differences in the types of conflict and interactions described.

Family and other interpersonal interactions.

African American participants reported experiencing little conflict over marriage equality and no conflict over the election outcome with family or close others. Some African American participants noted that marriage equality made it “easier for family and friends” to accept their same-sex relationship, although a few still had “silent” or “disapproving” family members. No African American participant explicitly reported having a family member who supported Trump. However, some African American participants reported seeing signs supporting Trump or symbols of white supremacy in their neighborhoods, and having co-workers who openly supported Trump. For example, a 53-year-old African American lesbian woman reported, “I live across the street from a white male and his family who fly the Confederate flag daily. Other neighbors have them too. Confederate flags help me determine who I should or should not get close to.”

Some Latina/x participants experienced interpersonal conflict within their family (often religious family members) concerning marriage equality, and with Republican family members during and after the election. A 27-year-old Latina/x bisexual woman noted, “cultural stigma [against same-sex marriage] still affects the level to which my family accepts me.” A 51-year-old Latina/x lesbian woman reported the impact of marriage equality on a familial relationship,

It put a huge wedge between my sister and I the most. She posted her anti marriage equality sermon on facebook, so I immediately unfriended her. We haven’t discussed it. It created more distance between my evangelical Christian family members and I. Left my home church due to new Pastor being anti marriage equality.

Latina/x participants also experienced conflict with family and in the workplace after the election. A 51-year-old Latina/x bisexual woman reported distancing herself after being, “shocked to learn of some of my family and friends are Trump supporters.” A 58-year-old Latina/x lesbian woman shared,

My brother is a strong Trump supporter. Trump has created a huge divide in our family. At work I realized that all the white men at work voted for Trump and hold his viewpoints. This frightens me and keeps my association with them very limited. Many of the foreigners in my workplace have experienced more discrimination this year than in all their time in the USA.

White participants experienced conflict with religiously conservative family members related to marriage equality and with Republican family members related to the election. A 37-year-old White bisexual woman explained the cumulative impact of the two events, “My parents and extended family are Trump voters who are still hoping to somehow get marriage equality reversed, so I can’t stand to talk to them.”

A few White participants reported experiencing conflict within a relationship because their partner supported Trump. For example, a married 39-year-old White lesbian woman reported,

My wife is a Republican and voted for Trump. I am a Democrat and voted for Clinton. This caused a great deal of tension in our relationship including many arguments. The day after the election we finally agreed to not discuss any politics for the next 4 years.

A few White participants reported they were Republicans who supported Trump, causing tensions with the LGBT community or friends. A 44-year-old White lesbian woman who lives with her partner of 15 years reported that marriage equality “was never important to me” and “not necessary.” She elaborated on her experience of the election,

I had MANY friends who were literally angry at me over my support of Trump so I stopped interacting with people, stopped putting myself in social situations (dinner parties) where I was the only conservative in the room. It has been isolating, but I believe in my conviction so am staying the course. My partner and I have had many arguments about politics since last summer and have resolved to just not talk about anything political. But I am treated as the outcast because I do not express fear and anxiety about our future. I feel safer now more than ever after the election because it means the end to a biased Department of Justice, better support of law enforcement. I was discriminated against because I supported Trump.

Societal Discrimination and Prejudice

Although many participants expressed a general increase in feelings of social acceptance following marriage equality, this was often followed by anticipation or experiences of increased discrimination and the legitimation of social prejudice following the election. Fears and experiences of prejudice, discrimination, harassment, and hate were often related to race first for African American and Latina/x SMW participants, then to gender/sex or sexual identity; White participants discussed prejudice related to their gender/sex or sexual identity (sometimes simultaneously acknowledging their White privilege). Concerns about safety while traveling emerged across narratives for all groups, and the perceived need for vigilance was particularly prominent in narratives of African American and Latinx participants.

Race and gender/sex.

Many African American participants perceived prejudice and hate as targeting them often first because of their race, then in their intersectional identity as a “Black woman.” Their sexual identity was often listed last among risks for experiencing prejudice. African American participants reported experiencing blatantly racist statements and hate crimes. The election caused significant concerns because it was perceived to have empowered people (especially White people) to openly express racism and anti-black prejudice. A 63-year-old African American lesbian woman explained her feelings:

My safety concerns are rooted in the fact that I am African American, more so than the fact that I am lesbian. I do believe, however, that people who are racists are also likely to be homophobic. So, I guess the short answer is, I feel race trumps (no pun intended) sexual orientation when it comes discrimination and its attendant acts of violence.

