The Buckle of the Bible Belt: Sexual Minority Emerging Adults’ Minority Stress in South Central Appalachia

Abstract

Introduction:

Sexual minority emerging adults in Appalachia face multiple sources of stigma and discrimination.

Methods:

We conducted four focus groups and five one-on-one interviews with sexual minority young adults and community stakeholders.

Results:

Themes emerged from qualitative analysis: 1) Appalachian culture engenders discrimination and isolation; 2) A need to identify safe spaces; 3) Lack of access to identity-affirming health services; and 4) participants draw strength from limited but persistent resistance, advocacy, and visibility.

Conclusion:

Sexual minority emegerging adults experience intersectional stigma in a socially conservative Appalachian setting. Attention to their unique experiences points towards specific service and community support needs.

For decades, researchers have examined experiences of minority stress and its negative consequences for mental and physical health among sexual minorities (e.g., those who identify as lesbian, gay, or bisexual; Meyer, 1995, 2003, 2013). Although research in rural and small urban locations is growing (e.g., Keene, Eldahan, Hughto, & Pachankis, 2016), the preponderance of research regarding sexual minority stress and its deleterious effects is based on sexual minorities who live in urban areas. As a result, there is a relative lack of knowledge regarding minority stressors specific to rural locations in the United States.

The Appalachian region of the United States includes 423 counties in 13 states: Mississippi, Alabama, Georgia, South Carolina, Tennessee, North Carolina, Kentucky, West Virginia, Virginia, Ohio, Pennsylviania, Maryland, and New York (Appalachian Regional Commission, 2018), South Central Appalachia, an 87-county subregion that includes parts of east Tennessee, southwest Virginia, and western North Carolina is a rural area of the country that remains understudied and where minority stress may be particularly severe. This area of the US contains some of the highest rates of structural stigma, with widespread lack of employment discrimination protections and high levels of prejudicial community attitudes (McVeigh &Diaz, 2009). This region also reports some of the poorest health outcomes and lowest access to mental and physical healthcare services in the nation (Behringer & Friedell, 2006; Short, Oza-Frank, &Conrey, 2012; Snell-Rood et al., 2017). Indeed, nearly 70% of Appalachian counties have been deemed mental healthcare shortage areas (Hendryx, 2008). Despite these geographic risk factors, published work on sexual minority stress and health in Appalachia is quite limited, with only a few studies exploring discrimination, identity concealment, and social isolation in this region (e.g., Bennett, Ricks, & Howell, 2014). The goal of this qualitative study was to investigate the nature and deleterious consequences of minority stressors for sexual minorities living in South Central Appalachia.

Sexual Minority Stress in Rural Areas

We grounded this investigation in minority stress theory, which captures the distal and proximal stressors attributable to prejudice and discrimination toward sexual minority individuals (Meyer, 1995, 2003, 2013). These stressors take the form of structural and interpersonal stigma such as negative cultural attitudes and discriminatory acts (distal stressors), as well as the more psychological experiences of internalized homophobia, anticipated stigma, and identity concealment (proximal stressors). Sexual minority stress has been consistently linked with negative mental and physical health outcomes for sexual minorities and a key explanation for the sizeable sexual orientation disparity in such outcomes. Specific negative outcomes among sexual minorities include anxiety and depression (Mays & Cochran, 2001; Schwartz, Stratton, & Hart, 2016; Walch, Ngamake, Bovornusvakool, & Walker, 2016), substance use (Lehavot & Simoni, 2011; Lewis, Mason, Winstead, Gaskins, & Irons, 2016; Lewis, Winstead, Lau-Barraco, & Mason, 2017; McCabe, Bostwick, Hughes, West, & Boyd, 2010), sexual risk behaviors (Rendina et al., 2017), and poorer overall health (Denton, Rostosky, & Danner, 2014; Frost, Lehavot, & Meyer, 2015; Katz-Wise, Mereish, & Woulfe, 2017).

