Identity in turmoil: Investigating the morally injurious dimensions of minority stress

ABSTRACT

Background: Sexual and gender minorities (SGMs) are at an increased risk for developing mental health disorders due to their socially stigmatized identities. Minority stress (i.e. discrimination, identity nondisclosure, internalized stigma) has been shown to impact mental health outcomes among SGMs. Both distal and proximal minority stressors may serve as potentially morally injurious events (PMIEs), which may lead to moral injury and trauma/stressor-related symptoms. Critically, minority stress-related moral injury among SGMs has never before been explored using a mixed-methods approach.

Methods: Thirty-seven SGM participants with diverse minority identities participated in the study. Using a convergent parallel mixed-methods design, we conducted semi-structured qualitative interviews, performed clinical assessments, and administered a comprehensive battery of quantitative measures. Here, we modified the Moral Injury Event Scale (MIES) for use with SGMs. Qualitative themes were extracted and then converged with MIES scores to investigate differential thematic presentations based on the quantitative intensity of SGM-related PMIEs.

Results: Data analysis indicated four core themes related to moral injury among SGMs: shame (internalizing stigma), guilt, betrayal/loss of trust, and attachment injuries (rejection, altered sense-of-self, and social cognition). The qualitative presentation of these themes differed depending on MIES severity. Attachment injuries emerged as a unique core feature of moral injury among SGMs, whereby the remaining core themes align with previous moral injury research. Furthermore, quantitative analyses revealed that the level of exposure to and intensity of minority stress-related PMIEs was positively associated with hazardous alcohol use and trauma-related symptoms.

Conclusions: This is the first mixed-methods study to investigate minority stressors as PMIEs, highlighting how these experiences may contribute to symptoms of moral injury among SGMs. Moral injury may serve as a valuable framework for better understanding trauma-related symptoms and mental health disparities among SGMs. These findings have the potential to inform novel treatment interventions aimed at addressing mental health burdens among SGMs.

HIGHLIGHTS

• The study identified four core themes related to moral injury among sexual and gender minorities: shame, guilt, betrayal/loss of trust, and attachment injuries.

• The intensity of minority stress-related moral injury was positively associated with hazardous alcohol use and trauma-related symptoms.

• This is the first mixed-methods study to explore dimensions of moral injury related to minority stress among sexual and gender minorities.

1. Introduction

Sexual and gender minorities (SGMs) can often experience overwhelming shame, guilt, and betrayal (moral affect) as a result of the social stress they are subjected to based on their oppressed and stigmatized identities, particularly during critical developmental periods (Mereish & Poteat, 2015; Pachankis & Jackson, 2023; Tan et al., 2020). Despite considerable progress, SGMs across the globe continue to face significant social, cultural, legal, political, and economic barriers, which significantly impact mental and physical health outcomes (Amnesty International, 2022; Rice et al., 2021; Tan et al., 2020). Specifically, a robust body of evidence indicates that SGMs are disproportionately affected by mental health burdens, including comorbid posttraumatic stress disorder (PTSD), substance use disorders, mood and anxiety disorders (e.g. generalized anxiety disorder and major depressive disorder), body image disturbances, and suicide ideation and attempts, regardless of age (Akdeniz et al., 2014; Cochran et al., 2013; Dürrbaum & Sattler, 2020; Frost, 2017; Fulginiti et al., 2021; Hatzenbuehler & Pachankis, 2016; Lehavot & Simoni, 2011; Meyer, 2016; Pachankis, 2015; Pitoňák, 2017; Plöderl & Tremblay, 2015).

Historically, SGMs have been persecuted, and their identities invalidated, stigmatized, and discriminated against (Abbruzzese & Simon, 2018; Katz-Wise & Hyde, 2012). Gender minorities, including transgender and gender-diverse (TGD) individuals, also face unique stressors associated with their identity and experience disproportionately high rates of discrimination, stigma, rejection and violence, all of which have been associated with psychological distress (Lloyd et al., 2019; Singh et al., 2022; Sue & Sue, 2016; Tan et al., 2020). Racism can also occur within LGBTQ + communities, in addition to heterosexism/homo- or binegative discrimination within racial/ethnic minority communities, illustrating the complexity of intra-minority stress experiences and the importance of intersectionality-informed frameworks (Balsam et al., 2011; Pachankis et al., 2020; Carter et al., 2022; Collins, 2000; Crenshaw, 1991; Purdie-Greenaway & Eibach, 2008). Furthermore, research that builds upon current diagnostic frameworks and treatment interventions to more accurately reflect the experiences of SGMs is urgently needed to improve mental health outcomes and rectify exclusionary models of disease that reinforce health inequities (Harnett, 2020; Nicholson et al., 2022).

1.1. Minority stress, trauma, and moral affect

The Minority Stress Model (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 2003) is a framework that aids in understanding the high rates of mental health burdens that disproportionately affect SGMs. This conceptual model proposes that the unique stressors experienced by SGMs (due to their socially stigmatized identities) act as catalysts for mental and physical health conditions (Frost & Meyer, 2023). Minority stressors have been broadly categorized into distal and proximal stressors. Distal stressors originate from the external environment (e.g. discrimination, violence, hate crimes, microaggressions, non-affirming experiences, systemic/legislative oppression, and institutional betrayal) whereas proximal stressors are internal processes (e.g. internalized stigma, rejection sensitivity, negative expectations for the future, and identity nondisclosure) (Frost & Meyer, 2023). Importantly, negative coming-out experiences and SGM-based rejection and discrimination from attachment figures (i.e. primary caregivers) during development and adulthood have been shown to have maladaptive effects on the calibration of attachment systems, thereby significantly impacting mental health, well-being, and future relationships (Cook & Calebs, 2016; Landolt et al., 2004; Mohr & Fassinger, 2003; Popa-Velea et al., 2019; Shenkman et al., 2021). Furthermore, structural stigma (including discriminatory laws, policies, and prejudicial societal attitudes) is also associated with adverse mental health outcomes among SGMs, where regional severity has been shown to influence how strongly these negative consequences manifest (Frost & Meyer, 2023; Hatzenbuehler et al., 2024; Pachankis & Bränström, 2018; Singh et al., 2022). In line with this, sexual minority youth raised in highly stigmatizing environments have been shown to display a blunted cortisol response following social stress, compared to those from less stigmatizing environments (Hatzenbuehler & McLaughlin, 2014). This indicates that the stress of growing up in environments that target sexual minorities for social exclusion may exert biological effects that are similar to traumatic life experiences (Flentje et al., 2020; Hatzenbuehler & McLaughlin, 2014). Elsewhere, structural stigma has been found to interact with gay-related rejection sensitivity on the individual level, leading to negative mental health outcomes (i.e. substance use) (Pachankis et al., 2014). Indeed, minority stressors represent a ‘fundamental ecological threat’ that can force SGMs to choose between expressing their authentic selves or the identities validated by society (Alessi & Martin, 2017).

A point of complexity is that while these minority stress experiences can be perceived as traumatic, only certain forms of minority stress fall within the Criterion A definition of trauma in the DSM-5-TR (APA, 2022), thereby imposing significant constraints on how we both research and address their impact on trauma-related symptoms (Minshew, 2022; Robinson & Rubin, 2016; Szymanski & Balsam, 2011). Among SGMs, minority stressors that do not meet Criterion A definitions have been associated with traumatic stress symptoms (Arnett III et al., 2019; Berlin et al., 2023; Holmes et al., 2016; Minshew, 2022; Robinson & Rubin, 2016; Szymanski & Balsam, 2011). For instance, homonegative microaggressions and traumatic stress symptoms are highly correlated, where heterosexist discrimination, victimization, and internalized heterosexism are positive predictors for PTSD symptoms (Robinson & Rubin, 2016; Straub et al., 2018; Szymanski & Balsam, 2011). In relation, a recent study examined the relationship between symptoms of psychiatric distress, minority stress exposure, and Criterion A traumas among TGD individuals (Salomaa et al., 2023). Here, researchers found that minority stress experiences (i.e. discrimination, social rejection, and structural barriers directly related to TGD identities) were perceived by both TGD participants and health-care providers as being more directly related to psychiatric symptoms (i.e. depression, avoidance, anxiety, stress, substance use, and shame) than Criterion A traumatic events. Importantly, while SGMs experience Criterion A traumas at much higher rates than the general population, being chronically shamed, humiliated, unaffirmed, and unloved can equally inflict profound harm (Minshew, 2022; Salomaa et al., 2023). Consequently, it has been hypothesized that minority stress experiences can lead to a variety of negative mental health outcomes through several overlapping neuropsychological mechanistic pathways of PTSD and trauma-related disorders, such as altered stress reactivity, hypervigilance, avoidance, interpersonal difficulties, emotion dysregulation, and alterations to the sense-of-self (Fenster et al., 2018; Hatzenbuehler, 2009; Marchi et al., 2023; Nicholson et al., 2022; Pachankis et al., 2015; Robinson & Rubin, 2016; Yehuda et al., 2015). Considering this evidence, it has been suggested that current frameworks for trauma-related disorders may benefit from more inclusive definitions of trauma to better represent the diverse experiences of marginalized communities (Berke et al., 2023; Holmes et al., 2016; Kira et al., 2021; Nadal et al., 2020; Shipherd et al., 2019; Williams et al., 2023).

Relatedly, Straub et al. (2018) found that associations between proximal minority stressors (internalized stigma related to sexual identity) and PTSD symptoms are mediated by moral affect, more specifically, shame. This is in line with Hatzenbuehler’s (2009) Psychological Mediation Framework, where moral affective processes may be classified as psychological mediators that can further increase vulnerability to adverse psychiatric outcomes in the context of minority stress (Hatzenbuehler, 2009; Meyer, 2003; Nicholson et al., 2022). This seminal study by Straub and colleagues (2018) offers further insight into how minority stress-related moral affect (i.e. shame, guilt, betrayal, anger) may mediate the presentation of trauma symptoms among SGMs. Indeed, utilizing a moral injury framework, as we describe below, may help to better characterize minority stress-related trauma symptoms among SGMs without the prerequisite of contextualizing and grounding these symptoms in a specific Criterion A trauma (Nicholson et al., 2022).

1.2. Moral injury

SGMs often experience complex moral affect, including feelings of shame, guilt, and betrayal associated with their stigmatized identity, which can be a risk factor for negative mental health outcomes (Hequembourg & Dearing, 2013; Pachankis et al., 2023; Straub et al., 2018). Moral injury is defined as a ‘trauma syndrome including psychological, existential, behavioral, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals’ (Jinkerson, 2016; Litz et al., 2009). Core features of moral injury include shame, guilt, existential conflict (including subjective loss of meaning in life), betrayal, and a loss of trust in oneself, others, or higher beings (Jinkerson, 2016; Koenig & Al Zaben, 2021). Here, shame refers to a painful self-conscious emotion typically accompanied by self-deprecation, defensive avoidance, and a desire to hide or externalize blame, whereas guilt is more behaviour-focused, and is associated with remorse and worry about the consequences of one’s actions (Tangney et al., 2007). Importantly, these core features of moral injury are associated with secondary symptoms pertaining to substance use, depression/anxiety, re-experiencing, interpersonal difficulties, and self-harm (Jinkerson, 2016). Indeed, individuals affected by moral injury have been shown to display higher rates of substance use disorders (SUD), particularly alcohol use disorder (AUD) (Battles et al., 2019; Hall et al., 2022; Kelley et al., 2019; Maguen et al., 2023). Notably, moral injury is also commonly associated with the presentation of PTSD symptoms (Barnes et al., 2019; Bryan et al., 2018; Fani et al., 2021; Koenig & Al Zaben, 2021; Lathan et al., 2023).

