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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Soc Sci Med. 2024 Jan 23;344:116604. doi: 10.1016/j.socscimed.2024.116604

The cumulative effects of stigma-related stress: Chronic stigma-related stress exposure exacerbates daily associations between enacted stigma and anxious/depressed affect

Christina Dyar 1
PMCID: PMC10923191  NIHMSID: NIHMS1961290  PMID: 38281458

Abstract

Purpose:

Sexual and gender minority individuals are at elevated risk for mood and anxiety disorders compared to heterosexual and cisgender individuals. Ecological momentary assessments studies have implicated experiences of enacted stigma (i.e., biased treatment) by linking these experiences with elevations in anxious and depressed affect. The current study utilizes a theory from the broader stress and affect literature to determine whether chronic enacted stigma exposure amplifies individuals’ negative affective reactions to experiences of enacted stigma at the daily level.

Methods:

We used data from a 30-day ecological momentary assessment study with 429 sexual minority women and gender diverse sexual minorities assigned female at birth (SMWGD) living in the US in 2020–21 to determine whether concurrent and prospective event-level associations between enacted stigma, anxious/depressed affect, and perceived coping efficacy were moderated by chronic enacted stigma exposure.

Results:

Results demonstrate that individuals with moderate to high chronic stigma exposure experience larger increases in anxious/depressed affect and larger decreases in perceived coping efficacy following daily experiences of enacted stigma. Further, these effects of daily stigma on anxious/depressed affect persist for longer among individuals with high chronic stigma exposure. Interestingly, chronic stigma exposure did not moderate associations between daily general stressors (i.e., those unrelated to identity) and affect or perceived coping efficacy, suggesting that these effects are specific to stigma-related stressors.

Conclusions:

These results help to advance our understanding of both long-term and daily effects of exposure to enacted stigma, highlighting the potentially profound cumulative effects of stigma exposure and the need to intervene in this cycle.

Keywords: sexual and gender minority, minority stress, affect, stress reactivity

Introduction

Sexual minority individuals (i.e., lesbian, gay, bisexual, and other queer individuals) and gender minority individuals (i.e., individuals whose gender identities do not match their sex assigned at birth) are at elevated risk for mood and anxiety disorders compared to heterosexual and cisgender individuals (Kerridge et al., 2017). These disparities have been theorized to arise from the stigmatization of sexual and gender diversity (Hatzenbuehler, 2009; Meyer, 2003). These disparities are particularly pronounced for sexual minority cisgender women (Ross et al., 2017) and for emerging adults (Rice et al., 2019). Rates may be similarly elevated among gender diverse individuals assigned female at birth (i.e., those who identify outside of the gender binary; e.g., nonbinary), but findings across studies remain mixed (Conn et al., 2023; Newcomb et al., 2020; Parodi et al., 2022). Many studies have linked experiences of enacted stigma (i.e., biased treatment by others based on one’s sexual orientation) with symptoms of mood and anxiety disorders. Importantly, several longitudinal and ecological momentary assessment (EMA) studies conducted predominately in the US have documented these effects prospectively, demonstrating that experiences of enacted stigma precede increases in symptoms of anxiety and depression as well as anxious and depressed affect among sexual and gender minorities (SGM; Birkett et al., 2015; Burton et al., 2013; Dyar et al., 2020; Eldahan et al., 2016; Puckett et al., 2023; Rendina et al., 2017; Tucker et al., 2016).

However, limited research has examined whether these effects of enacted stigma vary across individuals (for an exception see Livingston et al., 2020). Drawing from two theoretical models (i.e., exposure reactivity, psychological mediation framework), we aimed to test whether chronic enacted stigma exposure moderates event-level associations between daily experiences of enacted stigma, perceived coping efficacy, and anxious/depressed affect, such that individuals with higher chronic stigma exposure will have stronger negative reactions to daily experiences of enacted stigma.

Event-Level Associations Between Enacted Stigma and Anxious/Depressed Affect

A growing number of EMA studies have examined event-level associations between experiences of enacted stigma and concurrent or prospective changes in anxious/depressed affect. Studies of SGM broadly (Feinstein et al., 2022; Livingston et al., 2020; Mereish et al., 2021; Mohr & Sarno, 2016; Newberger et al., 2022) and sexual minority women specifically (Flanders, 2015; Salim et al., 2019; Smith et al., 2022) tend to find evidence linking enacted stigma with elevated anxious/depressed affect on the same day. However, evidence for the persistence of this effect into the next day is mixed. For example, two studies examining the prospective effects of sexual minority and gender minority enacted stigma, respectively, found that experiencing enacted stigma continued to predict increases in anxious/depressed affect into the next day (Eldahan et al., 2016; Puckett et al., 2023). However, another study of bi+ individuals (i.e., individuals with attractions to more than one gender) failed to find support for the persistence of the effects of bi+ stigma on anxious/depressed affect into the next day (Feinstein et al., 2022). These results provide strong evidence that enacted stigma is associated with increases in anxious/depressed affect on the same day but mixed evidence for the duration of this effect. The current study builds on this literature by utilizing more frequent assessments than many of the daily EMA studies discussed. This allowed us to examine associations with more temporal precision than studies with one assessment per day.