Sexual minorities in rural areas face a number of rurality-related stressors. In an online sample of sexual minority individuals from across the U.S., rural participants described the social climates in which they are silenced, isolated, and fearful of hate crimes (Swank et al., 2013). They also describe more minority stress in the form of employment discrimination, housing discrimination, and damage to property, compared to sexual minorities residing in more urban areas (Swank, Fahs, & Frost, 2013). Indeed, the general population in rural areas is more likely to endorse traditional family structures and gender roles, conservative ideology, and belong to fundamentalist religious groups (Miller & Luloff, 1980), than more urban populations. These factors may explain more prevalent negative attitudes toward sexual minorities in rural regions (e.g., Herek, 2002). Rural sexual and gender minorities may also anticipate and experience stigma in the context of healthcare, perceiving provider cultural competence as inadequate, and identifying nondisclosure of identity as a barrier to healthcare (see Rosenkrantz, Black, Abreu, Aleshire, & Fallin-Bennett, 2017, for review). In addition, sexual minorities living in rural areas may have difficulty finding mental health care providers who are specifically sexual-minority-affirming or who are knowledgeable about sexual minority mental health due to a belief among providers that there is not a need for special training or attention to this population (Willging et al., 2006).

Sexual Minority Experiences in Appalachia

Several features of Appalchian life can create challenges for sexual minority individuals living in this region, including religiously-driven heteronormativity, social isolation, and challenges accessting LGBTQ-affirmative healthcare. The predominance of adherents to conservative religions can create challenges for sexual minorities who are socialized into the cultural expectation of being religious while simultaneously being ostracized for holding an identity that defies their religious beliefs. Indeed, evangelical Christians are more likely than others to discourage homosexuality (Pew Research Center, 2018). Religion is omnipresent in daily life in the Appalachian region (Denham, 2016).

Sexual minorities in Appalachia may also experience a deep social isolation that results when their sexual identity clashes with both religious and family values which may threaten the health and wellbeing of sexual minorities in Appalachia, as shown in prior research on rural sexual minority health (e.g. Rosenkrantz, Black, Abreu, Aleshire, & Fallin-Bennett, 2017). In addition, sexual minorities in particularly rural areas of Appalachia also experience geographic isolation, which limits opportunities to socialize and create in-person community (Leedy & Connolly, 2007).

In a mixed methods study of healthcare providers in Appalachian Tennessee, researchers found a lack of LGBTQ-appropriate training for healthcare providers as well as providers’ self-reported enacting microaggressions toward LGBT patients (Patterson, Jabson Tree, & Kamen, 2019). Additionally, in a qualitative study in Eastern Kentucky, researchers’ analysis revealed participants perceived that tobacco use was associated both with local cultural norms and sexual minority identity (Bennett et al., 2014). These unique experiences of sexual minorities who also had Appalachian identities included social isolation of being a sexual minority in a rural area, religious-based minority stress particularly when it impacted familial relationships, and what the authors referred to as a “veiled” identity, whereby participants were known by others to be sexual minority but did not discuss it directly.

Sexual Minority Emerging Adults’ Minority Stress in South Central Appalachia

In the present study, we sought to gather in-depth accounts of minority stress experiences of sexual minority emerging adults in the understudied geographic region of South Central Appalachia. Although no known studies have focused on sexual minorities’ experiences in South Central Appalachia in particular, qualitative studies in other areas of Appalachia have identified some of the minority stressors and deleterious effects that sexual minorities in this specific region may face. Appalachia is a 205,000-square-mile region along the Appalachian Mountains spanning from southern New York to northern Mississippi (Appalachian Regional Commission, 2018). Ethnographic work in this part of the country has focused on Central and South Central Appalachia, the heart of the region, where distinct Appalachian cultural characteristics may be most pronounced (Keefe, 2005). South Central Appalachia is informally referred to as “the Buckle” of the Bible Belt, an informal designation given to Southern states due to the high percentage of the population that is religious, particularly conservative Christian religious (Pew Research Center, 2018). We specifically conducted the present study in Northeast Tennessee, which is located in the middle of this region.