Unlike PTSD, moral injury is not currently classified as a mental health disorder in the DSM-5-TR (APA, 2022). Nevertheless, moral injury can be considered a distinct trauma syndrome from PTSD, though there is some definitional overlap between the two (Barnes et al., 2019; Koenig & Al Zaben, 2021). In particular, overlap with moral injury exists primarily in the PTSD symptom cluster of negative alterations in cognitions and mood (Cluster D; APA, 2022). In contrast to PTSD, moral injury does not require exposure to Criterion A traumas; instead, it develops when transgressions of moral beliefs or values are committed, observed, or learned about with consequent feelings (Koenig & Al Zaben, 2021). In this regard, while a potentially morally injurious event (PMIE) may qualify as a Criterion A trauma, it is not necessary for the development of moral injury. As such, the etiology of moral injury and PTSD are distinct (Barnes et al., 2019). Importantly, it has been postulated by our group that utilizing a moral injury framework in the context of minority stress may help to improve the contextualization, diagnosis, and treatment of trauma-related symptoms (which may or may not include Criterion A traumas) among SGMs (Nicholson et al., 2022).

Since its conception, moral injury has primarily been investigated in military, Veteran, and healthcare settings due to the disproportionately high exposure rates of PMIEs in these populations (Čartolovni et al., 2021; D’Alessandro et al., 2022; Richardson et al., 2020; Riedel et al., 2022; Xue et al., 2022). Critically, however, limited studies have investigated moral injury among minority populations (Elbasheir et al., 2024; Hosein, 2019; McEwen et al., 2022), with even fewer focusing on SGMs (Anderson et al., 2024; Jones et al., 2022; Kondrath et al., 2024). Chronic exposure to minority stress, key elements of which include anticipations of rejection, identity nondisclosure and lying to close ones, internalized stigma, feelings of institutional betrayal (e.g. from healthcare and religious institutions), structural oppression, discrimination, and violence, may represent PMIEs that could increase the risk for developing identity-based moral injury among SGMs. Specifically, SGMs may (a) perceive their own identity as a moral violation due to internalized stigma, and (b) perceive others’ negative reactions to their minoritized identity as a moral transgression, together leaving them more vulnerable to developing moral injury and other adverse psychiatric outcomes (English et al., 2021; Jackson & Mohr, 2016; Jones et al., 2022; Mereish & Poteat, 2015; Meyer & Frost, 2013; Nicholson et al., 2022; Smith et al., 2016). In support of this, a qualitative study investigating religious trauma and moral injury as a result of religious-based LGBTQ + conversion practices found that SGMs experienced increased shame related to their identity as well as loss of trust (Jones et al., 2022). Importantly, evidence has demonstrated higher levels of explicit and implicit shame among SGM populations, which together help to explain the mental health disparities observed among SGMs (Pachankis et al., 2024). Among sexual minority adults, self-reported shame partially accounted for the association between distal SGM stressors and psychological distress (Mereish & Poteat, 2015) and suicidality (Mereish et al., 2019). Similarly, self-reported shame in sexual minority adolescents also partially accounted for the association between family rejection and depression (Mereish et al., 2021). Indeed, there remains a paucity of empirical evidence investigating the dimensions of minority stress-related moral injury among SGMs. Of importance, conceptual and diagnostic frameworks positioning minority stress experiences as PMIEs capable of resulting in moral injury, may facilitate a deeper understanding of the mental health disparities (particularly trauma-related symptomatology) that disproportionately affect SGMs and improve treatment outcomes (Nicholson et al., 2022).

1.3. The current study

This mixed-methods study was conducted to investigate dimensions of moral injury that are associated with minority stress exposure among SGMs. Here, both qualitative (semi-structured interviews) and quantitative (self-report questionnaire battery) methods were utilized to provide a more comprehensive investigation of SGM lived experience from an intersectional perspective. Our research questions were as follows: (a) What core features of moral injury are SGMs qualitatively experiencing due to their stigmatized identities? (b) Do the core features of moral injury among SGMs converge/diverge from current conceptualizations of moral injury in previously investigated populations? (c) If present, how do these core features of moral injury relate to specific minority stress experiences? and (d) Do themes emerging from the qualitative data converge/diverge with quantitative measures of exposure to and perceived intensity of SGM-related PMIEs, and is this associated with mental health outcomes? We hypothesized that themes of moral injury would be present among SGMs, with unique contextual specifiers and associations with minority stress (i.e. internalized stigma and rejection sensitivity). Additionally, we predicted that thematic presentations of moral injury (as identified in the qualitative interviews) would converge with quantitative measures of exposure to and perceived intensity of SGM-related PMIEs, which would further be associated with negative mental health outcomes.

2. Methods

2.1. Study design overview

This mixed-methods analysis was part of a large multiphase medical neuroimaging project, called the Minority Mosaic Study, which aimed to investigate the neurobiological basis of minority stress and how this may lead to risk or resilience for mental health outcomes. For the current investigation, we employed a convergent parallel mixed-methods design following best-practice guidelines as outlined by Creswell and Clark (2017). Here, qualitative and quantitative data were collected concurrently in two separate databases with the same participant sample, analysed separately, and then merged to gain additional insight into the presentation of moral injury among SGMs and address our research questions.

Semi-structured qualitative interviews which explored the lived experiences of SGM individuals were used to investigate dimensions of moral injury. As a means of creating group comparisons in relation to qualitative themes, participants were assigned to ‘low’ and ‘high’ groups based on their quantitative scores on the modified Moral Injury Events Scale (MIES), denoting exposure to and perceived intensity of SGM-based PMIEs. Here, we examined how thematic presentations of moral injury and associations with minority stress qualitatively differed depending on one’s MIES score using a joint display. Joint displays are visual tools used to integrate quantitative and qualitative data. Specifically, they aid researchers in utilizing quantitative data to delineate distinct groups, thereby facilitating the interpretation of qualitative thematic analyses (McCrudden et al., 2021). Finally, associations between SGM-based PMIEs and mental health symptoms (i.e. substance use, depression, and trauma-related symptoms) were investigated quantitatively.

Our mixed-methods study draws upon both pragmatic and constructivist epistemologies, to examine differences in the experiences of stress, identity development, and health among SGMs using an intersectionality-informed approach (Bowleg et al., 2023; Creswell & Clark, 2017, p. 34–37; Frost et al., 2020; Rivas-Koehl et al., 2023). The term intersectionality, rooted within Black feminist and critical race scholarship (e.g. Crenshaw, 1989), captures how different power relations such as oppression, racism, sexism, heterosexism, and classism, structure individual-level experiences, particularly for those with multidimensional minority identities (Bowleg et al., 2023; Crenshaw, 1989). Additionally, a critical-ideological approach was utilized to examine and challenge social inequalities, power dynamics, and structures of oppression within society (Ponterotto, 2005). Following guidelines proposed by Bowleg and colleagues (2023), our study aimed to accurately capture unique lived experiences by rooting the foundation of our research within intersectionality-informed minority stress frameworks (Rivas-Koehl et al., 2023). Here, we implemented targeted recruitment strategies to ensure diverse representation in our study. We also utilized identity mapping techniques during data collection (see below), which helped participants highlight and share experiences connected to their intersecting identities (Frost et al., 2020). Furthermore, to enrich our study with perspectives beyond those represented within the research team, we employed participatory action research by collaborating with LGBTQ2SAI + community organizations, such as the LGBT Purge Fund Canada. Collaborators provided valuable feedback on the research design, including the telephone screener, semi-structured qualitative interviews, and clinical assessments, as well as on recruitment strategies, and on interpreting and disseminating our research findings. Notably, several community collaborators provided valuable feedback based on their unique lived experiences related to multiple axes of marginalization, which strengthened our intersectional perspective. Overall, incorporating participatory action research greatly enriched our study by providing essential insights and direction.

2.2. Participants

The sample for this study included n = 40 SGM participants with diverse sexual orientation, gender, racial, and ethnic identities. During analysis, three participants were removed from the sample due to incomplete responses on the SGM-modified MIES, leaving a final sample of n = 37 (detailed demographic information is reported in Table 1). This study was approved by the University of Ottawa Institute of Mental Health Research Ethics Board (REB #2022028) and the Hamilton Integrated Research Ethics Board (REB #13564), and all participants provided written and verbal consent prior to the start of the study. Participants were recruited from across Canada through various online platforms (including social media sites such as Facebook, Instagram, etc.), clinics and agencies serving SGMs, as well as community partner organizations (which included national networks such as the LGBT Purge Fund and the Atlas Institute for Veterans and Families). All participants for the study were self-selected volunteers.

Table 1.

Descriptive statistics of demographic and clinical variables.

Age, M (std)	36.4(14)
Sex Assigned at Birth, % (N)
Female	75.7% (28)
Male	21.6% (8)
Prefer not to answer	2.7% (1)
Gender Identity, % (N)
Cis-man	13.5% (5)
Cis-woman	37.8% (14)
Trans-man	10.8% (4)
Trans-woman	5.4% (2)
Non-binary	16.2% (6)
Two-spirit	5.4% (2)
Unsure	5.4% (2)
Questioning	5.4% (2)
Sexual Orientation, % (N)
Gay	16.2% (6)
Lesbian	18.9% (7)
Bisexual	10.8% (4)
Pansexual	8.1% (3)
Queer	37.8% (14)
Other	5.4% (2)
Prefer not to answer	2.7% (1)
Racial Identity, % (N)
Indigenous	5.4% (2)
East Asian	5.4% (2)
South Asian	13.5% (5)
South American	2.7% (1)
White-North American	43.2% (16)
White-European	24.3% (9)
Mixed-race	5.4% (2)
Education (in years), M (std)	16.4 (3.47)
Household income, % (N)
< $15,000	10.8% (4)
$15,000–$30,000	16.2% (6)
$30,000–$45,000	5.4% (2)
$45,000–$60,000	2.7% (1)
$60,000–$75,000	18.9% (7)
$75,000–$90,000	8.1% (3)
$105,000–$120,000	13.5% (5)
> $120,000	10.8% (4)
Prefer not to answer	13.5% (5)
Marital Status, % (N)
Married/Common-law	29.7% (11)
Single	45.9% (17)
Long-term relationship	16.2% (6)
Divorced	2.7% (1)
Separated	2.7% (1)
Widowed	2.7% (1)
SGM-Modified MIES Total, M (std)	21.41 (10.27)
AUDIT Total, M (std)	5.47 (5.14)
PCL-5 Total, M (std)	34.78 (16.08)
BDI Total, M (std)	15.71 (10.61)
CTQ Total, M (std)	54.15 (13.71)
LEC-5, M (std) Total Exp	13.67 (6.88) 4.24 (2.41)

Notes: Table 1 provides an overview of the demographic characteristics of the sample and total scores for clinical variables of interest. Age was only provided by 34 participants. Abbreviations: SGM-Modified MIES = Sexual and Gender Minority Modified Moral Injury Event Scale, AUDIT = Alcohol Use Disorder Identification Test, PCL-5 =  Posttraumatic Stress Disorder Checklist for DSM-5, BDI = Beck Depression Inventory, CTQ = Childhood Trauma Questionnaire, LEC-5 = Life Events Checklist for DSM-5; Total = sum of all endorsed past trauma types (‘Happened to me’, ‘Witnessed it’, ‘Learned about it’, ‘Part of my job’); Total score min/max = 0–68; range in sample for Total = 2–35; Exp = directly experienced traumatic events (‘Happened to me’ only); Exp score min/max = 0–17; range in sample for Exp = 0–12.

