An Evaluation of Resilience as a Protective Factor for Mental Health Among Sexual and Gender Minority Young People

Abstract

Purpose:

Sexual and gender minority (SGM) individuals often face minority stressors that negatively affect their mental health, making it important to identify protective factors against the adverse psychological effects of minority stress. We investigated the potential protective effect of trait resilience in SGM individuals assigned female at birth (SGM-AFAB), who are understudied despite being at particularly high risk for mental health problems.

Methods:

As part of an ongoing longitudinal cohort study, 452 SGM-AFAB young people (age 16–31 years) completed measures of resilience, minority stressors (victimization, microaggressions, internalized heterosexism, and cisgenderism), and mental health (depression, anxiety, suicidal ideation) in 2017–2018. Moderating effects of resilience on associations between the minority stressors and mental health outcomes were tested using regression analyses.

Results:

Resilience attenuated the positive associations of microaggressions with both depression and anxiety and of internalized cisgenderism with depression (in transgender and gender-diverse participants), suggesting protective effects. Resilience did not moderate any other associations.

Conclusion:

These findings suggest that resilience serves as a protective factor against depressive and anxiety symptoms following experiences of microaggressions and against depressive symptoms following internalized cisgenderism among diverse SGM-AFAB individuals. These results underscore the importance of identifying factors that bolster resilience and developing intervention strategies aimed at promoting resilience within SGM-AFAB individuals, especially following experiences of microaggressions and internalized cisgenderism.

Introduction

Sexual and gender minority (SGM) individuals face significant stressors grounded in societal stigma, including both distal (e.g., anti-SGM victimization, discrimination, and microaggressions) and proximal minority stressors (e.g., internalized stigma),¹ which are consistently associated with poor mental health outcomes.^2–5 The systemic changes needed to reduce the burden of stigma on SGM people are likely to be slow, making it important to identify factors that protect SGM people from the negative psychological effects of minority stress until those changes occur. This is particularly true for SGM individuals assigned female at birth (SGM-AFAB), who experience pronounced levels of depression, anxiety, and suicidality.^6–9

Resilience

Resilience, defined as one’s ability to effectively adapt to adverse events and achieve positive outcomes,¹⁰ represents one promising protective factor for SGM mental health. Although it can be argued that resilience is present any time a person achieves a positive outcome following adversity, we conceptualize resilience as an individual trait that reflects one’s consistent capacity to adapt and thrive in the face of stressful experiences.^10,11 This conceptualization is the most informative for evaluating whether efforts to build SGM individual’s resilience (i.e., skills for overcoming adversity) may promote their mental health. Resilience theory proposes two broad models of how resilience can affect outcomes.¹² In the compensatory model, resilience counteracts risk through an independent, direct effect on outcomes. Consistent with this model, studies consistently show that higher trait resilience is concurrently associated with fewer symptoms of depression, anxiety, and suicidal ideation in the general population¹³ as well as among SGM youth and young adults.^14–18

Alternatively, the protective factor model posits that resilience mitigates the negative mental health effects of stress. In line with this model, Minority Stress theory,^1,19 the dominant framework for understanding SGM mental health, proposes that trait resilience can weaken the adverse effects of minority stress on mental health. In several general population studies, resilience attenuated the associations of stressful experiences—including bullying victimization and mental illness stigma—with poor mental health, supporting it as a protective factor.^20–24 Research on SGM populations, however, is sparse and has yielded mixed results that vary across different minority stressors and different mental health outcomes.