We focus this study on emerging adults in this region given the unique confluence of stressors faced by sexual minorities at this developmental stage. Sexual minority emerging adults living in rural regions experience more assault and harassment related to their sexual orientation than those in other geographic regions (Kosciw & Diaz, 2006). Sexual minority youth in rural communities may encounter especially hostile school climates (Kosciw, Greytak, & Diazn, 2009). As school climates and experiences are likely shaped by the larger communities in which they are situated (Kosciw et al., 2009), youth experiences may continue into emerging adulthood. Not only are sexual minority youth in general at risk for substance use, anxiety, and depression (e.g., DiFulvio, 2011), sexual minority emerging adults in rural locations experience the largest burden of sexual minority stress-related disparities, with significantly higher rates of depression (Galliher, Rostosky, & Hughes, 2004), binge drinking, and illegal drug use (Poon & Saewyc, 2009) than urban peers. Thus, we centered our investigation on sexual minority emerging adults, aged 18-29, who reside in South Central Appalachia and LGBTQ-community stakeholders who work with members of this population.

Method

Sample

We recruited 10 sexual minority emerging adults and 10 stakeholders who work with sexual minority emerging adults in varying capacities (e.g., counselors, social service agencies, GSA advisors, community leaders) in Northeast Tennessee to participate in focus groups (n= 15) and individual interviews (n=5) (see Table 1 for sample demographics). The average age of the sexual minority emerging adults was 23.00 (SD = 2.75, min = 20.00, max = 28.00) and the average age for stakeholders was 46.40 (SD = 13.99, min = 26.00, max = 66.00).

Table 1.

Participant Characteristics

Pseudonym	Age	Sexual Orientation	Gender Identity	Race/Ethnicity	Education
Sexual Minority Emerging Adults
Adam	24	Homosexual/Queer	Male	White	Bachelor’s
Rowan	22	Lesbian	Nonbinary	White	Bachelor’s
Cameron	21	Bisexual	Androgynous	White	Some college
Hunter	20	Gay	Male	White	High school
Sage	22	Bisexual	Nonbinary	White	High School
Darcy	24	Pansexual	Female	White	Some College
Mallory	20	Lesbian	Female	White	Associate’s
Teagan	28	Bisexual/Queer	Female	White	Bachelor’s
Whitney	24	Bisexual	Female	White	Bachelor’s
Wesley	27	Gay	Male	White	Master’s
Community Stakeholders
Pam	42	Bisexual/Pansexual	Female	White	Some college
Brenda	53	Lesbian	Female	White	Master’s
Theresa	60	Lesbian/Bisexual	Female	White	Master’s
Serena	35	Bisexual	Female	Hispanic/Latinx	Other
Evan	53	Homosexual	Male	White	MD/PhD
Kacey	26	Lesbian	Female	White	Master’s
Freddie	66	Gay	Male	White	Bachelor’s
Vincent	59	Heterosexual	Male	White	Other
Jacob	30	Gay	Male	White	Bachelor’s
Eloise	36	Did not respond	Female	White	MD/PhD

Procedure

In the spring of 2017, the research team conducted focus groups and interviews with 20 sexual minority emerging adults (n = 10) and stakeholders (n = 10), as part of a larger intervention development study for sexual minority emerging adults (reviewed and approved by the Yale University Institutional Review Board). Because data for the present qualitative study are from the first phase of the project, the purpose of which was to create culturally resonant intervention materials for rural Appalachian LGB emerging adults, both sexual minorities and stakeholders working with that population were chosen to provide insight into the stressors that sexual minority emerging adults encounter, and the ways that they cope with sexual minority-specific stress and any related health problems.

Participants were eligible for the study if they were 18-29 years old, identified as sexual minority (lesbian, gay, bisexual, pansexual, etc.), and lived in one of six contiguous counties in Northeast Tennessee. We recruited participants through geo-targeted postings on social media, LGBTQ community listservs, and universities in the region, with advertisements that specified participation in the development of an intervention to improve health in sexual minority young adults in Appalachia. Potential participants spoke with a trained research assistant who explained the study purpose and procedures, verified eligibility, and scheduled the focus groups and interviews. Participants determined their own participation in either a focus group or an individual interview. Stakeholders were affiliated with online- or community-based organizations that provide services to Appalachian sexual minority emerging adults in the same geographic region. We recruited stakeholders through in-person or email invitations to local LGBTQ advocates and service providers in the second author’s professional network (e.g., GSAs, universities, PFLAG Tri-Cities, counselors, social services).