As this study was part of the larger Minority Mosaic neurobiological fMRI project investigating the parallels between minority stress exposure and trauma-related disorders, exclusion criteria that are standard in PTSD neuroimaging studies were used (Nicholson et al., 2022; Nicholson et al., 2024), which included a history of psychotic spectrum disorders, bipolar disorder, and dementia, as well as acute suicidality within the past 3 months. (see clinical assessment section below). The inclusion criteria consisted of current self-identification as a SGM (captured using our comprehensive demographics form), being between the ages of 18-65, fluent in English, and having access to an electronic device to complete online components of the study.

2.3. Data collection procedure & instruments

Data collection took place between 2021 and 2023. Individuals interested in the study first completed eligibility telephone screeners (n = 74). For those who were initially eligible, separate appointments were scheduled for clinical assessments to determine full eligibility and to screen for the presence of DSM-5 mental health disorders (n = 45). Prior to the start of the clinical assessment, participants were briefed on the study’s objectives and scope, and both written and verbal consent were obtained. Fully eligible participants then completed a semi-structured minority stress-related qualitative interview (n = 41). The final step involved participants filling out a battery of questionnaires relating to minority stress experiences, moral injury, and mental health (n = 40). Participant attrition occurred for various reasons over the duration of the study. For instance, twenty-nine participants did not complete the clinical assessments after the telephone screener, primarily due to loss of contact. Moreover, four participants completed both the screener and the clinical assessment but did not proceed to the qualitative interview due to personal reasons or ineligibility. Lastly, one participant completed all components of the study except for the quantitative battery.

2.3.1. Qualitative interviews

The purpose of the qualitative portion of the current study was to better understand the lived experiences of SGMs in relation to morally injurious dimensions of minority stress via 1:1 semi-structured interviews. Participants were first provided with a short psychoeducation of minority stress, which included brief definitions of the various types of distal and proximal stressors (i.e. microaggressions, internalized stigma, discrimination, rejection sensitivity, etc.). Qualitative data collection was rooted within an intersectionality-informed framework and utilized an ‘identity mapping activity’, where participants were asked to choose words or phrases that describe different aspects of their identity related to their gender, race, ethnicity, sexuality, class, occupation, and any other socially salient aspects of their identity (Frost et al., 2020). The identity map was then discussed together with the interviewer and used as an anchor for the rest of the interview when referencing the participant’s minority identities. The remainder of the interview was concerned with participants’ experiences with minority stressors, intersectionality and communities, moral affect, disclosure of identity and coming out, authenticity, relationships and attachments, mental and physical health, and resiliency over their lifetime. Critically, personalized identity maps were referenced repeatedly throughout the interview to accurately reflect participants’ multidimensional minority identities, focusing on how different aspects of their identity influence various minority stress experiences, as opposed to examining sexual orientation or gender in isolation. The interviews, lasting about 2–3 h each, were conducted virtually via Zoom by a trained researcher and were audio-recorded.

2.3.2. Quantitative instruments

For the current study, participants completed a battery of self-report questionnaires to assess for demographic features, as well as experiences with minority stressors, morally injurious events, and mental health symptoms. The questionnaire battery was administered via REDCap (Harris et al., 2009), a secure web-based software platform hosted at both McMaster University and the University of Ottawa, designed to support data capture for research studies. Although out of scope for the current analysis, as part of the larger Minority Mosaic Study, our battery of questionnaires additionally included scales which broadly examined identity-based minority stress exposure and trauma-related symptoms, which will be further analysed elsewhere. The questionnaires analysed for the current study were a priori hypothesized to be related to the core features of moral injury among SGMs. This was based on previous syndromal conceptualizations of moral injury, and the secondary symptoms associated with the core features of moral injury as defined by Jinkerson (2016), which include substance use, depression/anxiety, re-experiencing symptoms, and interpersonal difficulties. Additionally, we further examined for potential associations with childhood trauma exposure.

The Moral Injury Events Scale (MIES; Nash et al., 2013) was modified for use with SGMs in order to capture exposure to minority stress-related potentially morally injurious events (PMIEs). The original MIES is a 9-item self-report scale with items inquiring about exposure to events that may have been perceived as transgressions or betrayals in relation to moral injury, and the subjective impact of these events. On our modified version of the MIES, participants were specifically asked to respond to the questions based on their experience as a sexual and/or gender minority. Participants responded on a scale ranging from 1 (strongly disagree) to 6 (strongly agree), with higher scores indicating greater exposure to and intensity of PMIEs. The original MIES has demonstrated a good preliminary factor structure and reliability (α =  0.82–0.89) (Bryan et al., 2016). On our modified version, 2 of the original 9 questions were removed as they pertained only to military members (please see supplementary material for the SGM-modified version of the MIES, Cronbach’s α within current sample = 0.802). In sum, the SGM-modified MIES was utilized to assess for both the presence of exposure and the perceived intensity of PMIEs related to one’s sexual and/or gender identity.

The Alcohol Use Disorder Identification Test (AUDIT) was used to assess hazardous/harmful alcohol consumption over the past year (Saunders et al., 1993). The AUDIT is a 10-item self-report questionnaire, with items assessing amount and frequency of alcohol intake, alcohol dependence, and problems related to alcohol consumption. Scores range from 0 to 40, whereby scores above 8 suggest hazardous/harmful alcohol consumption. The Beck Depression Inventory (BDI) was utilized to capture symptoms of depression (Beck et al., 1961; Beck et al., 1997). The BDI is a self-report 21-item measure that assesses symptoms within the past 2 weeks. Total scores range from 0 to 63, with scores between 21- 63 indicating moderate to severe levels of depression. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used in this study to assess the presence and severity of trauma-related symptoms among participants. This 20-item self-report measure evaluates the key symptom clusters of PTSD as outlined in the DSM-5: intrusions (e.g. unwanted traumatic memories), avoidance, negative alterations in cognition and mood (e.g. distorted blame of self or others), and alterations in arousal and reactivity. When completing the PCL-5, respondents were instructed to indicate how bothered they were by 20 trauma-related symptoms in the past month, with total scores ranging from 0 to 80. Research suggests that a PCL-5 cut-off score between 31 and 33 is indicative of probable PTSD (Weathers et al., 2013). The PCL-5 was chosen for its comprehensive coverage of PTSD symptoms and its applicability to various types of traumatic experiences, including those stemming from chronic minority stress. The PCL-5 was analysed in the current study given evidence which suggests that outcomes associated with exposure to PMIEs are distinct from, but associated with PTSD (see Griffin et al., 2019 for review). Indeed, moral injury is considered a separate syndrome from PTSD albeit with definitional overlap (as reviewed previously in detail). Notably, associations between PTSD symptoms and exposure to PMIEs have been shown previously to range from small to moderate (Currier, Holland, & Malott, 2015; Currier, Holland, Drescher, et al., 2015; Nash et al., 2013).

The Childhood Trauma Questionnaire (CTQ) is a self-report measure that consists of 28 items which assess childhood abuse and neglect, including physical, emotional, and sexual abuse, as well as physical and emotional neglect (total score 25–36 = none or minimal childhood trauma, 41–51 = low to moderate trauma, 56–68 = moderate to severe trauma, > 72 = severe to extreme trauma) (Bernstein et al., 2003). The Life Events Checklist for DSM-5 (LEC-5) is a self-report measure that screens for lifetime exposure to potentially traumatic events across 16 categories, including but not limited to natural disasters, various forms of assault, and severe accidents. Respondents indicate whether they have directly experienced, witnessed, or learned about these events in their lifetime, providing a nuanced picture of their trauma exposure. The LEC-5 is adept at identifying exposures to DSM-5 Criterion A events like direct or indirect exposure to actual or threatened death, serious injury, or sexual violence (Weathers et al., 2013). Incorporating the LEC-5 in this research allows for a detailed understanding of the types of traumatic events that participants have encountered over their lifetimes. Critically, it has been repeatedly documented that SGMs disproportionately experience such events when compared to the broader population (Meyer et al., 2021; Minshew, 2022; Tan et al., 2020). By quantifying the extent and nature of traumatic event exposure, the LEC-5 aids in contextualizing the study results and exploring how trauma and minority stress intersect, shaping the psychological experiences of this population.

2.3.3. Clinical assessment

Participants underwent an online clinical interview to screen for the presence of mental health disorders, which lasted approx. 1–3 h and was conducted over Zoom platforms with a clinically trained researcher. The Diagnostic Assessment Research Tool (DART), a semi-structured interview to facilitate the assessment of mental health disorders based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), was utilized for this purpose (APA 2022; Schneider et al., 2022). Psychometric validation of this tool has yielded good construct, convergent, and discriminant validity for a wide range of disorders and has been applied successfully in a variety of studies (Krause et al., 2022; Ouellette et al., 2022; Puccinelli et al., 2023; Schneider et al., 2022). The DART enabled for the systematic evaluation of mental health disorders within our sample, providing essential contextual and diagnostic information that contributes to a comprehensive understanding of the mental health burdens affecting SGMs in our study (McCabe et al., 2021). Participant eligibility for the study was only fully confirmed after completion of the DART clinical assessment.

2.4. Data analysis

2.4.1. Qualitative analysis

The recordings of the qualitative interviews were transcribed to text format by a third-party company, with which confidentiality agreements were in place before transcription. The interviews were transcribed verbatim and de-identified, transcriptions were then checked thoroughly for accuracy. Data from the interviews were analysed using thematic analysis (Braun & Clarke, 2012). A thematic analysis approach was chosen for its capacity to uncover and interpret patterns and themes within qualitative data, facilitating a more nuanced exploration of the experiences of SGMs (Braun & Clarke, 2012). Due to the wide range of topics assessed in the qualitative interviews, thematic analysis was determined as the best analysis method for this study, allowing for a high level of flexibility in categorizing and analysing the data (Braun & Clarke, 2012). The definition of a ‘theme’ in this study was guided by Braun and Clarke (2006), who conceptualize a theme as capturing something important about the data in relation to the research question and demonstrating a degree of patterned response or meaning within the dataset. Thematic analyses were conducted at the latent level, going beyond what was explicitly stated and instead aiming to uncover implicit aspects of the data and deeper layers of meaning (Braun & Clarke, 2006).

Three researchers (SN, JW, MP) well-versed in the minority stress literature, coded the interviews using MAXQDA software (VERBI Software, 2021). Following Braun & Clarke’s (2006 & 2012) guidelines, the researchers began by immersing themselves in the data through repeated readings, actively searching for meanings and patterns. This process involved critically examining how participants made sense of their experiences, articulated their beliefs about the world, and constructed their perceptions of it. In this study, complete coding was used, ensuring that anything of interest or relevance to answering our research questions was identified. Both deductive and inductive coding approaches were employed. In this iterative process, the researchers began with several deductive codes, including relationship with identity labels, minority stressors (e.g. internalized stigma, microaggressions, discrimination, rejection-related experiences, identity non-disclosure), fear/anxiety related to identity, coming out experiences, safety concerns, and moral affect (e.g. shame, guilt, betrayal, loss of trust, existential conflict). Deductive coding leveraged existing theoretical frameworks related to minority stress (Meyer, 2003) and moral injury (Jinkerson, 2016) to provide a structured foundation for analysis that was aligned with existing research. Critically, an inductive approach complemented the analysis, as researchers identified new codes such as attachment injuries, mental guard/hypervigilance, overcompensation, conservative religious upbringing, and importance of representation. This approach facilitated the identification of new themes in the data, building on previous research while still remaining open to unexpected findings in the exploration of new phenomena (Braun & Clarke, 2006). As open coding continued, axial coding (Lune & Berg, 2017) was simultaneously applied to account for higher-level themes being generated from the data. This allowed for the organization of lower-level codes into hierarchical categorical structures and themes.