Chronic Stress Exposure and Daily Stress Reactivity

The literature on stress and affect in the general population has long focused on stress reactivity (i.e., how strongly an individual reacts affectively to a stressful experience). Research has demonstrated substantial variability in stress reactivity, with some individuals showing little change in negative affect following a stressor, while others demonstrate substantial increases in negative affect (Caspi et al., 1987; Sheets & Armey, 2020). Some individuals even demonstrate a decrease in negative affect following a stressor, suggesting that coping effectively may be a positive experience for some (Caspi et al., 1987; DeLongis et al., 1988). One individual-level factor that has been theorized to predict stress reactivity is an individual’s history of stress exposure. The sensitivity hypothesis, a component of the exposure reactivity model of stress, posits that the accumulation of stressful experiences may affect how an individual reacts to acute stressors on a day to day basis (Almeida, 2005; Hammen et al., 2000). Hammen et al. (2000) proposes that experiencing higher levels of chronic stress depletes an individual’s coping resources, leading them to react more negatively to daily stressors, as indicated by a larger increase in negative affect following a daily stressor. Several studies with samples from the general population have demonstrated that reactivity to daily stressors was stronger among individuals who experienced more chronic stressors (e.g., Lockwood et al., 2022; Serido et al., 2004).

Sensitivity Hypothesis Applied to Enacted Stigma

In a similar vein, Hatzenbuehler (2009) discussed the potential for stigma-related stressors to deplete an individual’s coping resources because they are experienced on top of general life stressors. Although he does not directly posit that the accumulation of stigma-related stressors would amplify the negative effects of a subsequent experience of stigma-related stress, the proposed depleting effects of stigma-related stressors tie in well with the sensitivity hypothesis. Together, these two theories lead to two intriguing research questions. First, do individuals with a history of chronic exposure to enacted stigma experience more negative affective reactions to daily experiences of enacted stigma? Second, does the impact of daily experiences of enacted stigma on coping depletion also vary based on individuals’ history of chronic exposure to enacted stigma?

We are aware of only two existing studies that have attempted to address the first research question and none that have examined the second. Among a sample of SGM, Livingston et al. (2020) demonstrated that daily experiences of enacted stigma predicted concurrent elevations in negative affect only among individuals with a history of experiences of SGM victimization. Among a sample of racial and ethnic minorities, Ong et al. (2009) tested whether chronic experiences with racism moderated the daily concurrent effects of experiences of racism on negative affect but did not find evidence to support this hypothesis. Given the limited and mixed evidence for the sensitivity hypothesis with regard to experiences of stigma-related stressors, the current study aimed to examine whether chronic sexual minority enacted stigma exposure predicted differences in event-level associations between daily enacted stigma experiences and negative affect. It also aimed to build upon this prior work by testing whether the duration of event-level effects of daily enacted stigma differed based on an individual’s history of chronic stigma exposure.

The Potential Role of Perceived Coping Efficacy

Both Hammen et al. (2000) and Hatzenbuehler (2009) posit that over-exposure to stressors strain and ultimately overburden an individual’s coping resources, limiting an individual’s ability to successfully cope with additional stressors. Perceived coping efficacy captures this concept of coping depletion from the individuals’ perspective, with low perceived coping efficacy reflecting an individual’s perceived inability to effectively reduce negative emotions following stressful experiences. However, limited research has examined this construct among SGM, with only one prior EMA study demonstrating that perceived coping efficacy was reduced on days when stigma-related stress was experienced by sexual minority women (Dyar et al., 2021). The current study builds on this prior study by examining whether such within-person effects are moderated by chronic enacted stigma exposure and by examining the duration of such reductions in perceived coping efficacy following experiences of daily enacted stigma.

Chronic Enacted Stigma Exposure and Reactivity to General Stressors

Does chronic stigma exposure also increase reactivity to general stressors (i.e., those unrelated to one’s sexual, gender, and racial/ethnic identity)? The sensitivity hypothesis does not specify whether the chronic and daily stressors must share a domain in order for chronic stress to exacerbate the effects of daily stressors. There is somewhat mixed empirical evidence that chronic stress from one domain (e.g., home stress) may impact reactivity to daily stressors in another domain (e.g., work stress). For example, Serido et al. (2004) examined whether chronic work stress predicted increased reactivity to daily home stress and vice versa. Results suggest that not only does chronic stress in one domain amplify reactivity to daily stressors in the same domain, but it also amplifies reactivity to daily stressors in a separate domain (Serido et al., 2004). In another line of research, childhood trauma has been identified as a predictor of stronger anxious reactivity to unrelated daily stressors (Leger et al., 2022; Mayer et al., 2022). However, in the closest parallel to the current study, Ong et al. (2009) examined whether chronic exposure to racism predicted greater reactivity to both daily general stressors and daily racism but found no support for this hypothesis. The current study aimed to determine whether chronic exposure to enacted sexual minority stigma amplified reactivity to daily general stressors or whether this effect was domain specific (i.e., limited to affecting reactivity to daily enacted stigma).

The Current Study

The current study aimed to advance our understanding of factors that may amplify reactivity to daily experiences of enacted stigma. To do so, we utilized data from an EMA study with a sample of sexual minority cisgender women and sexual minority nonbinary individuals assigned female at birth (SMWGD). These groups are at high risk for mood and anxiety disorders and have received less research attention than other SGM groups. We aimed to determine whether concurrent, single lagged (~12 hours later), and double lagged (~24 hours later) associations between daily experiences of enacted stigma, anxious/depressed affect, and perceived coping efficacy were moderated by chronic exposure to enacted stigma. We hypothesized that associations between experiences of daily enacted stigma, anxious/depressed affect, and perceived coping efficacy would be moderated by chronic enacted stigma exposure. We expected that experiencing daily enacted stigma would concurrently and prospectively predict increases in anxious/depressed affect and decreases in perceived coping efficacy among all participants, with these associations being strongest and persisting for longer among those with high chronic stigma exposure. We also aimed to determine whether chronic enacted stigma exposure also predicted stronger reactivity to daily general stressors. We expected that concurrent and lagged associations between daily general stressors, anxious/depressed affect, and perceived coping efficacy would also be moderated by chronic stigma. These associations were expected to be stronger and persist for longer among those with higher chronic stigma exposure.