During the focus group or interview, participants discussed what it is like to be LGBTQ in Appalachia, their awareness of the stressors that LGBTQ young adults encounter, as well as the ways that they cope with the stress and the potential health problems that are of concern to the population. Focus groups and interviews lasted approximately 60-90 minutes each. Following the focus group or interview, participants were thanked for their time, given a copy of the consent document, provided a list of health and mental health resources in the region, and compensated with $30 for their time.

Qualitative Data Analysis

All focus groups and interviews were audio recorded and then transcribed verbatim by trained research assistants under the direction of the fourth author. We conducted a content analysis (Hseih, 2005) with open coding in order to allow emergent themes to be grounded in the data. A thematic analysis process guided our overall approach to qualitative analysis (Braun & Clarke, 2006). Specifically, the first three authors read all the transcribed interviews and created an initial codebook. The initial codebook was applied to transcripts of two interviews and one focus group in order to refine the initial codebook. Once the codebook was finalized, all transcripts were coded by at least two of the three coders using NVIVO software (2014). Consensus coding was systematically conducted among the three coders for all of the coded transcripts.

Results

Participants discussed a range of experiences related to the unique challenges of living in Appalachian Tennessee as sexual minorities. In this section, we describe these experiences organized into four main themes.

Appalachian Culture Engenders Deep Discrimination and Isolation

Participants across most interviews and focus groups spoke about the ubiquitous negative attitudes, ideas, and discriminatory behavior towards those with minority sexual orientation in the region. This stigma and discrimination were ideologically based and described as inherent to local culture, connected to deeply rooted religious beliefs, and seemingly immutable. Participants’ descriptions illustrated implicit (e.g. the notion that being a sexual minority is just not something one could even discuss) as well as explicit (e.g. hate speech) discrimination, in a range of settings such as school, neighborhood, home, church, and workplace and tied to specific locations such as particular towns of counties.

Several participants discussed encountering discrimination while in high school, from peers as well as educators.

Rowan: Sure, um, I grew up in [nearby] county which is about thirty minutes outside of here and I also have the uh, same experience in high school you know? You don’t come out gay in [nearby] county it’s just not what you do. (22, Lesbian, White, Nonbinary)

One particularly salient excerpt was from a participant who talked about having been threatened with a firearm while in high school:

Adam: Like, because that that’s means something fearful for this area, and, like, when I was in high school, I had uh, a very bad experience, ha, I had some guys chase me down with a shotgun in the high school parking lot over being gay.{laughs} And I just, after that I was like, you know what I am done. (24, Homosexual/Queer, White Male)

Another emerging adult talked about being excluded from a church musical group because of their sexual orientation:

Rowan: I…I was a Christian, I am to the point where I don’t know what I identify with anymore but I uh, I played in the church band, you know? Guitar, I was the lead guitarist and when they found out that I was gay, I was kicked out. (22, Lesbian, White, Nonbinary)

The effect of deeply-held religious beliefs and deep discrimination are illustrated by two community stakeholders who each talked about parents kicking children out of their homes after they disclosed their sexual orientation. Jacob, a 30 year old gay white male community stakeholder, said in a one-on-one interview: “And I have had, um, students come to me that were homeless because their parents kicked them out.” The following was mentioned in a focus group with community stakeholders.

Freddie: And you’re basically working against an ingrained, entrenched, faith-based, hate of the homosexual community, or anybody that does not conform to their rigid standards. Which of course is sad. Because, uh, the idea that they can bang their bibles and their guns and throw their children out onto the street because they’re gay, astounds me. (66, Gay, White Male)

Sexual minority emerging adults and stakeholders described the social isolation, lack of social support, and even rejection by family resulting from this deep-rooted, ideologically-based stigma in sexual minority lives in South Central Appalachia. These accounts often illustrated the particularly challenging intersection of rurality, religion, and low socioeconomic status. For example, stakeholders described how emerging adults’ financial dependence on their parents or families of origin can further exacerbate feelings of discrimination, concealment, and isolation.