To ensure the validity, reliability, and rigour of our qualitative data analysis, we employed a comprehensive and collaborative coding process guided by the principles of Guba and Lincoln's criteria for trustworthiness (Lincoln & Guba, 1985). Initially, to establish a consistent coding framework, multiple researchers independently coded single interviews, collaboratively developing a common coding tree. This process of investigator triangulation not only enhanced the dependability of our findings but also ensured a robust framework for the analysis of our qualitative data. Once a consensus on the coding tree was reached, the remaining interviews were divided among the researchers, with regular team meetings held to discuss and potentially revise the coding tree, ensuring continued cohesiveness and alignment in our analytical approach. The rigour of our analysis was further reinforced by employing audit trials, wherein each researcher independently reviewed and coded the same qualitative interview according to the agreed-upon coding framework. This procedure allowed for a critical examination of interpretations, potential biases, and positionality in the research process, thereby fostering a culture of reflexivity on our team.

2.4.2. Mixed methods analysis

In our mixed methods analysis, we employed a median split method (Creswell & Clark, 2018) to categorize participants into two groups based on their SGM-modified MIES scores [low group (MIES score = 6–19) vs. high group (MIES score = 20–41)]. This categorization allowed us to examine and compare qualitative themes pertaining to minority stress-related moral injury, as a function of varying levels of exposure to SGM-based PMIEs and the perceived intensity of these events (i.e. SGM-modified MIES). Importantly, this median split method was a data-driven approach that allowed for group comparisons of the extracted qualitative themes in the absence of established cut-off scores on the MIES (Creswell & Clark, 2017). Here, there were 18 participants in the low MIES group (MIES score M = 12.89, std = 4.42), and 19 participants in the high MIES group (MIES score M = 29.47, std = 7.16). Data on the MIES across all participants, and for the low and high MIES groups separately, were normally distributed. An independent samples t-test confirmed significantly higher MIES scores in the high vs. the low group (p < .001).

After we completed the blind qualitative thematic analysis and allocation of participants into the low vs. high MIES groups, we merged the qualitative and quantitative data using a joint display method to explore whether the identified qualitative themes were differentially expressed in the high vs. low MIES groups (see Figure 1 for a visualization of the mixed method analysis). Notably, all qualitative interviews were coded blindly without prior knowledge of the participants’ quantitative data to eliminate any potential bias in theme identification.

Figure 1.

Summary of convergent parallel mixed-methods design. Abbreviations: MIES = moral injury event scale, PMIEs = potentially morally injurious events, SGM = sexual and gender minority.

In summary, this mixed-methods analysis allowed us to investigate whether core dimensions of minority stress-related moral injury qualitatively differed as a function of varying levels of exposure to SGM-based PMIEs and the perceived intensity of these events (as measured quantitatively using the SGM-modified MIES). These mixed-methods results are presented using a joint display, which visually stratifies participants based on MIES scores to explore contrasting thematic presentations of minority stress-related moral injury (McCrudden et al., 2021).

2.4.3. Correlation analysis with the SGM-modified MIES

Lastly, a correlation analysis was conducted to investigate whether there were any associations between scores on the SGM-modified MIES and mental health outcomes using R statistical package version 4.3.2. In the current study, correlational analyses were guided by the syndromal definition of moral injury (Jinkerson, 2016), which postulates that the core symptoms of moral injury are associated with secondary symptoms including substance use, depression/anxiety, and re-experiencing symptoms. As such, we conducted Spearman’s rank correlations to examine associations between scores on the SGM-modified MIES and alcohol use (AUDIT), symptoms of depression (BDI), and trauma-related symptoms (PCL-5). We further probed for potential associations between scores on the SGM-modified MIES and the severity of childhood abuse and neglect (CTQ). Nonparametric Spearman’s rank correlations were utilized as data from the AUDIT and CTQ violated assumptions of normality; among the scales no outliers were detected. In some instances, individuals chose to select the ‘prefer not to answer’ response for items on various scales (AUDIT n = 1, PCL-5 n = 1, BDI n = 2, CTQ n = 4), as such, we conducted pairwise deletions for these participants during bivariate analyses. To control Type 1 error when analysing multiple dependent correlations, we applied the multistage Bonferroni correction (Larzelere & Mulaik, 1977). This procedure adjusts the significance threshold at each step based on the number of remaining hypotheses, often allowing more rejections than a standard Bonferroni correction applied uniformly across all tests. By adjusting the significance threshold as fewer hypotheses remain, the multistage Bonferroni method achieves a better balance between Type 1 error control and statistical power. Initially, the significance level was divided by the total number of comparisons (p < .05/4 = .0125). If any hypothesis was found significant, the threshold was iteratively recalculated by dividing the significance level by the difference between the initial number of tests and the number of significant results already identified (Larzelere & Mulaik, 1977). This iterative process was only conducted once (p < .05/3 = .0167) until no further significant results were detected. This method enhances the robustness and reliability of results by reducing the likelihood of false positives while maintaining statistical power, providing a balanced approach to multiple comparison correction (Larzelere & Mulaik, 1977; Brophy, 1988).

3. Results

The current study qualitatively identified four core components of moral injury related to minority stress exposure among SGMs, which included: shame, guilt, betrayal/loss of trust, and attachment injuries. Here, strong converging evidence between qualitative and quantitative data was found, whereby the qualitative intensity and presentation of moral injury themes was found to differ based on quantitative scores on the SGM-modified MIES (corresponding to exposure to and perceived intensity of SGM-based PMIEs). The analysis revealed a variety of minority stressors (i.e. identity nondisclosure, internalized stigma, discrimination, invalidation, experiences with rejection and rejection sensitivity, etc.) that were qualitatively associated with each of the core components of moral injury. Our findings suggest that attachment injuries may represent a unique core feature of moral injury among SGMs, in contrast to shame, guilt, and betrayal/loss of trust, which have been previously established as moral injury features in other populations (Griffin et al., 2019; Jinkerson, 2016). Finally, exposure and perceived intensity of SGM-based PMIEs (as measured on the modified MIES) were found to be strongly correlated with alcohol use and trauma-related symptoms in our sample.

The LEC-5 facilitated a deeper understanding of the various types of traumatic events that were experienced by participants. Here, exposure frequencies to various types of traumatic events are presented in a heat map in Figure 2. Notably, all participants in this sample had either directly or indirectly experienced at least one traumatic event as defined by the LEC-5, with direct exposure to unwanted or uncomfortable sexual experiences (84%) and physical assault (60%) being the most common. Of importance, these results are in line with previous studies demonstrating that SGMs, particularly those with intersecting racial and ethnic minority identities, experience disproportionately high rates of trauma exposure (Berger & Sarnyai, 2015; Katz-Wise & Hyde, 2012; Rothman et al., 2011; Tan et al., 2020). Further strengthening the ecological validity of our study, findings from the DART clinical assessment are in line with previous studies demonstrating higher rates of comorbid substance use, trauma and stressor-related disorders (including PTSD), generalized anxiety disorder, and major depressive disorder among SGMs (see Figure 3) (Akdeniz et al., 2014; Cochran et al., 2013; Dürrbaum & Sattler, 2020; Frost, 2017; Fulginiti et al., 2021; Hatzenbuehler & Pachankis, 2016; Lehavot & Simoni, 2011; Meyer, 2016; Pachankis, 2015; Pitoňák, 2017; Plöderl & Tremblay, 2015). Together, these results aid in the contextualization of the current findings, and are in keeping with previous studies demonstrating a high degree of complexity in relation to co-occurring mental health conditions and exposure to trauma among SGMs populations.

Figure 2.

Life Events Checklist for DSM-5.

Notes: Each row corresponds to an event type, each column corresponds to the way in which a participant experienced the event (e.g. happened directly to them, witnessed it, learned about it happening to a close family member or close friend etc.), and each cell represents the percentage of respondents for the given category. The color intensity represents the percentage value, with red indicating higher percentages. Results were rounded to zero decimal places. All participants had either directly or indirectly experienced one of the events mentioned in the LEC-5.

Figure 3.

Mental health diagnostic profile of the sample as captured by the DART.

Notes: Figure 3 represents the results of the DART clinical assessment for the sample. Orange bars represent participants who met criteria for a probable mental health disorder diagnosis, yellow bars represent participants who were subthreshold, and grey bars represent participants who did not meet criteria. Abbreviations: DART = Diagnostic Assessment Research Tool.

3.1. Theme 1: shame

One of the most prominent themes that participants discussed during the qualitative interviews was the concept of shame. Interestingly, one aspect that accompanied feelings of shame among participants was the internalization of negative attitudes about their stigmatized identities (i.e. internalized stigma). Bearing witness to not only speech but also acts of discrimination and violence that portrayed their identities as morally wrong and harmful, both in youth and adulthood, was associated with internalized stigma and the development of self-hatred. Additionally, higher levels of shame were associated with feelings of worthlessness and identity nondisclosure, as well as suppression of authenticity related to discrimination and/or fear of discovery. While the theme of shame was evident across the entire sample, the intensity of reports differed as a function of participants’ scores on the modified MIES, denoting exposure to and perceived intensity of SGM-based PMIEs.

3.1.1. Low MIES scores

Individuals within the low range of MIES scores (Figure 4) qualitatively reported shame as being associated with the internalization of negative attitudes about their SGM identity. Participants in the lower MIES range also noted that feelings of shame were more prominent during their youth/adolescence and were much less tied to their current identity. Nevertheless, participants acknowledged that they felt pressured to meticulously adjust and selectively manage how they presented themselves. These behaviours emerged as a consequence of the stigma associated with their identities, precipitating feelings of shame and a perception of inherent inadequacy.

I mean, sometimes I thought there was something wrong with myself. When I was young… Like, why am I not conforming? Why am I not following the rules and ways of living and all that? And yeah, I had that internal shame for quite some time. Why am I going through this struggle? Just because who I am? It was a bit difficult for me to sort of accept. (Participant 27; Lesbian, Cis-woman, South Asian, Assigned female at birth (AFAB); MIES score: 13)

Participants described adaptively modifying the extent to which they revealed their authentic selves, particularly within environments characterized by hetero- or cisnormativity, instead of actively concealing their identity. This was simultaneously associated with feelings of guilt related to suppressing their identity and disappointing members of their community.

I think maybe being raised with a bit of like it’s okay to be gay, but people shouldn’t be so loud about it, kind of thing. Feeling like, for straight people, you don’t want to be too loud about it, but then also like in gay circles “Oh, am I hiding? Am I hiding who I am?” (Participant 9; Queer, Cis-woman, White-European, AFAB; MIES score: 6)

Several participants also described how they felt as though they were ‘misfits in society’ due to their stigmatized identities and how these feelings developed into self-hatred, worthlessness, and fear. Illustratively, participant 1 reported that they perceived these feelings of worthlessness related to their sexual identity as being associated with symptoms of anxiety and depression. This showcases how individuals may attribute minority stress experiences and moral injury as being closely associated with negative psychological outcomes.