Methods

Participants and Procedures

The current analyses used data from a longitudinal study of substance use among 429 SMWGD conducted between August 2020 and May 2021. Participants were recruited via paid advertisements on social media (e.g., Facebook, Instagram). Advertisements included images of same-gender couples and individuals with Pride colors and flags, and asked members of the LGBTQ+ community to share their experiences by participating in the study. Ads were targeted to a range of interests relevant to the LGBTQ+ community (e.g., LGBTQ+ rights, media with LGBTQ+ characters, prominent LGBTQ+ individuals) and limited to individuals between age 18 and 25 in the United States. Eligible participants were 1) U.S. residents, 2) 18–25 years old, 3) assigned female at birth, 4) identified as women or under the non-binary/gender diverse umbrella (e.g., non-binary, genderqueer, agender, gender fluid), 5) identified as lesbian, bisexual, pansexual, or queer, and 6) met alcohol or cannabis use criteria (i.e., reported having four or more drinks at least twice and/or using cannabis on at least three days in the past month).1

Participants who appeared eligible based on their responses to the eligibility survey were text messaged by study team members to verify their eligibility and their access to a mobile phone with text message capabilities. To verify their eligibility, participants were asked to text demographic information (i.e., age, state of residence, email address), which was cross-checked with their responses in the eligibility survey. Participants who passed the eligibility verification were invited to participate and sent a link to the baseline assessment.

The study included a baseline assessment (e.g., demographics, stigma, substance use over the past 30 days; day 0), a 30-day EMA study (days 1–30), and a follow-up assessment. This study used data from the baseline assessment and the 30-day EMA study. During the EMA period, participants were asked to complete two surveys per day. Invitations for morning surveys were sent via email or text message (based on participant preference) at 8:00am in their time zone and participants had until 1:00pm to complete the survey. Invitations for evening surveys were sent at 6:00pm in their time zone and participants had until 12:00am to complete the survey. Participants who had not completed the survey by three hours after the survey invitation were sent a reminder. Those who missed more than three surveys in a row were contacted by study staff to check in and re-engage participants. Surveys were programmed in REDCap and took approximately two minutes to complete. Participants were paid up to $150: $20 for baseline, $20 for follow-up, $1 for each EMA survey, and a $5 bonus for every six EMA surveys completed in a row. The study received IRB approval at Northwestern University (where data was collected) and Ohio State University (where data is stored) and informed consent was obtained from participants. See Dyar et al. (2022) for further details about the study.

The sample included 429 participants (Table 1) and was comprised predominately of people of color, with only 33.6% identifying as non-Latinx White. There was a sizeable number of gender diverse participants (26.8%). See supplementary materials for details of demographic measures.

Table 1.

Demographics of Analytic Sample at Baseline (N = 429)

Demographic Variable n %
Sexual Identity
 Lesbian 112 26.1%
 Bisexual 111 25.9%
 Pansexual 112 26.1%
 Queer 94 21.9%
Race/Ethnicitya
 White 235 54.8%
 Black 102 23.8%
 Latinx 129 30.1%
 Asian 53 12.4%
 Other Race/Ethnicity 34 7.9%
Gender Identity
 Cisgender Women 314 73.2%
 Gender Minority 115 26.8%
Region of US
 Northeast 108 25.2%
 Midwest 99 23.0%
 South 102 23.8%
 West 120 28.0%
Education Level
 Some High School 5 1.2%
 High School 46 10.7%
 Some College 166 38.7%
 Associate Degree 23 5.4%
 Undergraduate Degree 143 33.3%
 Some Graduate School/Graduate Degree 46 10.7%
Current Student
 No 181 42.2%
 Yes 248 57.8%
Employment Status
 Not employed 125 29.1%
 Part-time 181 42.2%
 Full-time 123 28.7%
Age (M, SD) 22.27 (2.01)
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a

Percentages add up to more than 100% because participants could select multiple racial/ethnic identities.

Measures

EMA Measures

Daily Enacted Stigma was assessed by asking participants two questions. First, participants were asked an item adapted from Mohr and Sarno (2016): “Did you experience anything stressful or negative related to your sexual orientation since the last survey? This could be something that was relatively minor (e.g., feeling that your sexual identity was not respected) or major (e.g., being physically attacked because of your sexual orientation).” Participants were asked to indicate yes or no. Regardless of their response, participants were asked to “indicate which of the following events you have experienced since the last survey because of your sexual orientation” and provided with a list of 10 experiences of enacted stigma that have been utilized in previous EMA studies (e.g., “someone acted uncomfortable around me”; Dyar & London, 2018; Flanders, 2015). Utilizing both measures allowed us to capture a wider range of experiences of enacted stigma than either measure alone. Given that few participants endorsed multiple experiences of enacted stigma on the same day, we created a binary variable from these measures. Participants who indicated yes on the first item or indicated experiencing any items on the checklist were assigned a value of 1 and those who indicated no to both were assigned a value of zero.

General stressors were assessed via the Daily Inventory of Stressful Events (Almeida et al., 2002). The original measure includes questions about the experience of seven different types of daily stressors (e.g., “Did you have an argument or disagreement with anyone?”). We combined three items that asked separately about stressful experiences at work, school, and home into one item that asked about stressful experiences in all three settings to reduce participant burden for the EMA. Participants were asked to indicate whether or not each stressor occurred in the last 24 hours (0 [no], 1[yes]) and were specifically instructed not to include any events that were related to their sexual orientation. Items were summed to create a total score.