In the handful of existing studies, resilience attenuated the association of everyday forms of discrimination, including microaggressions, with suicide attempts¹⁷ and suicidal ideation,²⁵ but not with anxiety;²⁵ effects were inconsistent for depressive symptoms. Resilience also buffered effects of discrimination on depressive symptoms and psychological distress among bisexual women²⁶ and transgender and gender diverse (TGD) individuals.²⁷ Other studies have not replicated the association between anti-SGM victimization and mental health outcomes, including depression and suicide. Resilience also did not moderate associations of gender-related rejection with depression in TGD individuals²⁷ or antibisexual discrimination among bisexual adults.²⁶ The only two studies exploring whether resilience buffers the negative effects of internalized stigma on mental health used samples of TGD individuals; neither found evidence of a buffering effect.^26,27

Together, these findings suggest that resilience may be a protective factor for mental health among SGM people experiencing minority stressors, but only for certain minority stressors and mental health outcomes. Additional research is needed to clarify these associations.

Current study

The current study explored resilience as a potential protective factor against adverse mental health effects of minority stress among SGM-AFAB young people (late adolescents and young adults). Addressing limitations of existing research, including the use of predominantly White samples and limited assessment of minority stressors and mental health, we tested whether resilience attenuates the associations between different types of minority stress (including distal and proximal minority stressors) and various mental health outcomes (depression, anxiety, and suicidality) in a racially diverse SGM-AFAB sample. We focused on SGM-AFAB individuals because they are underrepresented in research²⁸ despite facing significant mental health disparities, and on late adolescence and young adulthood, the developmental eras during which mental health disparities peak among SGM individuals.^7,29

Methods

Participants and procedure

Data were drawn from FAB400, an ongoing longitudinal cohort study involving 488 adolescents and young adults (age 16–31 years at baseline, in 2016–2017) who identified as a SGM-AFAB individual. Eligibility criteria included being AFAB (i.e., sexual minority women, transgender men, and gender diverse individuals), fluent in English, and either identifying as a sexual or gender minority individual or reporting same-sex attraction or behavior. Participants were recruited through SGM-focused community venues in a major Midwestern city and through social media platforms. Enrolled participants could refer up to five peers and receive $10 for each successful referral. Participants received $50 compensation for each of seven study visits, which occurred every 6 months.

The study was approved by the institutional review board (IRB) at Northwestern University with a waiver of parental permission for participants under 18 years of age, under 45 CFR 46, 408(c). Informed consent was obtained from all participants of age 18 years or older, and informed assent was obtained from those younger than 18 years old.

For the current study, we used data from Wave 2, when resilience was first assessed. These data were collected from May 2017 to June 2018 from 452 participants who were diverse in racial, gender, and sexual identity (see Table 1 for sample descriptives).

Table 1.

Demographic Characteristics of the Sample

Variable	N (%)
Race
White	120 (26.5)
Black	167 (36.9)
Latinx	103 (22.8)
Other	62 (13.7)
Multiracial	34 (7.5)
Asian	25 (5.5)
Middle Eastern/North African	2 (<0.1)
Not indicated	1 (<0.1)
Sexual orientation
Monosexual	109 (24.1)
Gay	16 (3.5)
Lesbian	93 (20.6)
Bi+	232 (51.3)
Bisexual	161 (35.6)
Pansexual	71 (15.7)
Other	111 (24.6)
Queer	74 (16.4)
Asexual	11 (2.4)
Unsure/Questioning	15 (3.3)
Straight	5 (1.1)
Not listed	6 (1.3)
Gender identity
Cisgender	319 (70.6)
Transgender/gender diverse	132 (29.2)
Transgender	28 (6.2)
Male	14 (3.1)
Gender nonconforming	13 (2.9)
Gender queer	17 (3.8)
Nonbinary	57 (12.6)
Not listed	3 (0.7)
Decline to answer	1 (0.2)

Measures

Minority stress

Victimization

Using 10 items from the Daily Heterosexist Experiences Questionnaire,³⁰ participants rated the frequency of experiencing each of 10 acts of victimization (e.g., had an object thrown at you) “because you are, or were thought to be gay, lesbian, bisexual, or trans*.” This measure has shown reliability among other samples of SGM individuals.³¹ Items were rated on a six-point scale (0 = never to 5 = more than 10 times) and averaged (α = 0.68).