Brenda: … I had a student who, um, was afraid to go home over Christmas…because she was concerned that, um, the title to her car was in her mother’s name and they might not give it back to her and she might not get to come back to school. (53, lesbian, White female)

Some of the religious-based discrimination described was somewhat indirect, as illustrated here by a participant talked about religious friends or family who told her they would pray for her.

Sage: …a lot of the reasons why I am not a Christian anymore is because the environment I was around told me, well being gay is a sin and you know going back to the Orlando, um, shooting, when that happened and I, I was a mess like that whole time and that was around the time my roommates also were like just asking all these invasive questions and stuff and my one roommate was like… “Well, I pray that you turn away from your sin,” and that’s the thing is like, pray for me fine but don’t pray for me if you think that who I am as a person is a sin. Like that’s, that’s been my biggest issue …. (22, Bisexual, White, Nonbinary)

Navigating Safe Space that is Elusive and Continually Shifting

The discrimination that participants described was connected to their accounts of difficulty navigating areas or spaces that are deemed safe places to exist as a sexual minority emerging adult. These spaces were sometimes tied to specific physical locations and sometimes tied to individuals or groups. Many participants described specific physical spaces that are either deemed safe or unsafe as well as the process of navigating these spaces. They described a fear of finding themselves in an unsafe space that may leave them vulnerable to discrimination or even physical violence. Participants described how the few places where sexual minority people feel safe are constantly shifting and can be difficult to find outside of the small cities in the area:

Whitney: Yeah, I think that the people out in the county will come into the city more to find those coping mechanisms because they won’t find them out there. There’s like no, there’s no clubs. The closest club would be like [club name] and that’s not where you’re gonna find a support system. Or like, the mason’s lodge, it’s also not where you’re gonna find it. That’s not where you should look. So I think, I think they’re also coming to find better communities here because that’s where they know they can. Um, if they can get here. And if they can’t, they’re trying to find what they can in like high school, or like elementary school and middle school. Trying to find, if they’ve identified that early, trying to find these people that they know they can trust. And that’s where it gets a little bit harder because then you have to learn how to find people you can trust. And learn who you can tell and [you] who can’t (24, Bisexual, White Female)

Another participant said that this process of navigation is so stressful that they’d rather have all spaces feel unsafe to avoid the stress of having to continuously search for safe places:

Hunter: So I think being, um, a member of any marginalized community, but including the LGBT community, I think that can be even more challenging to navigate that path, um, in some ways it would almost be easier to be in a place where there was no safe place because you know how to function. But we’re in a place where you don’t know if it’s good or if it’s bad. So you could literally be on one side of the street and you have allies, and on the other side of the street, they could physically want to assault you (20, Gay, White Male)

Hunter also described how the rurality and religiosity of the region acts to isolate minority populations. He talked about both the lack of safe physical spaces for sexual and gender minority folks and the omnipresence of evangelical Christianity in church members who adhere to a literal interpretation of religious texts and ostracize sexual minority individuals. He described the local university as a particularly safe space, especially in the context of the spaces in the community that always seem to be changing.

Another layer of the challenge of feeling safe in any place in this cultural context is illustrated by Kacey who described her concern about both the high prevalence of guns and widespread negative attitudes about those who identify as sexual minority. She mentions that even previously-identified safe spaces seem potentially unsafe given the intensity of the negative attitudes expressed in the larger community.

Kacey: I do think the political climate has played a lot into it and I know that we touched on it a little bit at the beginning, but, um, I think specifically for myself personally, I know that a lot of students were, had expressed a lot of fear after Orlando in general {nonverbal and verbal agreement from group member} about knowing that this area is full of guns and full of people who don’t want you to exist, and, um, … And knowing that could happen at any moment, in any place here, and that students felt like, well if it can happen in a liberal city like Orlando, then what is preventing it from happening here? … And then after the election, um, I think that was even more amplified. (26, Lesbian, White Female)

Lack of Access to Affirming Health Services Compounding Existing Lack of Access

Several participants described difficulty either finding sexual minority friendly physical and mental health care providers or difficulty assessing whether their current providers were friendly. In fact, participants described assuming that organizations and providers were unfriendly until proven otherwise, given that thee perceived the majority of people in the area are unfriendly toward sexual minority people. Exacerbating this was the perceived lack of policy or legal protection for sexual minority people in the area. Moreover, the combination of a negative political climate and already low access to care in southern Appalachia resulted in a particularly difficult intersection for sexual minority young adults in need of healthcare or other services.