Anxious/depressed affect was assessed using four items from the Profile of Mood States Short Form’s depressed (discouraged; sad) and anxious (anxious; on edge) affect subscales (Cranford et al., 2006; Curran et al., 1995). Participants were asked to indicate how much they felt each emotion since the last survey. Response options ranged from 0 (not at all) to 4 (extremely). Affect was assessed prior to any other items on the daily survey to avoid order effects and was assessed in the morning and evening. Internal consistency was estimated using procedures recommended by Nezlek (2017) for longitudinal data and was acceptable (.76).

Perceived coping efficacy was assessed using two items adapted from the Coping Strategy Questionnaire (Rosenstiel & Keefe, 1983), which have been used in previous daily diary studies (Keefe et al., 1997; Massey et al., 2009; Stappenbeck et al., 2015), including those with SGM (Dyar et al., 2021). Participants were asked “Based on all the things you did to cope or deal with any negative thoughts or feeling since the last survey, how much control do you feel you had over the negative thoughts or feelings?” (0 [no control] to 6 [complete control]) and “How much were you able to decrease the negative thoughts or feelings (0 [couldn’t decrease them at all] to 6 [could completely decrease them]). These items were averaged and internal consistency calculated using procedures recommended by Nezlek (2017) for longitudinal data and was strong (.91).

Baseline Measures of Frequency of Chronic Stigma Exposure

The Sexual Orientation Microaggressions Scale (Swann et al., 2016) assessed the frequency with which individuals experienced microaggressions related to their sexual orientation in the month prior to the start of the EMA study. Participants were asked to indicate how often they experienced 19 different microaggressions (e.g., “You were told you were overreacting when you talked about a negative experience you had because of your sexual orientation.”) in the past month. Response options ranged from 1 (not at all) to 5 (21– 30 times [almost everyday]). Items were averaged to create a total score and Cronbach’s alpha indicated strong internal consistency (α = .93).

The LGBTQ+ Victimization Measure (Mustanski et al., 2016) assessed the frequency with which individuals experienced verbal threats or violence because of their LGBTQ+ identities over the past month (e.g., “have you had an object thrown at you”). Response options ranged from 0 (never) to 3 (three times or more) and items were averaged to create a total score (α = .78).

The Experiences of Discrimination Scale (Krieger & Sidney, 1997; Krieger et al., 2005) was used to measure sexual orientation based discrimination experienced over the past 30 days. The measure asks, “How often have you experienced discrimination, been prevented from doing something or been hassled or made to feel inferior in any of the following situations because of your sexual orientation?” Participants were presented with the following seven contexts: 1) in your family; 2) at school; 3) getting a job; 4) at work; 5) at home; 6) getting medical care; 7) in public (like on the street or in stores or restaurants). Items were rated on a 5-point scale (1 = never, 2 = almost never, 3 = sometimes, 4 = fairly often, 5 = very often) and responses were summed (α = .80).

Analytic Plan

Analyses were conducted in Mplus version 8.8. There were a total of 19,186 completed surveys from 429 participants. The median completion rate was 88.3% (M = 74%, SD = 28%). Within completed surveys, less than 1% of data were missing. Missing data were handled using Bayesian methods (Asparouhov & Muthén, 2010). Bayesian multilevel structural equation modeling (MSEM) with diffuse (non-informative) priors was used.2,3

First, we examined a single-level measurement model of the latent variable capturing chronic enacted stigma exposure in order to determine if a latent variable was an appropriate way to model this construct. Chronic enacted stigma exposure was indicated by past month experiences of microaggressions, discrimination, and victimization. The sizes of factor loadings were used to determine the utility of this latent variable as other indices of model fit (e.g., chi-square; CFI; RMSEA) are not available as this model was just identified. Standardized factor loadings greater than .45 were interpreted as demonstrating that the indicator loaded adequately onto the latent variable as this indicates sharing at least 20% of its variance with the latent construct (Comrey & Lee, 1992).

We examined the moderation of concurrent and prospective effects of a stressor variable (i.e., either daily experiences of enacted stigma or daily general stressors) on an outcome (i.e., either anxious/depressed affect or perceived coping efficacy) by the chronicity of experiences of enacted stigma. In each model, within- and between-person components of daily stressor predicted within- and between-person components of anxious/depressed affect or perceived coping efficacy. At the between-person level, the chronicity of experiences of enacted stigma was a latent variable indicated by past month experiences of microaggressions, discrimination, and victimization (see prior paragraph). This latent variable predicted the within-person association between daily stressors and anxious/depressed affect or perceived coping efficacy in a cross-level interaction. Significant moderation was identified by this association having p < .05.

Three sets of models were examined: unlagged, lagged by one timepoint, and lagged by two timepoints. In unlagged models, daily stressors and affect or perceived coping efficacy were assessed at the same observation. Unlagged models examining daily general stressors only included evening assessments as daily general stressors were only assessed in the evening survey. In the one timepoint lagged models, daily stressors experienced earlier in the day and reported in the evening assessment (i.e., at t-1) predicted perceived coping efficacy or anxious/depressed affect experienced that evening and into the next morning as reported in the next morning assessment (e.g., at t). In two timepoint lagged models, daily stressors experienced during one morning/afternoon (i.e., at t-1) predicted affect and perceived coping efficacy 24 hours later (i.e., at t+1).

In all models, we controlled for day of assessment and assessment type (weekend/weekday; morning/evening) at the within-person level. Further, we included first-order autocorrelations for the outcome in lagged models (i.e., correlation between variable at t-1 with variable at t), which effectively controls for the prior timepoint of the outcome. Within-person associations among daily enacted stigma, perceived coping efficacy, and anxious/depressed affect as well as autocorrelations were allowed to vary across individuals. Age, sexual identity, gender identity, and race/ethnicity were included as covariates at the between-person level, given known differences in the prevalence of anxiety and depression across these demographic variables (Bailey et al., 2019; Kerridge et al., 2017).