Microaggressions

On the 19-item Sexual Orientation Microaggressions Inventory, a reliable and valid measure of microaggressions among SGM individuals,³² participants reported how often they experienced common heterosexist microaggressions (e.g., “You were told not to ‘act so gay’”) on a five-point scale (1 = not at all to 5 = almost every day). Scores reflect average ratings across items (α = 0.91)

Internalized heterosexism

On the eight-item Desire to be Heterosexual subscale of the Internalized Homophobia Measure, which has demonstrated validity in SGM samples,³³ participants rated their agreement with statements (e.g., “Sometimes I feel ashamed of my sexual orientation”; 1 = strongly disagree to 4 = strongly agree). Scores were calculated by averaging ratings across items (α = 0.85).

Internalized cisgenderism

Participants who identified as TGD (i.e., as any identity other than female) completed a version of the eight-item Internalized Homophobia Measure³³ adapted for this study to assess internalized cisgenderism by referring to feelings about one’s minority gender identity rather than minority sexual identity. Participants rated agreement with items (e.g., “Sometimes I think that if I were cisgender, I would probably be happier;” 1 = strongly disagree to 4 = strongly agree). Scores represent the mean ratings across items (α = 0.85).

Resilience

On the Connor-Davidson Resilience Scale,³⁴ a reliable measure of trait resilience among SGM individuals,²⁷ participants responded to 10 statements (e.g., “I am able to adapt when changes occur”) on a five-point Likert-type scale (0 = not true at all to 4 = true nearly all the time). Item responses were summed (possible range 0–40; α = 0.91). Higher scores indicated higher trait resilience.

Mental health

Depressive and anxiety symptoms

Symptoms of depression and anxiety were measured using the Patient-Reported Outcomes Measurement Information System Depression and Anxiety Short Forms 8a,³⁵ which have demonstrated good psychometric properties in SGM samples.^36,37 Participants rated the frequency of experiencing each of eight depressive and eight anxiety symptoms in the past 7 days using a five-point Likert-type scale (1 = never to 5 = always). Scores represent the sum of items (possible range 8–40), with higher scores indicating higher levels of symptoms (depressive symptoms α = 0.95; anxiety symptoms α = 0.94).

Suicidal ideation

Modeling previous studies,^38–40 suicidal ideation was assessed using a single item from the Brief Symptom Inventory⁴¹ on which participants rated how intensely thoughts of ending their life distressed or bothered them during the past seven days (1 = not at all to 5 = extremely).

Demographic characteristics

Race/ethnicity

Participants reported their race (American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, or other) and ethnicity (whether they identified as Hispanic or Latino/Latina/Latinx). Participants who chose the “other” racial identity option were given the opportunity to specify their racial identity. Following National Institutes of Health recommendations,⁴² individuals who identified as Latinx were classified as such, regardless of race. For analyses, race/ethnicity was categorized into four groups: White, Black, Latinx, and Other (Asian, Multiracial, and Middle Eastern/North African, due to small numbers of each).

Sexual orientation

Participants were asked, “Which of the following commonly used terms best describes your sexual orientation/identity?” (gay, lesbian, bisexual, queer, unsure/questioning, straight/heterosexual, pansexual, asexual, or “not listed”). Responses were coded into three categories: monosexual (gay/lesbian), bi+ (bisexual and pansexual), and other (queer, straight, unsure/questioning, asexual, and not listed).

Gender identity

Each participant was asked, “What is your current gender identity?” with options including female, male, transgender, gender nonconforming, gender queer, and nonbinary, and not listed (please specify). Because all participants were AFAB, responses were coded as cisgender (female) or TGD (male, transgender, nonconforming, gender queer, nonbinary, and not listed).

Data analysis

For analyses predicting depression and anxiety, data from all 452 participants were used. Because 75 participants who completed the assessment remotely did not receive the suicidal ideation measure (per IRB requirements), analyses predicting suicidal ideation used data from only 378 participants. Analyses involving internalized cisgenderism included the 132 (29.2%) TGD participants who completed this measure.