The omnipresence of religion in the local culture permeates even health and mental healthcare settings. Some participants talked about being sent by parents to Christian therapists who attempted to “convert” them to heterosexuality. Others talked about going to healthcare providers’ offices where Christian symbols were present, making them wary of the attitudes of the staff and providers in those offices.

Hunter: Um, as a student it’s, you’re always trying to go wherever it’s the cheapest. Um, ‘cause you don’t have insurance and that sort of thing…and you walk into these places and right above the receptionist’s desk is a Bible verse. I went to some place and walked in and then just turned around and walked right back out because I know when I’m sitting there I can’t fill out that little paper that says you were, had, you know, sexual relations with these people, you know, have you ever done this, and they ask you all those things about your sexual history, and I’m like, “I can’t fill that out in front of these people,” ‘cause I know what they’re, you know, I know what their assessments are. So I can’t tell you how many times I’ve actually just not gone to the doctor. Just because at the end of the day, I’m like, “Well, I’d rather just take the chances of strep versus being lynched in the parking lot.” So, I mean, and that seems like a big jump, but it’s not. (20, Gay, White Male)

Hunter’s account of his experience illustrates his decision to delay or avoid care because of fear of mistreatment in healthcare settings. Other participants talked about feeling as though they might not be able to find a provider who they trusted to keep information about their identity confidential.

Drawing Strength from Limited but Persistent Resistance, Advocacy, and Visibility

Finally, many participants noted that their experience in this region is not entirely negative, and spoke about the local examples of resistance, allyship, activism, and sexual minority visibility. Some participants noted that the close-knit local activism-centered communities include members who are supportive of not just sexual minority community members but several marginalized groups.

Adam: There’s an active LGBT group here in [small city], and they are always doing events and it’s, it’s really diverse when you go to these events to see people coming from all walks of life. I mean you have Muslims that come to it, you have Blacks and Whites, I mean, they are all together. And everybody’s there for the same reason. You have straight people, you have gay people, you have lesbians, you have everybody, and they’re all there for the same reason. (24, Homosexual/Queer, White Male)

This activism may have been particularly salient to participants because it was surprising given the predominant anti-LGBT culture in the area. Stories about responses to recent local acts of discrimination came up in multiple focus groups and interviews and included hopeful descriptions of ways in which specific local communities rallied around the targets of discrimination.

Some participants talked about their own decisions to be more out and visible in terms of their sexual orientation as a result of the resistance of others. This illustrates simultaneous anguish and empowerment resulting from local public acts of discrimination and the response of local advocates.

Hunter: …anytime something negative like that happens…I feel like I experience two different reactions. Um, I think there’s my personal reaction, which tends to be like you would expect, um, I think I get more scared, I get more on the edge for a little bit, um, my need to analyze where I’m going increases, at least for a certain period of time until it dies back down. I guess I almost have like this fear adrenaline going. Um, and that’s on the personal scale. At the same time, however, I think when negative things like that happen, like that are very obvious visible negative things happen, I think my public, and what I mean by that, public, is like my, my relationship to the LGBT community broadly, I think I feel more empowered…Little bit of fear, but a little bit of empowerment, too. (20, Gay, White Male)

Discussion

This study examined the experiences of sexual minority emerging adults living in South Central Appalachia through focus groups and interviews with emerging adults and adults who were identified as community stakeholders. This study adds to the literature on the lived experience of sexual minority emerging adults living in rural areas and particularly this region. Overall, findings showed that the sexual minority stress encountered in this region includes a unique constellation of stressors influenced by regional and cultural factors related to rurality and place, high levels of evangelical religiosity, and low socioeconomic status.