Then I attributed it all to I hated the fact that I was gay, you know? I don’t want to be like this dyke. Who the hell wants to be this misfit in society, you know? … So that’s how I handled it. It was internalized. I hated myself. I didn’t want to be this way. I wasn’t worthy. You know, like, pick it all, throw it all in a basket, and that’s what you are. And then from the anxiety, then it develops into depression, right? And then you just feel like you’re not worthy to be on this Earth, you know? (Participant 1; Lesbian, Cis-woman, White-North American, AFAB; MIES score: 16)

Overall, participants within the low range of exposure to SGM-based PMIEs exhibited clear indicators of shame and internalized stigma, particularly during youth/adolescence, which was commonly linked with feelings of worthlessness, self-hatred, fear of rejection, and suppression of authenticity.

Figure 4.

MIES severity & shame.

Note: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of shame are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.

3.1.2. High MIES scores

While participants within the high range of MIES scores similarly reported SGM-based shame and internalized stigma, associated emotions and cognitions appeared to have more pronounced consequences as compared to the low MIES group (Figure 4). Within this group specifically, shame-related coping mechanisms included substance use, overcompensation/perfectionism, and pervasive identity concealment. For example, participant 4 explained how the feelings of shame she felt related to her identity ran so deep that the only way she could be intimate with a partner was by numbing these emotions through alcohol use. Due to severe intimacy and emotional constriction tied to this shame, as well as learned threat hypervigilance, alcohol use served as a negative coping mechanism to temporarily rid herself of anguish and allow herself to be emotionally vulnerable.

Well, the first time I would sleep with somebody, I’d have to be drunk. I was never sober. I just—it was the only way I could drop my guard. (Participant 4; Lesbian, Cis-woman, White-North American, AFAB; MIES score: 30)

Within the high MIES range, other participants also noted how feelings of shame related to their stigmatized identities created pressure for them to overcompensate for seemingly negative aspects of themselves. For example, participant 10 noted how they hated themselves for being gay and consequently tried to prove to themselves they were valued by becoming an over-achiever and adopting perfectionist traits, thereby compensating for the aspects of their identities deemed morally wrong by society.

You know, I hated myself for it, basically, for being gay … I needed to prove to myself, that I was valued, because of that internalized hatred that I had … I was the stereotypical over-achiever … I was always trying harder. I don’t know if that was more to prove to myself or to others, sort of, my value. I think that might have been more of a competition that I was putting on myself, for my own self-worth. (Participant 10; Gay, Two-spirit, Indigenous, Assigned male at birth (AMAB); MIES score: 32)

Individuals in this group were also inclined to change their appearance and behaviours as a result of deeply rooted feelings of shame, some completely suppressing parts of themselves in an attempt to act and present in ways that were more fitting with societal norms. In these instances, individuals frequently perceived themselves as the perpetrator of a moral transgression due to pervasive identity invalidation. For example, participant 33 described how they were taught that their queerness was a bad thing, which ultimately caused them to suppress/conceal that part of their identity to act and present in ways that were more fitting with society’s expectations.

I was trying to push my queerness down because I was taught it’s bad for me, for everyone else, for my girlfriend, for everyone. I tried to push it down. We broke up and everything. I tried to be more feminine, very cis and all that. I grew my hair out. But it didn’t work. (Participant 33; Queer, Trans-masculine, South Asian, AFAB; MIES score: 38)

Additionally, in comparison to the low MIES group, participants in the high MIES range described experiences of shame and identity concealment that persisted long into adulthood.

I was closeted until mid-university. And really ashamed of gender and different things like that until even after university. With the shame and stigma … I didn’t want people to know that I was queer or trans or mentally ill and all these things, so I just kept quiet. I didn’t share these parts of me because I was afraid of how other people would react. (Participant 39; Queer, Non-binary, White-North American; MIES score: 20)

Overall, shame was identified as a core feature of moral injury in SGMs and was strongly linked to internalized SGM stigma. Depending on the severity of scores on the SGM-modified MIES, these outcomes manifested in varying levels of intensity, presenting alongside feelings of self-hatred and fear of rejection, with increased pressure to not only conceal but also attempt to alter sexual and gender identities. Increased shame and moral injury were also qualitatively associated with additional negative coping mechanisms (i.e. alcohol use). Here, we found converging evidence between participants’ quantitative self-reports of exposure to and perceived intensity of SGM-based PMIEs and qualitative thematic data from the semi-structured interviews.

3.2. Theme 2: guilt

Another core theme identified from the qualitative analysis was guilt related to one’s stigmatized identity, which upon convergence with the quantitative data, presented in unique ways depending on exposure to SGM-based PMIEs and their perceived intensity, as measured on the modified MIES.

3.2.1. Low MIES scores

Participants within the low range of MIES scores described feelings of guilt in qualitatively different ways as compared to participants in the high range (Figure 5). In the low group, many individuals described complex feelings of guilt surrounding aspects of identity disclosure during youth/adolescence. For example, participant 18 noted feelings of guilt surrounding their coming out experience, detailing a sense of alienation due to their sexual identity and detrimental impacts on parental relationships. These complicated feelings never fully subsided, further highlighting the insidious effects of SGM-based PMIEs.

I don’t feel those things now (guilt). But I definitely felt them growing up. There’s obviously still some reminiscence from that … there’s some internalized homophobia that probably still exists from me … Definitely the guilt was stronger when I was younger about just not being able to be normal … It’s more of a sadness now versus a guilt. (Participant 18; Gay, Cis-man, White-North American, AMAB; MIES score: 6)

Several individuals further described how guilt and moral injury-related thoughts, emotions and behaviours stemmed from their religious upbringing, whereby socialization and involvement within religious communities led them to believe their SGM identity was innately wrong. Critically, however, the encoding of moral principles through religious doctrines throughout development was also apparent in the high MIES group. These experiences led to varying levels of guilt and shame in relation to one’s SGM identity, whereby the emergence of associated moral affect often occurred long before disclosing their identity to others.

Figure 5.

MIES severity & guilt.

Notes: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of guilt are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.

3.2.2. High MIES scores

Among participants within the high range of MIES scores (Figure 5), guilt was associated with manifestations of psychosomatic symptoms, fear, distress, and anticipatory rejection, which ultimately affected relationships in a more severe way and created barriers with respect to living authentically. For example, participant 20 described how they were raised to believe that being gay was morally wrong and emphasized the enduring effects this had on their psychological well-being. They described how being physically intimate with individuals of the same gender caused them intense physical distress and psychosomatic symptoms, as they felt as though they were violating moral standards.

The first time I kissed a girl, I had a full-blown panic attack because I felt, like, I had been raised as a girl and I'd been raised that being gay is wrong and now I'm kissing a girl and I'm like, breaking all of these moral rules, you know? It took several dates and several different partners I guess to stop having that like literal physical, shaking reaction. (Participant 20; Queer, Non-binary, White-North American, AFAB; MIES score: 26)

This example showcases how moral injury-based emotions such as guilt and shame, can manifest as psychosomatic reactions within the body. Furthermore, several other participants discussed anticipations of rejection from their families and how this led to identity nondisclosure and suppression of authenticity in adulthood, which was associated with strong feelings of guilt, remorse, and worry about the consequences of their actions. Participants also noted that these feelings of guilt caused strain on their current relationships with family members and friends, and were intricately associated with pronounced fear, hypervigilance, and avoidance behaviours. These examples highlight the lasting effects of developmental minority stress exposure on mental health and well-being in adulthood among SGMs.

Furthermore, participants articulated a sense of guilt and remorse pertaining to the falsification of their identity, emphasizing conflicts with moral principles and values.

I felt very guilty about lying (…) in order to survive, you’ve got to lie. And yeah, because you’re taught not to lie, right? So it’s one of your core values. And you had to break a core value. And I found that difficult to reconcile. And I also turned—a friend came to me in a time of need and out of self-preservation and fear, I wasn’t available for that person. And I’ve always felt guilty about that. (Participant 8; Lesbian, Cis-woman, White-North American, AFAB; MIES score: 34)

Overall, participants with higher MIES scores seemed to experience guilt more profoundly, reporting psychosomatic manifestations, as well as high levels of fear, worry about consequences, and hypervigilance. Collectively, this further reinforced the internalization of negative attitudes as well as identity nondisclosure and associated avoidance behaviours out of fear of rejection. Again, the severity of participants’ MIES scores converged with the qualitative data and the intensity by which themes emerged, indicating that higher levels of exposure to and perceived intensity of SGM-based PMIEs were associated with more pronounced presentations of guilt.

3.3. Theme 3: betrayal & loss of trust

Another core feature of moral injury that we found in the current study was betrayal and loss of trust in others, which also appeared to present in unique ways depending on exposure to and perceived intensity of SGM-based PMIEs on the modified MIES.

3.3.1. Low MIES scores

Participants within the low range of MIES scores (Figure 6) described interpersonal experiences where they felt betrayed and lost trust in others. Illustratively, participant 18 noted how he experienced situations where he was actively discriminated against by peers and even authority figures (e.g. teachers). He articulated his desire for family and friends to courageously speak out and intervene more assertively when confronted with instances of hateful speech directed at him or others within the LGBTQ community. Participants reported that not receiving this kind of support led them to experience feelings of betrayal and consequently lose trust in those closest to them.

When people didn’t come for my safety … or when that friend told those guys to leave me alone, I didn’t feel like it was enough. I didn’t feel much better from it. And I just wanted more help, or that teacher that didn’t support me in that scenario. I wish other people, whether they were friends or family, would speak up more when they would hear gay slurs or something like that. (Participant 18; Gay, Cis-man, White-North American, AMAB; MIES score: 6)

Similarly, participant 29 recounted instances when family members consistently disregarded her correct pronouns, while also encouraging her to conceal her SGM identity at school due to apprehensions about potential adverse outcomes.

They don’t call me by my name, they don’t use my pronouns. I’m still their brother. My older brother, at the time I came out in high school … told me to repress it, and to not let other people know because of what other people would think. (Participant 29; Pansexual, Trans-woman, Mixed-race, AMAB; MIES score: 13)

These experiences of rejection, prejudice, and microaggressions, from close family members and friends, were collectively perceived as acts of betrayal, leaving individuals feeling unsupported, unsafe, and invalidated. In turn, these instances of betrayal became intricately linked with the erosion of trust.

Figure 6.

MIES severity & betrayal/loss of trust.

Notes: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of betrayal/loss of trust are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.

3.3.2. High MIES scores

Within the range of high MIES scores (Figure 6), participants additionally noted experiences of intra-community betrayal and loss of trust. Specifically, numerous participants articulated the challenges they faced in identifying as gender diverse or transgender, recounting instances of rejection within the LGBTQ2SAI + community, notably from cisgender gay men and lesbian women.

I think there are a lot of people in the community … mostly some gay men, but also some lesbians as well, who are not accepting of trans people generally, who wouldn’t be accepting of me as part of the LGBTQ community … I would say that’s what makes it a slightly more difficult sort of belonging. (Participant 16; Pansexual, Trans-woman, White-European, AMAB; MIES score: 21)

Additionally, several TGD participants reported experiences of intra-community betrayal wherein members of the LGBTQ2SAI + community invalidated their identities if they did not conform to binary conceptualizations of gender or if they were not undergoing medical transitions.

I've also actually had micro-aggressions from people who, in the LGBT community, didn't think I was trans enough. I wasn't a valid transgender person because I wasn't transitioning to a male identity. So, you know, I thought “Wow, really? And this is someone that should know better.” (Participant 21; Non-binary, White-European, AFAB; MIES Score: 36)

In a similar vein, other participants highlighted challenges in obtaining appropriate healthcare, specifically narrating instances where their SGM identities were dismissed by healthcare providers resulting in feelings of institutional betrayal and invalidation. Relatedly, other participants faced considerable obstacles in accessing healthcare, as they refrained from disclosing their identities to healthcare providers due to feelings of guilt and shame. This was accompanied by participants perceiving themselves as the perpetrator of a moral transgression based on their SGM identity.