Hypotheses were tested with hierarchical regression analyses using the PROCESS macro in SPSS version 29.⁴³ In step one of each model, one mental health outcome (i.e., depression, anxiety, suicidal ideation) was regressed onto one minority stress variable (i.e., microaggressions, victimization, internalized heterosexism, internalized cisgenderism) and demographic controls (dummy-coded variables for race, sexual orientation, and gender identity). This assessed for associations between each minority stressor and mental health outcome in the full sample. In step two, we added resilience and an interaction term (calculated by multiplying the minority stress predictor with resilience) that tested the moderating effect of resilience. According to standard practice,⁴³ simple slopes analyses were used to probe all interactions with significance values of p < 0.10.

Results

Means and standard deviations for all variables, as well as zero-order correlations among variables, are presented in Table 2. Resilience was associated with fewer depressive and anxiety symptoms and less suicidal ideation (Pearson correlation coefficients [r] = −0.24 to −0.47). All four minority stressors were positively correlated with each of the mental health outcomes (rs = 0.10–0.26).

Table 2. Means, Standard Deviations, and Correlations

Variable	M	SD	1	2	3	4	5	6	7	8
1. Age	20.36	3.52
2. Victimization	0.20	0.32	−0.08
3. Microaggression	1.63	0.52	−0.15**	0.63**
4. Internalized heterosexism	1.65	0.56	−0.22**	0.14**	0.17**
5. Internalized cisgenderism	2.23	0.75	−0.29**	0.09	0.20*	0.55**
6. Resilience	25.84	7.76	0.23**	−0.06	−0.06	−0.27**	−0.26**
7. Depression	17.30	7.84	−0.19**	0.20**	0.26**	0.26**	0.25**	−0.47**
8. Anxiety	18.89	7.82	−0.23**	0.22**	0.24**	0.23**	0.21*	−0.46**	0.77**
9. Suicidal Ideation	1.21	0.53	−0.10	0.13**	0.12*	0.10*	0.19*	−0.24**	0.44**	0.35**

*p ≤ 0.05; **p ≤ 0.01.

M, Mean; SD, standard deviation.

Results of regression analyses indicated that most of the associations between the minority stressors and mental health persisted when controlling for race, sexual orientation, and gender identity (see Table 3, “Step 1” columns). Exceptions were the associations between internalized cisgenderism with both depression and anxiety, and the associations of victimization, microaggressions, and internalized cisgenderism with suicidal ideation, which became nonsignificant in these models.

Table 3. Results of Hierarchical Regression Analyses Predicting Mental Health

	Mental health outcome
	Depression		Anxiety		Suicidal ideation
	Step 1	Step 2	Step 1	Step 2	Step 1	Step 2
Predictor	b (SE)	b (SE)	b (SE)	b (SE)	b (SE)	b (SE)
Victimization	4.52 (1.13)**	4.43 (1.04)**	4.61 (1.13)**	4.44 (1.02)**	0.14 (0.09)	0.18 (0.09)*
Resilience		−0.44 (1.04)**		−0.41 (0.04)**		−0.01 (0.003)**
Victimization × Resilience		−0.20 (0.14)		0.08 (0.13)		0.001 (0.01)
Microaggressions	3.78 (0.68)**	3.62 (0.63)**	3.22 (0.69)**	3.27 (0.63)**	0.09 (0.05)	0.11 (0.05)*
Resilience		−0.45 (0.04)**		−0.42 (0.04)**		−0.01 (0.004)**
Microaggressions × Resilience		−0.18 (0.08)**		−0.13 (0.08)†		−0.004 (0.006)
Internalized heterosexism	2.42 (0.64)**	1.83 (0.61)**	2.30 (0.64)**	1.28 (0.61)*	0.11 (0.05)*	0.03 (0.05)
Resilience		−0.43 (0.05)**		−0.41 (0.05)**		−0.01 (0.003)**
Internalized heterosexism × Resilience		−0.04 (0.08)		0.02 (0.08)		−0.008 (0.006)
Internalized cisgenderism	0.83 (0.93)	1.39 (0.89)	1.59 (0.92)†	1.33 (0.97)	0.16 (0.08)†	0.18 (0.09)*
Resilience		−0.48 (0.08)**		−0.43 (0.09)**		−0.02 (0.008)*
Internalized cisgenderism × Resilience		−0.22 (0.11)*		−0.12 (0.12)		−0.02 (0.01)