Specifically, participants described discrimination rooted in long-held cultural traditions and beliefs so strong that participants need not test the waters to determine whether it was dangerous to openly identify in any way other than heterosexual, noting that, for example “You don’t come out gay in [redacted] county, it’s just not what you do.” (Adam, 24, Homosexual/Queer, White Male). The discrimination prevents emerging adults from publicly declaring their sexuality, making it difficult to connect with other sexual minority emerging adults, particularly in the more sparsely populated areas of the region. Indeed, participants described negative messages about minority sexual orientation coming from their coworkers, friends, families, teachers, and evangelical churches often at the center of communities in this region, creating an almost pervasive anti-LGBT environment.

Additionally, participants described a tenuous network of safe places, both difficult to find and stressful to navigate. Isolation related to identifying as a sexual minority in the South has been examined in previous literature (McIntosh & Bialer, 2015); however, themes specific to the experiences of sexual minority emerging adults in South Central Appalachia and the navigation of safe and unsafe spaces in the region are unique in the literature. Our study revealed that sexual minority emerging adults in this region are navigating daily through a world in which they must anticipate stigma from multiple sources and conceal their identity to find safety. Given the lack of brick and mortar locations for sexual minority individuals to seek resources and community, identity-specific safety is often found with individual people rather than in specific locations.

Participants describe how this high minority stress environment intersects with the background lack of access to healthcare in this region to generate substantial difficulties finding physical and mental healthcare services that are affirmative of sexual minority patients. For instance, Hunter talked about difficulty finding care he could afford and then leaving a physician’s waiting room because he was felt there were signs the provider or staff were unfriendly. Other participants mentioned negative experiences in healthcare settings including not feeling represented by options on intake paperwork and heteronormative assumptions expressed by providers and staff. This finding echoes a recent mixed method study of healthcare providers in Appalachian Tennessee that showed the high frequency with which healthcare providers commit microaggressions toward LGBT patients (Patterson et al., 2019).

Finally, participants described some resistance to the pervasive discrimination in the region. Many of the comments about acts of resistance and advocacy specifically mentioned it being located on a specific university campus in a small local city. Of the emerging adults who spoke about these positive responses to negative events or treatment, several were from more sparsely populated local communities where no such resistance was present. This finding supports the prior work on small cities serving as a refuge for sexual minorities living in rural areas (Keene, Eldahan, White Hughto, & Pachankis, 2017). Yet, this resistance appears tempered by the lack of support, geographic isolation, and ideologically-based discrimination. Indeed, several participants mentioned resistance and discrimination in the same sentence. Adam notes: “…and there’s a street that’s covered in rainbow flags, and it was recently vandalized, and they hosted a huge party, I mean, just to say ‘Hey, you can’t touch it,’ you know. And the flags was replaced of course, but…”. Moreover, advocacy and allyship were frequently mentioned by participants as occurring specifically in reaction to negative events: Vincent: “[local PFLAG] kind of resurfaced as a support organization locally because of an incident that hit the papers”, Some participants referred specifically to an incident in which a deceased farm animal was used in an apparent hate crime. For example, Wesley: “the carcass [was left] on one of my friend’s doorsteps, and the reaction to that with the, all the rainbow flags on the street…”. In fact, participants most frequently described support in the context of negative events, painting a picture of resistance that ebbs and flows with the surrounding political climate and specific acts of discrimination.

In sum, findings contextualize minority stress experiences within the cultural context of South Central Appalachia. Participants in our study provided voice and depth to previous quantitative examinations of sexual minority stress indicating that higher levels of stigma are experienced by sexual minority individuals in rural areas (Swank, Fahs, & Frost, 2013). They also align with qualitative findings about sexual minority individuals in Appalachia experiencing stress, discrimination, and isolation (Bennet, Ricks, & Howell, 2014). Our findings underscore the need to directly consider how cultural and regional characteristics of place compound minority stress experiences and the ability to cope with them. Such consideration can be helpful in the development and tailoring of interventions to improve the wellbeing of emerging adults in different regions of the country or other countries (Pachankis, 2018).