Among individuals falling within the high MIES score range, experiences of betrayal and loss of trust often resulted in heightened emotions of anger and hopelessness, rooted in the perceived inability to implement meaningful change. Here, anger was associated with pronounced presentations of negative cognitions about the world and self, wherein individuals reported that they felt powerless to change how they were treated, leading them to internalize these negative thoughts and emotions. Furthermore, individuals with elevated MIES scores detailed the necessity to distance themselves from those whom they perceived as having betrayed them, citing a lack of support for their identities and an erosion of trust as the primary catalysts for their decision to isolate. Illustratively, participant 33 conveyed the necessity of terminating relationships with friends who persistently invalidated their identity and failed to respect their pronouns.

I had to cut off close friends, who were like, “No, this is just a phase, this is not something I can accept.” And they continued to keep talking to me with my dead name or the wrong pronouns. It was very painful. I didn’t want to deal with that. I just stopped talking to them. (Participant 33; Queer, Trans-masculine, South Asian, AFAB; MIES score: 38)

This participant additionally conveyed the profound disappointment and sense of betrayal they experienced when their intimate partner rationalized and attributed discriminatory encounters to the expression of their gender identity. This was further compounded by confusion and loss of trust, as their partner concurrently appeared supportive of their identity in other settings.

In summary, while individuals with low MIES scores seemed to report events of interpersonal betrayal/loss of trust with close family and friends, those with high scores additionally reported accounts of intra-community minority stress (i.e. from the LGBTQ2SAI + community), and institutional betrayal (i.e. from healthcare institutions), as well as isolation, emotional shutdown, and feelings of anger associated with these experiences. Furthermore, those with high MIES scores reported intense feelings of hopelessness as a result of betrayals, along with accompanying negative cognitions about the world and self. Additionally, those with high MIES scores also recounted instances of interpersonal betrayal within their romantic relationships. In these instances, it appeared that intimate partners had internalized negative attitudes and beliefs towards SGMs, and subsequently projected these perspectives onto participants (i.e. through microaggressions/discrimination, withdrawing support, and rejection) thereby contributing to additional stress.

3.4. Theme 4: attachment injuries

The final core feature of moral injury that individuals were describing in relation to experiences with minority stress were themes surrounding attachment injuries. Here, minority stress-related attachment injuries are operationally defined as minority stress experiences among SGMs during development or adulthood (including, but not limited to, interpersonal experiences of rejection, abandonment, invalidation or discrimination from parents/caregivers based on one’s identity), which result in maladaptive attachment systems that markedly impact relationship dynamics (Cook & Calebs, 2016).

3.4.1. Low MIES scores

Individuals within the low range of MIES scores (Figure 7) delineated attachment injuries linked to experiences with SGM-based PMIEs, which created challenges in establishing and sustaining relationships with intimate partners. For example, participant 29 articulated how they were somehow always attracted to partners that were ‘damaged like them’ (i.e. individuals who had endured minority stress-related trauma and mental health burdens). This was viewed by the participant as an obstacle, hindering the potential longevity of any relationship they sought to form. They elaborated on this recurrent theme in their romantic relationships, noting a consistent pattern of attracting partners who shared similar burdens related to minority stress due to their stigmatized identities. This example underscores the profound impact of minority stress experiences on attachment systems and patterns of seeking in relationships.

I feel like I can be loved but just other circumstances and the people I attract have made it hard for things to work … The people I attract are people like me who are queer people who also deal with lot of mental health and trauma and stuff like that, and when, like this baggage comes with them … That can make it really hard for relationships to happen and continue on long term. (Participant 29; Pansexual, Trans-woman, Mixed-race, AMAB; MIES score: 13)

Participants further described how they were hypervigilant towards anticipations of rejection from potential partners due to low self-worth, which resulted in both avoidant and highly anxious behaviours in terms of approaching and handling conflict within intimate relationships. Negative alterations to the sense-of-self coupled with prevailing anticipations of rejection (due to perceptions that one’s SGM identity was morally wrong), ultimately resulted in challenges in forming secure relationships with intimate partners.

Unfortunately, I think it cut me off from some people. All that stress of wondering what people are going to think. “Are they still going to love you?” … As a young girl, this is what you think, “And nobody is going to love me. There’s something wrong with me.” (Participant 7; Lesbian, White-North American, AFAB; MIES score: 12)

You never get to be your real self. It goes right down to the very core of everything. We can’t really share everything. Because you’ll risk losing it … If you tell even the person you love the whole truth of the person you are, you lose them. (Participant 2; Trans-man, White-North American, AFAB; MIES score: 14)

Figure 7.

MIES severity & attachment injuries.

Note: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of attachment injuries are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.

3.4.2. High MIES scores

Participants who reported higher levels of exposure to and perceived intensity of SGM-based PMIEs (Figure 7), had more severe accounts of attachment injuries and negative alterations to their sense-of-self, leading them to feel undeserving of experiencing a secure and fulfilling relationship. When discussing intimate relationships, participants often expressed a sense of ‘unworthiness of love’ and an inability to feel loved, which was intrinsically tied to their SGM identity.

I really started to question my deservingness of love. You know, because here was this person telling me that they loved me but not giving me what I needed, and I started questioning, like, am I asking for too much, am I just not capable of feeling loved? (Participant 3; Bisexual, Questioning, White-North American, AFAB; MIES score: 34)

These accounts delve into the intricate ways in which attachment injuries can manifest as negative shifts in one’s sense-of-self and social cognitive processes, profoundly impacting emotional well-being and resulting in an overarching belief that one is unlovable.

No matter how much love I can give, or how much I can care about somebody, because I’m trans or because of all the dark technicalities connected with me being trans … The love I can give or the care I can give is never enough. It won’t be enough to keep them in a relationship with me. (Participant 33; Queer, Trans-masculine, South Asian, AFAB; MIES score: 38)

Participants recounted their struggles with embracing emotional vulnerability in relationships, often leading them to prematurely terminate connections with potential partners and friends due to a persistent fear of rejection and a deficit in trust.

I found it difficult to let anyone get close to me, whether as a friend or as a potential partner. You know, I might meet somebody, and I’d like them, and I always found a reason to end the relationship. I’d let them get close, we’d be intimate, but I couldn’t be emotionally intimate with them, as much as I wanted to. I just, I couldn’t open the door and let them in. It was very difficult for me. (Participant 4; Lesbian, Cis-woman, White-North American, AFAB; MIES score: 30)

Even within enduring relationships, individuals frequently described grappling with feelings associated with being unlovable. This led to heightened anxiety and a tendency to overcompensate within the relationship, often accompanied by persistent anticipation of the relationship ending. These intense feelings of rejection and sensitivity towards perceptions of abandonment showcase how minority stress-related PMIEs may be associated with attachment injuries and difficulties in maintaining future relationships.

Taken together, those with higher MIES scores seemed to have more severe barriers regarding forming attachments in adulthood, with more profound negative shifts to the sense-of-self and altered social cognition, which was associated with individuals feeling undeserving of both giving and receiving love. Overall, participants felt as though their SGM identity stood in the way of them experiencing healthy/secure connections, and often reported high levels of distress associated with being emotionally vulnerable.

3.5. Intersectional SGM experiences with race and ethnicity

Our qualitative analysis additionally identified important nuances regarding the presentation of moral injury themes among individuals with multidimensional minority identities. Here, we identified unique contextual factors – related to cultural, societal, and structural stigma, intergenerational shame, and acculturation – that were associated with the experiences of SGMs with intersecting racial and ethnic minority identities.

More specifically, participants from Indigenous communities, who have historically faced oppression and colonization, and continue to face systemic marginalization within Canada, shared unique experiences of shame. For example, one participant highlighted the profound intergenerational impact of shame, describing how it has been passed down through families as a result of colonial violence, cultural erasure, and ongoing stigmatization. This account of shame was not only tied to personal identity but was described as being deeply embedded in the collective trauma experienced by Indigenous communities in Canada, thereby reflecting the long-term effects of historical injustices.

Growing up, I had kind of like that duality. My grandparents were very shameful of being Indigenous and didn’t want to talk about it ever. So I think that initially, I already felt that kind of shame piece of my identity and wanting a better life. My whole family has wanted a better life for myself and my brother and have sacrificed a lot for that, because being Indigenous hasn’t necessarily been a positive in our society because of the barriers. (Participant 43; Queer, Two-spirit, Indigenous, AFAB; MIES score: 7)

Additionally, one participant shared how their experience of identity-based shame and institutional betrayal was closely tied to the complexities of navigating membership within various LGBTQ2SAI+, racial/ethnic, and religious communities. They described experiencing unique forms of discrimination from each of the communities they belonged to, with each community rejecting different aspects of their identity. This multifaceted stigmatization heightened their sense of shame, as they continuously contended with conflicting expectations and discriminatory attitudes from various social and cultural groups.

I've definitely felt ashamed of, for example, the way that the Muslim community treats the 2SLGBT community, or the way that South Asian communities treat women. (Participant 51; Queer, Cis-woman, South Asian, AFAB; MIES score: 18)

Similarly, several ethnic and racial SGM participants recalled experiences of guilt that were more relational in nature – focusing on others, such as families and collective communities, rather than on the self at the individual level. Specifically, one participant who immigrated to Canada described guilt in relation to prioritizing their own needs over their family, which arose from being torn between values instilled by two cultures. Here, the process of acculturation (i.e. the psychological and cultural adjustment due to interaction with multiple cultures) (Berry, 1997; Berry, 2005; Morela et al., 2016) led to the emergence of conflicting values between the participant and their family.

Because when you're in Sri Lanka, you are part of your, like, you belong to your family. You are an extension of your family. So, you basically dedicate your whole life to the well-being of the family and everything, which is great but being me is the most important thing and I come first, which is sort of a selfish statement that I had so much guilt over. (Participant 27; Lesbian, Cis-woman, South Asian, AFAB; MIES score: 13)

The experience of guilt among second-generation immigrant ethnic and racial SGM participants was also linked to the process of acculturation and the tension between conflicting cultural values. For example, one participant described feeling guilt over not fulfilling the cultural expectations associated with being a traditional eldest daughter.

Sometimes, I think when I was first grappling with me being the outspoken queer woman, I think I felt guilty that my parents were burdened with an eldest daughter who was not going to conform to their expectations. But I mean, even now, in boundary setting with them and being like, I actually need space, I need some time off, or I'm doing something on my own, there is a bit of guilt, but that's more the guilt of me pushing back on their cultural expectations. (Participant 51; Queer, Cis-woman, South Asian, AFAB; MIES score: 18)

Finally, some racial/ethnic SGM participants reported unique experiences of attachment injuries, which were linked to growing up in structurally stigmatizing societies with culturally oppressive norms regarding SGM identities. These participants described their attachment injuries as complex and multifaceted, with the societal context adding an additional layer of difficulty. For instance, after coming out and leaving their home country, where laws and policies criminalize same-sex relationships, one participant described challenges in maintaining a secure relationship with their father. The participant also mentions hopes of bringing their partner to their country of origin and being acknowledged, welcomed, and accepted by their family.