Finally, we conducted sensitivity analyses in which only cisgender sexual minority women were included to determine whether the pattern of results was the same with the inclusion of gender diverse sexual minority individuals. This helped to determine whether it was appropriate to combine sexual minority women and gender diverse individuals in the current analyses.

Results

Measurement Model of Chronic Enacted Stigma Experiences

As expected, the three types of enacted stigma all loaded well on the latent variable: microaggressions (λ [standardized factor loading] = .96); discrimination (λ = .49); victimization (λ = .64). Therefore, we proceeded to use this latent variable in the moderation models described below.

Moderation of Within-Person Effects of Daily Enacted Stigma on Anxious/Depressed Affect

Chronic enacted stigma exposure significantly moderated unlagged and one timepoint lagged associations between daily experiences of enacted stigma and anxious/depressed affect but did not moderate this association when two lags were included between the stigma experience and affect (Table 2). Examination of the simple slopes for the moderation of the unlagged analysis (Table 3) indicated that daily experiences of enacted stigma only significantly predicted concurrent anxious/depressed affect among individuals with average or higher than average (i.e., 1 SD above the mean) chronic enacted stigma exposure. Specifically, during observations when participants with average or higher than average chronic stigma exposure experienced an incident of enacted stigma, they reported more anxious/depressed affect than they did on days when they did not experience enacted stigma. However, anxious/depressed affect was not significantly elevated during observations when individuals with infrequent stigma exposure experienced an incident of enacted stigma.

Table 2.

Moderation of event-level effects of enacted stigma

Model Model Path b 95% CI p
Enacted Stigma → Negative Affect Unlagged Enacted Stigma → Negative Affect
 Average Slope .16 .10, .22 < .001
 Chronic Enacted Stigma → Slope .10 .04, .16 < .001
Lag 1 Enacted Stigma → Negative Affect
 Average Slope .05 −.02, .12 .15
 Chronic Enacted Stigma → Slope .09 .02, .16 .01
Lag 2 Enacted Stigma → Negative Affect
 Average Slope −.01 −.09, .06 .77
 Chronic Enacted Stigma → Slope .05 −.02, .11 .16
Enacted Stigma → Perceived Coping Efficacy Unlagged Enacted Stigma → Perceived Coping Efficacy
 Average Slope −.16 −.24, −.08, < .001
 Chronic Enacted Stigma → Slope −.14 −.21, −.07 < .001
Lag 1 Enacted Stigma → Perceived Coping Efficacy
 Average Slope .02 −.08, .13 .72
 Chronic Enacted Stigma → Slope −.08 −.17, .02 .10
Lag 2 Enacted Stigma → Perceived Coping Efficacy
 Average Slope .09 −.02, .21 .10
 Chronic Enacted Stigma → Slope −.18 −.28, −.08 < .001
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Within-person covariates included in all models: day of assessment; assessment type (weekend/weekday; morning/evening). First-order autocorrelations for the outcome were included in lagged models. Between-person covariates included: age, sexual identity, gender identity, and race/ethnicity.

Table 3.

Within-person simple slopes for significant interactions

Association Model Level of Moderator b 95% CI p
Enacted Stigma → Negative Affect Unlagged −1 SD Chronic Enacted Stigma .06 −.03, .15 .23
Mean Chronic Enacted Stigma .16 .10, .22 < .001
+1 SD Chronic Enacted Stigma .26 .19, .34 < .001
Lag 1 −1 SD Chronic Enacted Stigma −.04 −.15, .07 .50
Mean Chronic Enacted Stigma .05 −.02, .12 .15
+1 SD Chronic Enacted Stigma .14 .06, .23 < .001
Enacted Stigma → Perceived Coping Efficacy Unlagged −1 SD Chronic Enacted Stigma −.02 −.14, .10 .76
Mean Chronic Enacted Stigma −.16 −.24, −.08 < .001
+1 SD Chronic Enacted Stigma −.30 −.39, −.20 < .001
Lag 2 −1 SD Chronic Enacted Stigma .27 .10, .44 .001
Mean Chronic Enacted Stigma .09 −.02, .22 .10
+1 SD Chronic Enacted Stigma −.08 −.21, .04 .18
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A similar pattern emerged for the one timepoint lagged model, with daily experiences of enacted stigma predicting significant subsequent increases in anxious/depressed affect only among individuals with higher than average chronic stigma exposure. In other words, when participants with higher than average chronic stigma exposure experienced an incident of enacted stigma on one morning/afternoon, they experienced subsequent increases in anxious/depressed affect into that evening and the next morning.

The two timepoint lagged association was not moderated by chronic stigma exposure and the average within-person association between enacted stigma experienced during one morning/afternoon and anxious/depressed affect 24 hours later was not significant. This suggests that anxious/depressed affect is no longer increasing 24 hours following an experience of enacted stigma, often a single microaggression in the current study, even among individuals with high chronic stigma exposure.

Moderation of Within-Person Effects of Daily Enacted Stigma on Perceived Coping Efficacy

Chronic enacted stigma exposure significantly moderated unlagged and two timepoint lagged associations between daily experiences of enacted stigma and perceived coping efficacy but did not moderate this association when only a single lag was included between the stigma experience and perceived coping efficacy (Table 2). Examination of the simple slopes for the moderation of the unlagged analysis (Table 3) indicates that daily experiences of enacted stigma only significantly predicted lower concurrent perceived coping efficacy among individuals with average or higher than average (i.e., 1 SD above the mean) chronic enacted stigma exposure. Specifically, during observations when participants with average or higher than average chronic stigma exposure experienced an incident of enacted stigma, they reported lower perceived coping efficacy than they did on days when they did not experience enacted stigma. However, perceived coping efficacy was not significantly reduced during observations when individuals with infrequent stigma exposure experienced an incident of enacted stigma.