Other African American participants referred specifically to the discrimination they faced as a “woman of color” or a “Black woman.” A 45-year-old African American participant noted, “the discrimination I face is based on race and sex” and not sexual identity. Another African American participant, age 30, reported, “As a black woman I felt alienated and ignored, as black women have always felt in this country. I have a triple minority – black, woman, and gay.”

While some Latina/x participants reported not being targeted in public spaces specifically for their race because they were perceived as or “passed” for White, the more common narrative was being fearful of or experiencing anti-Latinx prejudice in public spaces. Many felt they were seen first as Latina/x and targeted for discrimination on that basis because of the prejudicial rhetoric of the Trump campaign and administration. One Latina/x participant offered an assessment of the impact of the 2016 election of Trump: “Concern for my safety is at an all-time high. It is like his policies are attacking every part of my identities, as if they are illegitimate.” Another participant, a 56-year-old lesbian woman, reported,

I don’t feel safe as a woman. I don’t feel safe as a Hispanic [which you can see more openly] and I am a citizen. I don’t feel safe being a lesbian. I don’t have a sense of security. A White man in a van harassed me for being female and Hispanic.

Public stereotype-based harassment and prejudice was perceived to be a direct result of Trump’s anti-immigrant and anti-Latinx rhetoric and actions. A 61-year-old Latina/x lesbian woman shared,

I have a Hispanic last name. I felt over the years biased opinions made based on this, both good and bad. Trump made sure that in talking how bad, and dirty Mexicans are that it just brings more hate speech toward me.

Participants also reported experiencing comments mimicking the racist rhetoric of Trump, as one Latina/x participant reported, “People keep telling me to go back to my country. This is the country I was born in. This is the country I served. This is my country.”

No White respondent described perceptions of prejudice on the basis of their race. They were more likely to report being targeted for harassment or prejudice based on their gender/sex and their sexual identity. While few reported negative social interactions because of marriage equality, Trump’s election was perceived to legitimize harassment of women and discrimination against women generally. A 55-year-old White bisexual woman observed simply, “Still experience harassment just because I’m a woman.”

Travel concerns.

Members of each of the three groups expressed a fear of traveling (within their locale or to different locales), although for different reasons. The majority of participants lived in northern or Midwestern states (most lived in Illinois) and large metropolitan areas (mostly Chicago). Many African American participants expressed fear of traveling to the southern United States and to rural areas, which were perceived as more conservative and racist, especially after the 2016 election, and to hold greater risk of confrontation, discrimination, and violence. Marriage equality was perceived by a few participants as increasing their visibility as sexual minorities and therefore their risk of experiencing prejudice. A 51-year-old lesbian woman, married for three years, explained that it was “hard to know” the reason for the prejudice she experienced,

As an African American woman, they may be responding to my race or my marriage status. Hard to know what sets someone off. Since June 2015, I have felt more discrimination due to race particularly when we did a road trip to the south. When my wife and I travel outside an urban area we tend not to show [public displays of affection], discuss our status, etc. Too risky. I feel I have to be more vigilant in protecting myself and being aware of safety for others. The current climate has made it permissible for people to not be civil.

For Latina/x participants, concerns about travel were often linked to the possibility of government harassment or being detained by ICE, as described in the section below, where they lived or if they traveled to another locale.

White participants also expressed fears of traveling to states that they perceived as conservative and prejudiced after the marriage equality decision. These fears focused on visibility of a relationship and backlash after marriage equality. A 46-year-old White lesbian woman explained,

In my job, I travel a lot across the USA. Going to the southern states to visit customers and prospects, life is different down there and I don’t trust some of the people I meet based on how freely they speak of people that are different from them, so I keep my opinions to myself and don’t volunteer information about my personal life. Regardless of this marriage law, it won’t protect me when I am on the road, traveling alone.

Civil Rights, Government Harassment, and Police-State Violence

Across all groups, there was a commonly expressed fear that marriage equality would be interfered with by the Trump administration or taken away by the U.S. Supreme Court if Trump had the opportunity to nominate Supreme Court justices. All groups were also concerned about the erosion of civil rights in general, feeling that significant progress in LGBT civil rights and protections against discrimination based on race/ethnicity made under the Obama administration would be rolled back during the Trump administration.

Civil rights.

One common narrative arc began with feeling happy about or at least supportive of marriage equality, then expressing fears that advocacy efforts focused solely on marriage equality neglected to address other important issues. African American participants were likely to cite the U.S. Supreme Court decision limiting federal government oversight of voting practices under the Voting Rights Act of 1965 (Shelby County v. Holder, 570 U.S. 529, 2013) as a critical roll-back of rights that should be an important political issue but was overshadowed by the marriage equality decision (U.S. v Windsor, 570 U.S. 744, 2013) issued at the same time. A 38-year-old African American lesbian woman offered, “shortly after the SCOTUS marriage equality ruling, the Voting Rights Act was gutted, which reminded me that though one part of my identity was being validated, another (as a person of color), was not.”