Tough. Especially with my father, it's really tough because we are very close. He always treated me as a son that he never had. So, we are very, like buddies, we do a lot of things together, used to at least, and it's so difficult. He had his 67th birthday or something, in February and I sent him a card saying that we have to talk about the elephant in the room. He has read the card, but he never spoke about it with me. So, I'm like, whatever. I mean, I need to talk to him face to face. Because me and my partner need to go to Sri Lanka together. And you know I want to show her my home country and he needs to acknowledge her. (Participant 27; Lesbian, Cis-woman, South Asian, AFAB; MIES score: 13)

Overall, we identified unique contextual specifiers related to qualitative themes of shame, guilt, betrayal, and attachment injuries among SGM participants with intersecting racial and ethnic minority identities. Although unique contextual factors and nuances were identified in the current study in association with intersecting racial and ethnic minority identities, differential thematic presentations in relation to quantitative measures of exposure and perceived intensity of SGM-based PMIEs (i.e. unique intersectional thematic presentations among participants in the low vs. high MIES groups) did not emerge in the mixed-methods analysis.

3.6. Correlation analysis with the SGM-modified MIES

Spearman’s rank analyses revealed a significant positive correlation between the SGM-modified MIES and the AUDIT [r_s(34) = .45, p = .006] and the PCL-5 [r_s(34) = .41, p = .014] when correcting for multiple comparisons using the multistage Bonferroni procedure. Follow-up tests on individual PCL-5 subscales evidenced positive correlations between the MIES and trauma-related symptoms of avoidance [PCL-C, r_s(34) = .35, p = .034], negative alterations in cognition and mood [PCL-D, r_s(34) = .46, p = .005] and hyperarousal [PCL-E, r_s(34) = .45, p = .006]. We did not detect significant correlations between MIES scores and the BDI [r_s(33) = .30, p = .078], nor the CTQ [r_s(31) = .05, p = .799] at both corrected and uncorrected thresholds. In summary, increased reports of exposure to and perceived intensity of SGM-based PMIEs, were associated with increased alcohol use and trauma-related symptoms.

4. Discussion

SGMs are at an increased risk for developing mental health burdens as a result of their socially stigmatized identities (Dürrbaum & Sattler, 2020; Hatzenbuehler & Pachankis, 2016; Mereish & Poteat, 2015; Tan et al., 2020). Indeed, research has consistently shown that exposure to minority stress directly influences the mental health outcomes of both SGM adolescents and adults (Mereish et al., 2021; Pachankis & Jackson, 2023). This mixed-methods study is among the first to integrate qualitative and quantitative data to examine minority stressors as PMIEs that may contribute to the development of moral injury symptoms among SGMs. In the current study, we uncovered novel insights into the unique presentation of minority stress-related moral injury among SGMs (see Figure 8 for summary illustration). Our analyses revealed the presence of three core features previously associated with moral injury in other populations (Jinkerson, 2016), namely, shame, guilt, and betrayal/loss of trust, which were linked with a variety of minority stressors. Moreover, the theme of attachment injuries surfaced as a novel core feature of moral injury in the current study. Here, the identification of attachment injuries offers a unique lens through which to understand the development of minority stress-related moral injury among SGMs. Strong converging evidence between qualitative and quantitative data was found, whereby the qualitative presentation of moral injury themes differed depending on quantitative scores on the SGM-modified MIES (corresponding to exposure and perceived intensity of SGM-based PMIEs). Taken together, we propose that a minority stress-informed moral injury framework may offer a deeper understanding of the mental health disparities—particularly trauma-related symptoms—that disproportionately affect SGMs, and inform more effective treatment approaches (Nicholson et al., 2022).

Figure 8.

Morally injurious dimensions of minority stress.

Note: Summary illustration of the four core components of moral injury that were identified in the current study as being related to minority stress among SGMs. Illustration designed by Hey Chels Studio Inc.

4.1. Shame

The theme of shame in the current study was qualitatively associated with internalized stigma, in addition to feelings of self-hatred, fear of rejection, identity concealment/nondisclosure, and negative coping mechanisms (i.e. alcohol use). Consistent with the current findings, past research has shown that shame among sexual minorities is not only related to internalized stigma, but also other negative mental health outcomes, such as substance use (Hequembourg & Dearing, 2013). Blais and colleagues (2014) also found that the relationship between minority stress exposure (i.e. victimization/bullying) and self-esteem was partially mediated by internalized homophobia (Blais et al., 2014). Additionally, it has been shown that internalized SGM stigma positively predicts trauma-related symptoms, which has been found to be indirectly mediated by shame (Straub et al., 2018); these findings offer further insight into how minority stress-related moral affect (i.e. shame) may be associated with the presentation of trauma-related symptomatology. Indeed, we postulate that drawing upon moral injury frameworks may help to improve the characterization and contextualization of minority stress-related trauma symptoms among SGMs without the prerequisite of grounding these symptoms in a specific Criterion A trauma (Nicholson et al., 2022).

Relatedly, shame has been shown to be a mediator between both distal and proximal minority stressors and a myriad of negative mental and physical health outcomes among sexual minorities (Mereish, 2019; Mereish et al., 2021; Mereish & Poteat, 2015). Indeed, several research studies have found higher levels of shame among SGMs, which together, help to explain the disparities observed among these populations in relation to psychological distress, depression, social anxiety, and suicidality (Mereish, 2019; Mereish & Poteat, 2015; Pachankis et al., 2024). Research among SGM adolescents and young adults has also found that the resolution of shame is a central goal of healthy identity development and of SGM-affirmative psychotherapy (Burger & Pachankis, 2024; Greene & Britton, 2012; McDermott et al., 2008). Furthermore, demoralization has been shown to be negatively associated with psychological well-being and TGD-community connectedness (Woodrum et al., 2024). As such, it is becoming evident that addressing minority stress-related moral affect (i.e. shame) represents an essential target for the treatment of transdiagnostic symptoms that disproportionately affect SGM communities. Notably, in relation to moral injury studies among non-SGM populations, both shame and guilt have repeatedly been shown to be two of the most central components of moral injury (Jinkerson, 2016).

4.2. Guilt

In the current study, more severe qualitative presentations of guilt were associated with psychosomatic symptoms in response to perceived violations of moral norms, as well as fear, distress, internalized stigma, and anticipations of rejection that resulted in identity nondisclosure and/or suppression of authenticity. In line with these findings, a recent study revealed a positive correlation between perceived levels of minority stress and somatic symptoms among SGMs (Gubán et al., 2025). Furthermore, research has shown that guilt and shame are associated with both family rejection and depressive symptoms among sexual minority adolescents (Mereish et al., 2021). Here, parental affirmation was found to be a protective factor and associated with lower feelings of guilt, shame, and depression, whereby negative indirect effects of parental affirmation on depressive symptoms were found to be significant through guilt and shame pathways (Mereish et al., 2021). In other words, parental affirmation may lessen depressive symptoms by ameliorating feelings of guilt and shame among sexual minority adolescents. Research has also demonstrated that guilt plays an important role among SGMs who largely conceal their identities from others, acting as a mediator between stigma and self-esteem; interestingly, this is not the case for those who largely disclose their SGM identity to others (Srivastava & Singh, 2023). Furthermore, within the theme of guilt in the current study, the influence of a religious upbringing was underscored, shedding light on how SGM stigmatization rooted within religious institutions can profoundly impact identity-based moral injury. Consistent with prior qualitative investigations into moral injury among SGMs (Jones et al., 2022), these experiences may lead to internalized negative attitudes and institutional betrayal. In the current study, experiences with religion were discussed predominately in relation to themes surrounding guilt and betrayal/loss of trust, and not in the context of existential/spiritual conflict. Interestingly, existential/spiritual conflict was the only core symptomatic feature outlined by Jinkerson (2016) that was not identified as a prominent theme in our data; given the preliminary nature of our study, further research is needed to confirm whether existential/spiritual conflict represents a core feature of moral injury development among SGMs.

4.3. Betrayal and loss of trust

Another core feature of minority stress-related moral injury that was highlighted in the current study was the theme surrounding betrayal and loss of trust in others. Here, participants emphasized the detrimental impacts of interpersonal betrayal from friends and family in relation to their SGM identity, linking these experiences with emotions of anger and hopelessness, alongside significant negative repercussions on their mental health. More severe qualitative presentations were associated with institutional betrayal stemming from negative experiences with healthcare providers/systems of care, whereby individuals collectively expressed feelings of shame and invalidation in a setting where they anticipated safety and support. Previously, it has been shown that various experiences of betrayal – such as institutional betrayal – have been linked to greater negative psychological and physical health outcomes among sexual minorities (Smith et al., 2016). Institutional betrayal from healthcare systems has also been shown to be particularly harmful and prevalent among TGD individuals (Bindman et al., 2022; Lightfoot et al., 2021; Morris et al., 2020; Pulice-Farrow et al., 2022). In the current study, more severe accounts of betrayal were also reported in the context of perceived LGBTQ2SAI + safe spaces. These experiences were largely understood by SGMs in our study as representing a form of ‘sanctuary trauma’, which refers to circumstances wherein an individual who has suffered severe stressors encounters additional stress instead of the supportive and protective environment that was expected (Esaki et al., 2013; Nicholson 2022; Robins et al., 2005; Silver, 1985; Silver, 1986). Regarding these experiences with betrayal, participants felt unsafe, rejected, or harmed from within LGBTQ2SAI + communities. Sanctuary trauma is particularly harmful because it is inflicted by institutions, communities, or individuals who are expected to offer support and care. As such, these experiences can amplify existing stressors or traumas, thereby intensifying feelings of betrayal, isolation, powerlessness, and hopelessness (Esaki et al., 2013; Robins et al., 2005, Silver, 1985; Silver, 1986). Our results suggest that further exploration of sanctuary trauma/harm is warranted within minority stress frameworks. Indeed, it has been shown recently that intra-minority stress from the gay community predicts mental health over and above a comprehensive battery of traditional minority stressors (Pachankis et al., 2020). From an intersectionality perspective, individuals identifying as TGD in the current study described more severe forms of sanctuary harm related to intra-community minority stress, in addition to betrayal/loss of trust from within healthcare systems. Continued research is needed to elucidate further differential presentations of moral injury among SGMs with diverse intersecting identities in larger/representative samples. Further investigations into sanctuary trauma, intra-minority stress and betrayal may shed light on how stressors experienced by SGMs within their own communities or within systems of care may heighten the risk for adverse mental health outcomes, particularly in relation to moral injury (Nicholson et al., 2022).

4.4. Attachment injuries

Lastly, attachment injuries were identified in the current study as a novel and central moral injury theme among SGMs. Previously, secondary symptomatic features pertaining to interpersonal difficulties and social problems have been proposed to be related to moral injury in other populations (e.g. among military personnel and healthcare workers; Griffin et al., 2019; Jinkerson, 2016; Richardson et al., 2020). In our research, participants described experiencing challenges in both forming and maintaining relationships in adulthood, stemming from notable disruptions to attachment systems as a result of exposure to minority stressors. Additionally, participants noted profound negative alterations to their sense-of-self, ultimately resulting in them feeling incapable or undeserving of both giving and receiving love. Overall, participants with higher MIES scores felt as though their identity stood in the way of experiencing healthy relationships and often reported high levels of distress associated with being emotionally vulnerable. The finding of attachment injuries as a unique theme related to moral injury among SGMs may be related to the potential occurrence of rejection and abandonment (i.e. SGM-based PMIEs) from close relational figures during developmentally sensitive periods that coincide with the calibration of attachment systems (Popa-Velea et al., 2019; Shenkman et al., 2021). Indeed, it has been suggested that the hardships experienced by many SGMs, such as parental/peer rejection and negative coming out experiences, may alter working models of attachment, thus affecting relationships through greater avoidance of intimacy and interdependence (Landolt et al., 2004; Mohr & Fassinger, 2003; Shenkman et al., 2021). Critically, attachment patterns have been shown to be related to mental health outcomes among SGMs (Popa-Velea et al., 2019; Shenkman et al., 2021; Skidmore et al., 2023). Specifically, insecure attachment style has been shown to be a predictor of depression among LGB young adults and attachment avoidance has been shown to have a mediating effect on the association between being a sexual minority and depressive symptoms, anxiety symptoms, and life satisfaction (Popa-Velea et al., 2019; Shenkman et al., 2021). Moreover, among sexual minority youth, attachment style has also been shown to mediate the relationship between sexual orientation and substance use (Rosario et al., 2014).