The single timepoint lagged model was not significantly moderated by chronic stigma exposure and the average within-person association between enacted stigma experienced during one morning/afternoon and anxious/depressed affect later that day was not significant. This suggests that perceived coping efficacy does not continue to decrease throughout the day following an experience of enacted stigma, but rather that this effect is relatively short lived.

The two timepoint lagged model was significantly moderated by chronic stigma exposure. Examination of the simple slopes indicates that daily experiences of enacted stigma predicted increases in perceived coping efficacy 12–24 hours after the enacted stigma experience among individuals with lower than average (i.e., 1 SD below the mean) chronic enacted stigma exposure. This suggests that individuals with low chronic stigma exposure may ultimately experience increases in perceived coping efficacy following a successful experience coping with enacted stigma, although this does not translate into lower anxious/depressed affect following an experience of enacted stigma.

Moderation of Within-Person Effects of General Stressors

Chronic enacted stigma exposure did not moderate any associations between daily experiences of general stressors and anxious/depressed affect or perceived coping efficacy (Table 4). The average unlagged, single lagged, and double lagged within-person associations between daily experiences of general stressors and anxious/depressed affect or perceived coping efficacy were significant. Specifically, during observations when participants experienced more general stressors than usual, they reported lower perceived coping efficacy and more anxious/depressed affect. Similarly, participants experienced significant increases in anxious/depressed affect and decreases in perceived coping efficacy in the evening/morning following an experience of general stress. In the double lagged model, the direction of the within-person effects flipped. Participants experienced significant decreases in anxious/depressed affect and increases in perceived coping efficacy 24 hours after an experience of general stress. This suggests that following an experience of general stress individuals may experience increases in perceived coping efficacy and decreases in anxious/depressed affect that may surpass their expected levels of perceived coping efficacy and anxious/depressed affect on days on which general stress was not experienced.

Table 4.

Moderation of event-level effects of general stress

Model Model Path b 95% CI p
General Stress → Negative Affect Unlagged General Stress → Negative Affect
 Average Slope .26 .25, .28 < .001
 Chronic Enacted Stigma → Slope −.002 −.02, .02 .82
Lag 1 General Stress → Negative Affect
 Average Slope .09 .07, .11 < .001
 Chronic Enacted Stigma → Slope .004 −.01, .02 .66
Lag 2 General Stress → Negative Affect
 Average Slope −.02 −.04, −.002 .03
 Chronic Enacted Stigma → Slope −.01 −.02, .01 .49
General Stress → Perceived Coping Efficacy Unlagged General Stress → Perceived Coping Efficacy
 Average Slope −.26 −.29, −.23 < .001
 Chronic Enacted Stigma → Slope −.01 −.05, .01 .33
Lag 1 General Stress → Perceived Coping Efficacy
 Average Slope −.10 −.12, −.07 < .001
 Chronic Enacted Stigma → Slope −.01 −.04, .02 .49
Lag 2 General Stress → Perceived Coping Efficacy
 Average Slope .04 .02, .07 < .001
 Chronic Enacted Stigma → Slope .01 −.01, .04 .32
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Within-person covariates included in all models: day of assessment; assessment type (weekend/weekday; morning/evening). First-order autocorrelations for the outcome were included in lagged models. Between-person covariates included: age, sexual identity, gender identity, and race/ethnicity.

Sensitivity Analyses

Sensitivity analyses including only sexual minority cisgender women demonstrated the same pattern of results as analyses including both sexual minority cisgender women and gender diverse individuals, suggesting that it is appropriate to combine these groups in the current analyses.

Discussion

The current study was among the first to examine how chronic and acute enacted stigma exposure interact to predict anxious/depressed affect and perceived coping efficacy among SGM. Results provide support for the sensitivity hypothesis, indicating that daily experiences of enacted stigma more strongly predict increases in anxious/depressed affect and decreases in perceived coping efficacy among SMWGD who have a history of chronic exposure to enacted stigma. Further, effects of daily enacted stigma on anxious/depressed affect persisted for longer among those with moderate to high chronic stigma exposure. Some additional notable findings emerged. SMWGD with low chronic stigma exposure appeared to be resilient in the face of daily experiences of enacted stigma as they did not experience significant changes in anxious/depressed affect or perceived coping efficacy following such experiences. Chronic stigma exposure did not amplify reactivity to daily general stressors (i.e., those unrelated to one’s sexual identity), indicating that chronic stigma exposure may only sensitize individuals to future experiences of stigma-related stressors.

Chronic Stigma Exposure and Reactivity to Daily Stigma Experiences

Chronic stigma exposure significantly moderated event-level associations between daily enacted stigma and anxious/depressed affect, such that daily enacted stigma experiences predicted elevated concurrent anxious/depressed affect for those with moderate to high chronic stigma exposure. These findings are consistent with results of Livingston et al. (2020) who found a similar pattern of concurrent results, but inconsistent with Ong et al. (2009) who did not find support for this pattern of moderation. Differences in the type of chronic and daily stigma exposure examined (i.e., sexual minority stigma in this study and racism in Ong et al.) and differences in the age, sexual orientation, and racial/ethnic compositions of the two samples may help to explain why Livingston and our findings may diverge from Ong’s results. For example, research with the general population indicate that stress reactivity may differ for young adults and older adults (Stawski et al., 2019), suggesting that samples from different developmental periods may find different results.