Beyond the narrative juxtaposition of marriage equality and the Voting Rights Act, African American SMW frequently expressed concerns about ways that advocacy and narratives around marriage equality failed to recognize other important civil rights issues, particularly after the election. For example, a 42-year-old African American lesbian woman offered,

I get frustrated with people relying on marriage laws as the only marker of LGBT progress, because we are still more likely to be poorer and we still experience discrimination. In the end, the right to marry did not solve problems for racial minorities.

Although African American participants expressed support for marriage equality and the gains made in LGBT rights, deep concerns about ongoing threats to the civil rights and well-being of women of color were reflected in narrative references to going “back to the 1950’s segregation and violence against those advocating on behalf of civil rights.” As a 51-year-old African American lesbian woman shared, “I feel that this country is trying to go back in time to the days of Jim Crow laws.” A 63-year-old African American lesbian woman noted, “I am still disappointed at how marriage equality still does not encompass most struggles for women of color, and specifically, Black women.”

Government harassment and police-state violence.

All groups described concerns about government harassment and possible violence by state actors (e.g., the police, immigration enforcement personnel, government officials). These worries were expressed exclusively in relation to the election outcome with different foci across the groups. A common narrative of African American participants was the explicit expression of concerns about racial discrimination and violence against Black people by government officials – especially police shootings, violence, and harassment -- before and continuing or increasing after the 2016 election. Although Black participants expressed concerns about discrimination against all minority groups, the group narrative included deep fears and concerns about violence against Black people, especially Black men and boys, and the increased risk for all Black children. A 67-year-old African American lesbian woman summed up these concerns,

The current climate of blatant hatred, supported by Trump, combined with the police killings of black people, makes me feel like I have a target on my back. I fear for my sons and grandsons, and for all non-white people in this country.

Among Latina/x participants the primary narrative focus of concern was on the activities of ICE (the U.S. Immigration and Customs Enforcement division of the Department of Homeland Security). These concerns increased and became more intense following the 2016 election and policy changes implemented or threatened by the Trump administration. Participants were concerned for their own safety, such as being placed in ICE detention or targeted for harassment by ICE, even though they were U.S. citizens. A 35-year-old Latina/x lesbian woman explained, “Anti-immigration policies are affecting my community and as a brown person I am afraid it will spur hate towards my family and myself even though we are citizens.”

Latina/x SMW often described being afraid to leave their homes because of fears of being stopped by ICE, imprisoned, and separated from their family. A 29-year-old Latinx participant explained, “I suffer from anxiety attacks to where I don’t leave the house because I might get mis-gendered on the street to where I can be stopped by ICE or the cops for being Brown and trans.” Other Latina/x participants worried about their family members, even those who were U.S. citizens. For example, one Latina/x participant reported that her mother is so frightened after the election that,

“she had me get her a US passport so she can carry it with her should ICE decide to grab her. My uncle is also fearful because he can’t find proof he is a citizen. We’re still looking for his passport and documentation.”

White participants’ concerns about government harassment and police-state violence focused mostly on impact on other groups. White participants expressed fears about violent and repressive government action against LGBT people, people of color, and Muslims, some likening the Trump administration actions to “Nazi Germany” or a “fascist state.” For example, a 73-year-old White lesbian woman shared,

I’m frankly scared to death; maybe because we have a president who thinks that neo-Nazis, klansmen, and skinheads are fine people, and has bragged on TV about committing sexual assault. Maybe it’s because the head of the EPA worked for the coal industry, or the head of the education department has no experience with public education, and the head of the housing department doesn’t believe in public housing. Not to mention a congress who is willing to take food from the mouths of children, elderly and handicapped to fund tax breaks for people who need it the least.

Discussion

Our analyses focused on differences among African American, Latina/x, and White sexual minority women’s reactions to marriage equality and the 2016 election. Results of the thematic analysis provide a more nuanced understanding of the impact of these events on SMW of different races/ethnicities. The results highlight the importance of considering multiple intersecting minority identities (including gender/sex, gender expression, and race/ethnicity) when assessing reactions to, impacts of, and risks associated with macro-level (political, cultural, and social) events (see Ghabrial, 2017 for a discussion of simultaneity of oppressions for LGBTQ-POC).