Numerous researchers have examined conflicts between an individual’s religious identity and their sexual orientation, with some of this work focusing on strategies to resolve such conflicts (see Anderton et al., 2011 for review). Indeed, findings of the current study echo the findings of a recent meta analysis examining the relationships between religiousness or spirituality and health of sexual minorities in which researchers found that the positive relationship that exists between religiousness or spirituality and health in the general population is more complex for sexual minorities (Lefevor et al., 2021).

However, little research has closely examined the effects of living in highly religious rural Appalachian communities that center around evangelical christian churches with negative views about sexual minorities. Sherkat (2002) described the social nature of religion in which family motivates people toward religious participation. Indeed, the strong link between family and religion among Appalachians may further complicate the experience of sexual minority identity.

Another focus of future research attention should be on the impact of religious and familial rejection for Appalachians who identify as sexual minority. Whereas religiosity is often thought of as protective against substance use (drinking, marijuana use, cigarette smoking) for heterosexual individuals (Rostosky, Danner, & Riggle, 2007), that may not be the case for many who identify as sexual minority in this region. In our data from South Central Appalachia, religiosity appears to promote rejection from multiple levels of one’s support network. This rejection includes being disowned by one’s parents, leaving some emerging adults homeless. Given that some sexual minority subpopulations, such as bisexual women, experience worse outcomes such as heavy drinking in the face of religiosity (Rostosky, Danner, & Riggle, 2010), it seems imperative to study the health impact of religious-based rejection more broadly in South Central Appalachia, a region that is currently experiencing high levels of opioid use disorder (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2017).

Though not expressed explicitly, it is likely true that in addition to recognizing the stigmatizing attitudes of others, participants also held feelings of internalized homonegativity (see Berg et al., 2016, for review), conscious or unconscious negative feelings about their own sexuality, as a result of exposure to those negative attitudes of those around them. An explicit focus on the effects of these internalized negative beliefs, which may be particularly likely in groups experiencing negative messages from multiple contexts simultaneously, should be included in future research in this area.

There have been recent examinations of the ways in which young sexual minorities use virtual spaces to find community connection and social support (e.g. Hanckel & Morris, 2014), but our findings indicate that connection with online communities and connecting with local communities online may be a crucial method of coping for sexual minority emerging adults living in rural areas. In addition, depth of Appalachian cultural experience or length of time lived in the region should be investigated in relation to minority stress experiences. Anthropological work suggests that being in a family in which three generations have lived in Appalachia could be determinative of Appalachian identity (Keefe, 1986). Researchers might examine whether there are differences in sexual minority stress between those who identify as Appalachian and those who have migrated to Appalachia.

Limitations

Although the present study provides new information on the minority stress experiences of sexual minority emerging adults in Appalachia, we draw conclusions with some caution given findings are based on a relatively small sample of emerging adults and stakeholders and, therefore, may not represent experiences of all sexual minority emerging adults in the region. For example, emerging adult participants in the study had to openly identify as sexual minority to be in the study and their experiences may be different from those who are not willing or able to be “out”. In addition, the racial/ethnic diversity of the sample was limited, reflecting in large part the homogenous White racial breakdown in this region. Emerging adults who identify as both sexual and ethnic minority in this region likely have an even more complex set of experiences that also warrant additional research.

Clinical Implications

In addition to illuminating a range of unique intersectionally stigmatizing experiences of emerging adults in Appalachia, findings from this study have specific implications for mental health care for this population. Emerging adults in this study specifically voiced their feelings of isolation from local communities, need for safe spaces, need for more affirming care, and cited visibility of other sexual minority groups and individuals as a source of resilience. Clinicians need to be aware of the unique stressors and sources of coping when aiming to work with this inidviduals in this population.

Conclusion

These findings indicate a distinctive collection of minority stress factors specific to the region. Additional research with larger and more diverse samples is needed to further elaborate the extent and impact of this culturally-compounded minority stress in Appalachia. This gap in the literature may be particularly important to address given that those living in Appalachia are already experience health disparities, a lack of healthcare resources, and missing community supports for sexual minorities. Such work will inform the future development and adaptation of interventions intended to support sexual minority emerging adults, and future social policy to reduce the effects of minority stress in Appalachia.

Data availability statement:

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.