Our study further builds upon these prior studies by demonstrating that daily enacted stigma also predicted concurrent decreases in perceived coping efficacy. These reductions in perceived coping efficacy alongside increases in anxious/depressed affect suggest that not only does the sensitivity hypothesis apply to enacted stigma but that this elevated reactivity to stigma may arise from coping depletion as proposed by Hammen et al. (2000). Our results also build on the results of Livingston et al. (2020) and Ong et al. (2009) by demonstrating that increases in anxious/depressed affect following experiences of daily enacted stigma persist for longer among those with high levels of chronic stigma exposure – something not directly posited by Hammen et al. (2000) or tested by prior work on stress reactivity. This differential duration of lagged effects of enacted stigma may help to explain the somewhat mixed literature on prospective effects of enacted stigma on affect in EMA studies, as a sample with a higher proportion of individuals with chronic stigma exposure may find a significant average effect while studies with a lower proportion may not. These findings also highlight several potential directions for future research. For example, the greater risk hypothesis in intersectionality theory posits that exposure to stigma based on multiple marginalized identities may deplete coping resources and amplify the effects of experiences of enacted stigma. As these theorized mechanisms parallel those posited by the sensitivity hypothesis, methods like those used in the current study may help to test the greater risk hypothesis.

In contrast to our hypothesis that daily stigma experiences would predict elevated anxious/depressed affect and decreased perceived coping efficacy for all participants, individuals with low levels of chronic stigma exposure displayed remarkable resilience in the face of daily stigma experiences. Their anxious/depressed affect and perceived coping efficacy did not differ significantly on days when they experienced enacted stigma compared to when they did not. The lack of changes in both affect and perceived coping efficacy is consistent with the sensitivity hypothesis, which proposes that it is the overburdening of coping resources that contributes to elevated stress reactivity. This suggests that individuals with low chronic stigma exposure were able to leverage coping resources to counter the negative effects of a daily enacted stigma event. These resources may have been overburdened and depleted among those with moderate to high chronic stigma exposure as indicated by reductions in perceived coping efficacy following enacted stigma experiences among those with moderate to high chronic stigma exposure. Future work should examine whether individuals with low chronic stigma exposure may be more likely to engage in coping strategies that effectively reduce anxious/depressed affect (e.g., reappraisal) and if this accounts for their lower levels of reactivity to daily stigma experiences.

Duration of Effects of a Microaggression

How long does the effect of a microaggression last? While a few studies have examined prospective effects between enacted stigma and affect at the daily level, studies to date have not directly aimed to test whether the effects of enacted stigma persist past a single lag. In an exception, Livingston et al. (2017) demonstrated that substance use was most likely later in the day after an experience of enacted stigma. The current study sheds some additional light on the duration of the effects of daily enacted stigma experiences on affect. Results suggest that the effects of daily stigma on anxious/depressed affect persist throughout the day and into the next morning for those with high chronic stigma exposure. However, these effects are no longer detectable 24 hours after the stigma experience. This is very similar to the duration of detectable effects of general stressors in the current study, which indicate that anxious/depressed affect following a general stressor has rebounded to above the expected level if no stressor was experienced by 24 hours after the stressor occurred. Of note, this pattern of affect rebounding past an individual’s typical level following a stressor has been documented in other studies in the general population and has been attributed to successfully coping with the stressor or relief that the stressors has passed (DeLongis et al., 1988). While these findings indicate that the duration of event-level effects of daily enacted stigma is relatively brief even among those with high chronic stigma exposure, we also detected between-person effects of enacted stigma. Individuals who experienced more enacted stigma during the EMA period reported more anxious/depressed affect on average across the study, highlighting the longer-term cumulative impact of these stressors despite their short-term event-level effects. Further, these individuals’ daily experiences accumulate, contributing over time to higher chronic stress exposure and likely further increasing reactivity to individual experiences of stigma. This study demonstrates both the short and long-term potential effects of exposure to individual enacted stigma events and the accumulation of these experiences over time.

Chronic Stigma Exposure and Reactivity to Daily General Stressors

In contrast to the pattern demonstrated for daily enacted stigma, chronic stigma exposure did not amplify affective reactivity to daily general stressors or contribute to greater decreases in perceived coping efficacy following daily general stressors. This suggests that the exacerbating effects of chronic stigma exposure are unique to daily experiences within the same domain. This is intriguing as many prior studies have demonstrated cross domain effects of chronic stress on reactivity to daily stressors in other domains (e.g., chronic home stress affecting reactivity to daily work stressors and childhood trauma affecting reactivity to daily stressors; Leger et al., 2022; Lockwood et al., 2022; Mayer et al., 2022; Serido et al., 2004). If chronic exposure to stigma was simply depleting resources for coping with stress in general, chronic stigma exposure would also predict increased reactivity to other types of daily stressors. Therefore, this finding suggests that something more nuanced is happening as a result of chronic stigma exposure that makes its exacerbating effects unique to stigma-based stressors. Potential underlying factors are numerous. One possibility is that chronic stigma exposure may drain coping resources that are particularly effective at reducing reactivity to stigma-related stressors, although it is unclear what those stigma-specific coping resources are. Another possibility is that chronic stigma exposure may change an individual’s appraisal of future experiences of stigma, making future experiences appear to be more negative and as a result more difficult to cope with. Alternatively, chronic stigma exposure may trigger distinct reactions to future experiences of stigma. For example, the heavy psychological and emotional toll of continued exposure to stigma may contribute to a sense of fatigue and feelings of helplessness or frustration. These reactions in turn may uniquely reduce individuals’ ability to cope with future experiences of stigma. Future research should explore potential factors that may lead chronic stigma exposure to uniquely amplify reactivity to daily experiences of enacted stigma.