Although we observed many similarities across the three groups, important differences emerged. Race-based discrimination was a ubiquitous experience for African American and Latina/x SMW in the sample. While many African American and Latina/x participants perceived increased support (or at least not active opposition) of their relationships and sexual identity within their communities after marriage equality, the political environment during and after the election was perceived as actively hostile toward their communities. Many SMW of color reported perceptions that they were targeted by others because of their race first. Some African American participants did not separate their race and gender/sex, referring to their position and status as “Black women.” Sexual identity was often mentioned last in descriptions of discrimination and prejudice, presumably because race/ethnicity and gender/sex are more visible.

For Latina/x participants, open hostility from others (often specifically White people) was a stressor that increased during and after the election. Fear of government discrimination and deportation, even for Latina/x SMW who were U.S. citizens, was commonly reported. Fear for self and family in this political context was also commonly reported as was its impact on sense of safety and well-being.

Visibility based on gender appearance or expression was perceived by masculine presenting participants as a risk for harassment, especially among African American SMW (see also Everett, Steele, Matthews, & Hughes, 2019). Perception of masculine presenting African American SMW – being mis-gendered as “Black men” -- was associated with experiences of being perceived as “predators.” The so-called “bathroom bills” were also referenced by participants in all groups as influencing social perceptions of their presence in public restrooms and hostility towards them in those spaces. Participants perceived that such hostility increased under the Trump administration’s roll-back of the rights of transgender people to use gender appropriate restroom facilities.

There were thematic similarities across groups consistent with findings in previous research on the impact of marriage equality, such as an increased sense of security or legitimacy of relationships (e.g., Lannutti, 2018; Riggle et al., 2018), and the impact of the 2016 election, such as increased fear and anxiety (e.g., Drabble et al., 2018; Veldhuis et al., 2018). However, findings from the current study highlight the importance of including sufficient representation of racial/racialized groups to understand the full range of impacts of macro-level events, especially under conditions of structural racism. Although different racial/ethnic groups may experience similar levels of anxiety and fear, the reasons may differ substantively [see for example, Shangani and colleague’s (2019) study of how minority stress in sexual minority adults has different impacts based on race/ethnicity and socioeconomic status].

Interactions in communities and families within the larger cultural/socio-political environment may also differ across racial/racialized groups and provide different levels of support or stress (c.f., Swendener & Woodell, 2017). For example, no African American participant reported that someone in their family voted for Trump and there appeared to be little family conflict related to marriage equality. However, some Latina/x and White participants reported that family members voted for Trump. These findings contradict rhetoric of higher rates of homophobia in African American communities and align with emerging research calling for a more nuanced analysis of factors that influence support for LGBT civil rights. They also suggest that African American communities may have become more supportive of marriage equality after President Obama announced his support (see Lee, 2018, for a discussion of Black support for marriage equality).

Recent research suggests that attitudes about sexual minority rights and same-sex marriage in the United States are strongly influenced by multiple factors including religious involvement, religious affiliation, and geographic residence (e.g., residing in a county with a higher proportion of conservative Protestants; Adamczyk et al, 2016). Resistance based on religion and political ideology may have contributed to the wide range of experiences related to marriage equality reported by White and Latina/x participants. For example, Latina/x participants may have ancestry or identity linked to a variety of Latin American countries (or Hispanic identity), some of which are more conservative religiously and politically (and supportive of the Republican Party in the United States) than others (Ellison, 2011; Krogstad, Flores, & Lopez, 2018).

Limitations and Future Research

The sample in this study included sufficient data from African American, Latina/x, and White SMW for saturated qualitative analysis. However, data from SMW with other racial/racialized identities, such as Native American/First Nations, Asian American, or Middle Eastern, was not available in large enough numbers to be represented in this analysis. Even within the three groups represented in this sample, a full range of socio-economic and other experiences are not fully represented, including an underrepresentation of bisexual women. Further, within Latina/x SMW, differences between participants who emigrated from Cuba or are second generation Cuban-Americans may differ substantially from participants who emigrated/immigrated from Mexico or are second-generation Mexican American (or other countries of origin). There may be differences among African American SMW in experiences based on residence (e.g., those still living in Chicago versus those living in other cities or in rural areas; or those living in different neighborhoods in Chicago). Further research is needed to better understand differences within groups. Additionally, sexual minority men were not included in this study and may have different experiences related to their intersectional identities (e.g., McConnell, Janulis, Phillips, Truong, & Birkett, 2019).

The demographics of the sample groups illustrate differences in income and education across the groups. White participants on average reported higher incomes and higher levels of education than African American and Latina/x participants. These differences may have impacted study findings as they may influence the communities within which the participants interacted and the concerns they expressed. Also, Latina/x participants were younger than African American and White participants, possibly influencing the experiences of these participants. For example, younger Latina/x participants may have been more likely to be second-generation United States citizens than older participants, influencing their experiences in the political environment.