All models were estimated controlling for race, sexual orientation, and gender identity. Separate models were used for each minority stress predictor.

†p ≤ 0.10; *p ≤ 0.05; **p ≤ 0.01.

B, unstandardized beta; SE, standard error.

Tests of resilience as a protective factor

Results from regression models testing resilience as a moderator of the association between minority stressors and mental health outcomes are presented in Table 3 (see “Step 2” columns). Only three tests of moderation were statistically significant: the interaction between microaggressions and resilience was associated with both depressive and anxiety symptoms, and the interaction between internalized cisgenderism and resilience was associated with depressive symptoms.

Simple slopes analysis revealed that although there was a positive association between microaggressions and depressive symptoms across levels of resilience, including low [unstandardized beta (B) = 5.04, standard error (SE) = 0.91, t-statistic (t)(436) = 5.51, p value (p) <0.001], average [B = 3.62, SE = 0.63, t(436) = 5.79, p < 0.001], and high levels of resilience [B = 2.20, SE = 0.79, t(436) = 2.78, p < 0.01], this association was weaker at higher versus lower levels of resilience (see Fig. 1A).

FIG. 1.

Associations between minority stressors and mental health, by level of resilience. Low, average, and high values are −1 standard deviation, the mean, and +1 standard deviation from the mean, respectively. *p <0.05.

The same pattern was observed for the association between microaggressions and anxiety symptoms. Simple slopes analysis showed a positive association between microaggressions and anxiety symptoms across levels of resilience, including low [B = 4.27, SE = 0.91, t(436) = 4.67, p < 0.001], average [B = 3.27, SE = 0.63, t(436) = 5.22, p < 0.001], and high levels of resilience [B = 2.27, SE = 0.79, t(436) = 2.86, p < 0.01]; yet, this association was weaker at higher levels of resilience (see Fig. 1B).

Simple slopes analysis decomposing the moderating effect of resilience on the association between internalized cisgenderism and depression revealed a positive association between internalized cisgenderism and depression for individuals with low levels of resilience [B = 3.03, SE = 1.37, t(121) = 2.22, p = 0.03], but not for those with average levels [B = 1.39, SE = 0.89, t(121) = 1.56, p = 0.12] or high levels of resilience [B = −0.25, SE = 1.06, t(121) = −0.23, p = 0.81] (see Fig. 1C).

Resilience showed no moderating effect on the associations between either victimization or internalized heterosexism and any mental health outcome.

Discussion

Overall, these study findings suggest that resilience may act as a protective factor for mental health among SGM-AFAB young people; however, its protective effect may be present for only certain mental health outcomes in the face of particular minority stress experiences. Specifically, these data suggest that resilience buffers the effects of microaggressions on both depressive and anxiety symptoms, as well as the effects of internalized cisgenderism on depressive symptoms among TGD individuals. In contrast, we observed no evidence that resilience protects SGM-AFAB young adults from negative mental health effects of internalized heterosexism or victimization or that it protects against the adverse effects of any minority stressor on suicidality.