In line with the current results, the Integrated Attachment and Sexual Minority Stress (IASMS) Model outlines the bidirectional association between minority stress and adult attachment among sexual minorities, describing how attachment systems can be both shaped by minority stressors while simultaneously influencing the perception of minority stress experiences (Cook & Calebs, 2016). More specifically, this model suggests that proximal and distal minority stressors can overburden the attachment system, whereby an individual with a secure attachment style, for instance, may transition to a more insecure or disorganized attachment style. Typically associated with experiences of trauma, disorganized attachment styles develop in response to deeply contradictory internal working models surrounding attachment figures and their behaviours (e.g. my father loves and protects me but is simultaneously ashamed by me and causes me extreme pain) (Brand, 2024; Hesse & Main, 2000). The IASMS model also postulates that an individual with attachment injuries may experience minority stressors as more severe and be more likely to adopt maladaptive emotion regulation strategies (Cook & Calebs, 2016). Additionally, the model emphasizes that in the sexual identity development process, experiences of rejection are critical for understanding transitions from a secure to insecure attachment style between childhood and adulthood (Cook & Calebs, 2016).

Importantly, in the current study, participants’ accounts indicate how rejection-related cognitions, emotions, and behaviours were intricately linked with SGM-based morally injurious events. Individuals described how they were hypervigilant towards anticipations of rejection due to low self-worth, which resulted in both avoidant and highly anxious behaviours in terms of approaching and handling conflict within intimate relationships (i.e. altered social cognition). The Rejection Sensitivity Model put forward by Feinstein (2020) emphasizes the role of past minority stress experiences, cognitive biases, and emotion regulation strategies in shaping responses to perceived rejection. This model postulates that those who develop high rejection sensitivity tend to anticipate rejection in various social situations, leading to maladaptive behaviours such as anxious or avoidant responses. Landolt et al. (2004) found that gender nonconformity in childhood was associated with greater parental and peer rejection, and that this rejection was associated with increased attachment insecurity. Past research also suggests that sexual minorities with attachment anxiety may be more vulnerable to depression due to an increased desire for validation from others and difficulties with self-validation, making them particularly sensitive to discrimination and rejection (Wei, et al., 2005; Zakalik & Wei, 2006). Importantly, rejection sensitivity among SGMs has been linked to negative mental health outcomes, including substance use, PTSD, depression, social anxiety, and generalized anxiety, and has also been shown to mediate associations between discrimination and mental health burdens (Cohen et al., 2016; Dyar et al., 2018; Feinstein, 2020; Feinstein et al., 2012; Sattler et al., 2017).

4.5. Associations between moral injury, substance use and trauma-related symptoms

Through quantitative analyses in the current study, we found that scores on the SGM-modified MIES (denoting exposure to and perceived intensity of SGM-based PMIEs) were positively correlated with alcohol use and trauma-related symptoms. Indeed, past research has shown that SGMs are at an increased risk for developing substance use and trauma-related disorders (Fish & Pasley, 2015; Goldberg et al., 2013; Tan et al., 2020). To our knowledge, this is the first study to report an association between minority stress-related moral injury and both hazardous alcohol use and trauma-related symptoms among SGMs. Interestingly, these quantitative findings parallel qualitative themes that emerged in the current study surrounding alcohol use as a means by which to cope with minority stress-related shame, which was found to be closely associated with emotional constriction as well as hypervigilance. These results are also in line with syndromal definitions of moral injury (Jinkerson, 2016), which postulate that the core symptoms of moral injury are associated with secondary symptomatic features including substance use, re-experiencing, and interpersonal difficulties. Interestingly, in the current study, we also found that scores on the SGM-modified MIES correlated with PCL-5 subscales pertaining to trauma symptoms of avoidance, negative alterations in cognition and mood, and hyperarousal, but not re-experiencing. Critically, moral injury is considered a separate syndrome from PTSD with distinct etiology, albeit with some definitional overlap (Barnes et al., 2019; Koenig & Al Zaben, 2021); in support of our correlation analysis, this overlap has largely been found to be within the affective domain of negative alterations in cognition and mood (Cluster D; APA, 2022). Additionally, previous research has revealed avoidance as a coping strategy in response to minority stress experiences among sexual minority adolescents (Goldbach & Gibbs, 2015). Hyperarousal, hypervigilance, and avoidance symptoms are also hypothesized to transdiagnostically mediate associations between experiences of minority stress and negative mental health outcomes (Pachankis, 2015). Taken together, these results support our hypothesis that utilizing a moral injury framework within the scope of minority stress may help to improve the characterization, contextualization, and treatment of trauma-related symptoms and substance use disorders among SGMs (Nicholson et al., 2022).

4.6. Future directions and limitations

These emerging findings highlight the need for additional research to further elucidate the core features and secondary symptomatic profiles associated with minority stress-related moral injury among SGMs. Our results suggest that the SGM-modified MIES may be a useful tool by which to measure exposure to minority stress-related PMIEs and the perceived intensity of these events. Notably, in the absence of any currently available scale that has been validated to capture minority stress-related moral injury among SGMs, we modified the MIES. The original MIES has three questions that capture betrayal, two of which are specific to military experiences and were ultimately removed from our study as they would not be relevant to civilian populations. Consequently, our modified MIES consisted of seven moral injury items including questions pertaining to transgressions by the self (four questions), transgressions by others (two questions), and betrayal (one question). Given that there were more questions on transgressions by the self than there were transgressions by others/betrayal, the cumulative MIES scores utilized in our mixed-methods analysis primarily reflect moral injury related to transgressions by the self. Indeed, this is an inherent limitation of the MIES version that was available during data collection, whereby additional studies are needed to further develop moral injury scales in the context of minority stress. This has motivated our research group to develop a moral injury scale specifically tailored for SGM individuals, enabling a more accurate assessment of exposure to minority stress-related PMIEs.

With respect to our mixed-methods analysis that utilized a median split, we employed a data-driven approach in our study that balances scientific rigour with the practical limitations of our sample size and of the quantitative scales available to measure minority stress-based moral injury. Notably, the goal of our mixed-methods analysis was to compare the presentation of group-level qualitative themes among individuals with low vs. high exposure to SGM-based PMIEs. While we did not use this categorization for an explicit quantitative analysis, our use of the median split (in the absence of established cut-off scores on the MIES) is worth noting as a limitation due to its arbitrary threshold. Indeed, this points towards the need for further research to develop and validate improved scales to measure minority stress-related moral injury, and to establish cut-off scores for moral injury.

Furthermore, we detected elevated trauma-related symptoms among SGMs on the PCL-5 corresponding to 21 participants scoring above the threshold for probable PTSD; this is in comparison to 6 participants meeting criteria for PTSD on the clinician-administered DART. Discrepancies between PTSD diagnoses established via clinician-administered assessments vs. self-report questionnaires, such as the PCL-5, have been reported elsewhere (Bovin et al., 2016; Krüger-Gottschalk et al., 2022; Resick et al., 2023). Previous research has shown that participants typically score higher on self-report measures in comparison to clinician-administered semi-structured assessments (Bovin et al., 2016; Krüger-Gottschalk et al., 2022; Resick et al., 2023). Critically, however, in relation to the SGM sample in the current study, this also highlights an important limitation of how we currently conceptualize and measure trauma-related symptoms in the context of minority stress. Indeed, the DSM-5 has faced criticism for failing to adequately account for the persistent and chronic effects of minority stress exposure (Holmes et al., 2016; Kira et al., 2021; Williams et al., 2023). On balance, previous research has demonstrated the importance of considering the impact of minority stress experiences in order to accurately measure trauma-related symptoms (Holmes et al., 2016; Kira et al., 2021; Williams et al., 2023), whereby trauma symptoms have also been shown to be associated with minority stress events that do not meet Criterion A definitions among SGMs (Arnett III et al., 2019; Berlin et al., 2023; Holmes et al., 2016; Minshew, 2022; Robinson & Rubin, 2016; Szymanski & Balsam, 2011). During the DART clinical assessment, participants were asked if they had ever experienced a traumatic event and were provided with DSM-5 definitions of trauma. After giving a brief summary of their trauma exposure, participants were asked to answer symptom questions in reference to their most distressing index trauma. Given the known co-occurrence of Criterion A traumas, insidious identity-based trauma, and chronic minority stress exposure among SGMs (Arnett III et al., 2019; Berlin et al., 2023; Cook & Calebs, 2016; Minshew, 2022; Szymanski & Balsam, 2011), in order to extract an ecologically valid measure of trauma symptom severity, we did not restrict participants when completing the PCL-5 to anchor all of their responses to a single most distressing traumatic event. Critically, however, we captured detailed information about Criterion A trauma exposure during the DART assessment and using the LEC-5, allowing us to comprehensively contextualize trauma symptoms in this SGM population. Notably, all participants in the sample had experienced at least one Criterion A trauma. As a future research direction, we are currently conducting a dedicated analysis to examine this complex interplay in more detail.

Although the presentation of themes surrounding betrayal and loss of trust appeared to be more severe for participants identifying as TGD, continued research is needed to explore further the intersectionality of these experiences. Indeed, it is critical to understand how moral injury features may be differentially expressed among diverse minority identities, particularly among SGM individuals with intersecting racial and ethnic minority identities. Additionally, although saturation was reached for the qualitative analysis, our quantitative analyses were restricted given our preliminary sample size. Finally, future research is needed to explore minority stress-related moral injury longitudinally in order to better understand its developmental impact.

5. Conclusion

This pioneering mixed-methods study provides novel insights into the intersection of minority stress and moral injury among SGMs. Our study revealed four qualitative themes related to moral injury presentation among SGMs: shame (internalizing stigma), guilt, betrayal/loss of trust, and attachment injuries (rejection, altered sense-of-self, and social cognition). Here, attachment injuries emerged as a unique feature, underscoring the complexity of SGM experiences in relation to the presentation of moral injury. Interestingly, the qualitative presentation of these themes was found to differ depending on quantitative measures of exposure to and perceived intensity of SGM-related PMIEs. Furthermore, our findings revealed that exposure to and intensity of SGM-related PMIEs was positively associated with hazardous alcohol use and trauma-related symptoms. Taken together, we propose that a minority stress-informed moral injury framework may facilitate a deeper understanding of the mental health disparities (particularly trauma-related symptoms) that disproportionately affect SGMs. Moving forward, the conceptual framework of moral injury offers promising avenues for further research and the development of targeted interventions aimed at mitigating mental health burdens among SGMs. Ultimately, by recognizing and addressing the unique challenges faced by SGM individuals, we can work towards creating more inclusive models of care and treatment for all members of society.

Funding Statement

Andrew A. Nicholson received funding from the LGBT Purge Fund Canada, the Department of National Defence in the capacity of a Mobilizing Insights in Defence and Security (MINDs) grant, and the Atlas Institute for Veterans and Families.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, Andrew A. Nicholson, upon reasonable request.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2025.2479396.