How masculine presentation, transmasculine identity, or genderqueer or non-binary identities influence perceptions associated with marriage equality and the election needs to be further explored. Our results suggest that participants have unique experiences related to their gender expression and presentation, especially in the social environment. Explicit questions about gender presentation, and intersecting gender/sex (e.g., non-binary or transgender) and sexual (e.g., bisexual or queer) identities, may yield different experiences and concerns, especially across racial/ethnic groups.

Researchers need to recruit large enough samples of women of color, and other LGBTQ people of color, to adequately assess the meanings of risks and impacts associated with changes in the political and social environment. Data aggregated across groups may miss important factors impacting health and well-being because differences by racial/ethnic identity are not analyzed, or because all non-White groups are considered together. Physical and mental health disparities need to be understood in the context of multiple and on-going political events and cultural changes. A nuanced understanding is necessary in the creation of culturally sensitive and competent interventions to support SMW and LGBTQ people and people of color during and after macro-level events that activate minority stressors (Russell, 2012).

The impacts of marriage equality and the 2016 election cannot be fully separated in the current study. Participants responded to the survey after both events had occurred and often discussed the election in responses to the first set of questions on marriage equality, thus conflating their own answers. Although among participants marriage equality was generally seen as positive for LGBTQ people and the election of Trump was generally seen as negative for LGBTQ individuals and people of color, the effects of these occurrences are difficult to separate because of their close temporal and sequential occurrence. Furthermore, other changes or events in the political and social environment may have influenced participant responses. Future quantitative research may attempt to model separate impacts, such as testing marital status as a buffer or mediator of negative impacts of the election or other political events that may be perceived as unsupportive or detrimental to LGBTQ individuals and people of color.

Race/ethnicity may moderate the links between gender and minority stressors. In analyses of quantitative data from Wave 3 of the CHLEW study, the authors found that many relationships between masculinity and femininity and minority stress varied across racial/ethnic groups, and in some cases the effects appeared to work in opposite directions for White SMW when compared to Black and Latina/x SMW (Everett, Steele, Matthews & Hughes, 2019). For example, masculinity was associated with lower levels of victimization, discrimination, and stigma consciousness among Black and Latina/x SMW, but higher levels among White SMW. Thus, quantitative results based on CHLEW sample data (e.g., Steele, Everett & Hughes, 2020) has highlighted the importance of an intersectional lens when conducting research with SMW.

Overgeneralization of research based on predominately White samples or aggregating across different racial/ethnic groups may mask important differences between the experiences of individuals. It is essential for service providers, especially providers of psychological and health care services, to consider the experiences of clients in their socio-political context. For example, to provide culturally responsive care for African American/Black SMW, considerations of physical safety may arise and need to be validated and addressed.

Policies that impact racial/ethnic groups differently need to be assessed for their connection to health disparities. For example, health disparities related to sexual-minority-related stressors may disproportionately impact racial/racialized/ethnic minority people (see the American Psychological Association’s Stress in American reports; American Psychological Association, 2019). SMW and LGBTQ people, because of stigmatization and sexual minority stress, may be especially at risk for the negative health impacts of discriminatory policies (e.g., non-discrimination laws that allow “religious exemptions” or are not inclusive of sexual orientation or gender expression/identity). These risks may be greater for SMW and LGBTQ people with multiple minority identities, including intersecting racial/racialized identities.

Acknowledgments

This work was supported by the National Institute of Alcohol Abuse and Alcoholism (R01 AA013328–14 PI: Hughes).

Contributor Information

Ellen D.B. Riggle, Departments of Gender and Women’s Studies and Political Science, University of Kentucky, 1615 Patterson Office Tower, Lexington, KY 40506-0027.

Laurie A. Drabble, College of Health and Human Sciences, San José State University, One Washington Square, San José, CA 95192-0049

Alicia K. Matthews, Department of Health Systems Science, University of Illinois at Chicago, 845 S. Damen Ave., MC 802, Chicago, IL 60612

Cindy B. Veldhuis, School of Nursing, Columbia University, 630 West 168th Street, Mail Box Code 6, New York, NY 10032

Robyn A. Nisi, Department of Health Systems Science, University of Illinois at Chicago, 845 S. Damen Ave., MC 802, Chicago, IL 60612.

Tonda L. Hughes, School of Nursing & Department of Psychiatry, Columbia University, 630 West 168th Street, Mail Box Code 6, New York, NY 10032.

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