Our findings highlight the potential of resilience to protect SGM-AFAB young people against internalizing symptoms in the face of both distal and proximal minority stress. Extending previous evidence that resilience was protective against discrimination’s effects on internalizing symptoms,^25,27,44 we found that resilience similarly protects against the negative effects of microaggressions, or everyday—often covert—experiences of stigma, although it did not entirely eliminate these effects. This is particularly important given the high frequency with which SGM individuals face microaggressions⁴⁵ and their stronger associations with internalizing symptoms compared to other distal stressors.⁴⁶

Further, among TGD participants, resilience attenuated the association between internalized cisgenderism and depressive symptoms, such that the association was present for only individuals with low resilience. Contrasting previous findings,²⁵ this suggests that resilience may protect TGD people against internalizing symptoms in the face of proximal minority stress. Interestingly, however, resilience did not show a protective effect against internalized heterosexism in this sample. More research is needed to better understand the nuances of resilience as a protective factor against the adverse psychological effects of proximal minority stress, including internalization of stigma against different minoritized identities.

In contrast, resilience did not attenuate the small positive associations of anti-SGM victimization with the mental health outcomes in this study, echoing past findings that resilience did not buffer associations between anti-SGM victimization and either depression or suicidality.^17,27 Perhaps the severity or acuity of victimization events (e.g., violence, property destruction) overwhelms even highly resilient SGM individuals’ coping abilities in ways that microaggressions and some forms of internalized stigma do not. Future research is needed to identify other factors that can support SGM victims of these events, protecting them from adverse mental health outcomes.

The present findings revealed no support for a protective effect of resilience on suicidality. This could be related to our use of a nonclinical community sample with low levels of suicidal ideation (Mean = 1.21 on a 1–5 scale). In past research, resilience attenuated the association between victimization and suicidal behaviors for SGM individuals with a mental health diagnosis but not for those without a diagnosis.⁴⁴ Together, these findings suggest that resilience may not have a protective effect for the many SGM young people without diagnosed psychopathology; research is needed to identify protective factors for this group.

Limitations

Conclusions should be drawn keeping study limitations in mind. The cross-sectional nature of the data prohibits conclusions about direction of effects. Future longitudinal research could establish temporal ordering and more rigorously test for protective effects. Generalizability of findings may be limited by the community-based, nonprobability sample that did not include SGM individuals assigned male at birth or older adults. Our measure of victimization showed somewhat low reliability, which may attenuate its associations with other variables.

As with all measures of individual traits, self-reports of resilience may have been affected by some individuals’ restricted self-awareness, overestimation of their positive attributes,^47,48 or emotional state at the time of data collection. We only assessed resilience at the individual level; future research should explore how resilience at other levels (e.g., the community) affects SGM mental health. Further, focusing solely on trait resilience risks placing the burden of overcoming adversity on the individual, neglecting pervasive systemic issues that SGM individuals face, and perpetuating discrimination.^19,49 We recognize the need for systemic change to address the harmful effects of inequities and stigma faced by SGM individuals.

Conclusion

Despite these limitations, the study findings extend the literature by positioning resilience as a potential protective factor against depression and anxiety following experiences of microaggressions and internalized cisgenderism among diverse SGM-AFAB individuals. As such, this study underscores the importance of efforts to enhance resilience within the SGM-AFAB community, a group that experiences striking disparities in mental health^6,7,50 and is understudied in the literature.²⁸ For example, the “Positive Action—Promoting Change” program,⁵¹ a group intervention for transgender individuals that focuses on empowerment via strengthening identity and sharing stigmatizing experiences, has shown efficacy in building resilience in a pilot study. Future tailored interventions to promote mental health among SGM-AFAB young people could adopt similar resilience-enhancing strategies along with psychoeducation on how minority stress affects mental health.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Authors’ Contributions

C.G.: Conceptualization, methodology, investigation, writing—original draft preparation, visualization. M.E.N.: Methodology, writing—original draft, review and editing, supervision. S.W.W.: Conceptualization, methodology, writing—original draft, review and editing, supervision, funding acquisition.

Author Disclosure Statement

The authors report there are no competing interests to declare.

Funding Information

Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number R01HD086170.