Clinical Implications

Study findings indicate that the accumulation of experiences of enacted stigma may not only directly contribute to high average anxious/depressed affect but may also amplify the negative effects of future experiences of enacted stigma. This dual effect of cumulative enacted stigma exposure may ultimately have profound negative effects on the mental health of SGM individuals as the accumulation of enacted stigma continues over time. This accumulation further heightens reactivity to subsequent experiences of enacted stigma, resulting in a snowballing of the effect of enacted stigma. This highlights the need for interventions that may help to buffer these effects by reducing reactivity to experiences of enacted stigma. Two existing evidence-based interventions aim to reduce anxiety and depression among SGM by teaching effective skills for coping with stigma-related stress (i.e., ESTEEM and EQUIP; Pachankis et al., 2015; Pachankis et al., 2020). These interventions teach strategies for disrupting ruminative thought patterns and encourage the use of reappraisal in coping with stigma-related stress experiences. These interventions produce significant decreases in anxiety and depression as well as in rumination and emotion dysregulation broadly (Pachankis et al., 2015; Pachankis et al., 2020). Such interventions are theorized to operate in part by reducing the impact of stigma-related stress experiences on mental health by decreasing the use of maladaptive and increase the use of adaptive strategies for coping with stigma-related stress experiences, making these ideal interventions for reducing reactivity to stigma-related stress experiences among individuals with chronic stigma exposure. That said, it is important to acknowledge that SGM individuals’ stigma-related experiences are rooted in other people’s negative attitudes toward and stereotypes about SGM individuals. As such, efforts to improve SGM health at the individual level must be paired with efforts to dismantle the oppressive systems that maintain negative attitudes toward SGM individuals.

Limitations

Study findings should be considered in light of their limitations. First, individuals who used alcohol or cannabis regularly, lived in the US, and were between ages 18 and 25 were included in this study. As a result, it is unclear whether similar patterns will be found among SMWGD who live outside the US, older individuals or adolescents, or those who use alcohol or cannabis less frequently. Notably, monthly cannabis use and binge drinking are common in this age group, with 20–22% of 18–25 year old individuals living in the US engaging in cannabis use in the past month from 2015–2019 (Palamar et al., 2021) and 29.2% having engaged in binge drinking in the past month in 2022 (Substance Abuse and Mental Health Services Administration, 2023a). These rates are consistently higher among SMWGD compared to heterosexual women (for review see Dyar, 2022). For example, 27.4% of 18–25 year old sexual minority women reported using cannabis 3+ days in the past month, compared to only 13.5% of 18–25 year old heterosexual women (Substance Abuse and Mental Health Services Administration, 2023b). Therefore, while the alcohol and cannabis inclusion criteria used for this study limit the generalizability of these findings, they likely generalize to a large proportion of SMWGD between ages 18–25 who live in the US. Second, we did not assess chronic experiences of general stress during the baseline survey and were thus unable to determine whether chronic exposure to non-identity related stressors may also contribute to amplified reactivity to daily experiences of stigma. Third, this study focused on sexual minority stigma; future research should consider how the current study findings do or do not generalize to stigma based on other identities and to the effects of experiencing stigma based on multiple marginalized identities.

Conclusions

The current manuscript utilized EMA data to determine whether chronic stigma exposure amplified the impact of daily experiences of enacted stigma on anxious/depressed affect and perceived coping efficacy. Results demonstrate that individuals with chronic stigma exposure experience larger increases in anxious/depressed affect and larger decreases in perceived coping efficacy following daily experiences of enacted stigma. Further, these effects of daily stigma on anxious/depressed affect persist for longer in this population. These results help to advance our understanding of both long-term and daily effects of exposure to enacted stigma, highlighting the potentially profound cumulative effects of stigma exposure and the need to intervene in this cycle.

Supplementary Material

Supplementary Materials

Acknowledgements:

We would like to thank Shariell Crosby and Sophia Pirog for their invaluable work on this project. We also thank Project QuEST participants for their vital contributions to understanding substance use among sexual minority women and gender diverse individuals.

Role of Funding Sources

This research was supported by a grant from the National Institute on Drug Abuse (K01DA046716; PI: Dyar). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Author Note:

The study received IRB approval at Northwestern University (STU00208936; where data was collected) and Ohio State University (2021B0225; where data is stored).

Footnotes

1

Cannabis use criteria were selected to provide adequate power (which increases as the expected number of alcohol and cannabis use days reported increases) while maintaining generalizability (by keeping the criteria for the minimum number of substance use days reported at baseline low) and to be broadly consistent with inclusion criteria of other EMA studies of cannabis use.

2

MSEM utilizes latent variables, rather than group- and grand-mean centering, to separate within- from between-person variance (Ludtke et al., 2008). By removing the between-person variance from the within-person variance, the within-person variables indicate the extent to which an individual was experiencing more/less of a construct than usual (above/below their person mean) on a particular day (e.g., experiencing more/less minority stress than usual).

3

We used Markov Chain Monte Carlo (MCMC) algorithms to generate a series of 100,000–300,000 random draws from the multivariate posterior distribution of our sample for each model. Thinning by a factor of 10 was used to reduce the correlation between estimates produced by adjacent random draws, resulting in 10,000–30,000 random draws that were used to estimate model parameters. Trace plots and the Gelman-Rubin potential scaling reduction (PSR) were used to determine whether convergence was achieved (Depaoli & Clifton, 2015; Muthen, 2010).

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