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. Author manuscript; available in PMC: 2014 May 17.
Published in final edited form as: J Aggress Maltreat Trauma. 2013 May 17;22(5):10.1080/10926771.2013.785455. doi: 10.1080/10926771.2013.785455

Prejudice Events and Traumatic Stress among Heterosexuals and Lesbians, Gay Men and Bisexuals

Edward J Alessi 1, James I Martin 2, Akua Gyamerah 3, Ilan H Meyer 4
PMCID: PMC3885323  NIHMSID: NIHMS529520  PMID: 24415898

Abstract

This mixed-methods study examined associations between prejudice events and posttraumatic stress disorder (PTSD) among 382 lesbians, gays, and bisexuals (LGB) and 126 heterosexuals. Using the Composite International Diagnostic Interview, we assessed PTSD with a relaxed Criterion A1; that is, we allowed events that did not involve threat to life or physical integrity to also qualify as traumatic. We first assessed whether exposure to prejudice-related qualifying events differed with respect to participants’ sexual orientation and race. We found that White LGBs were more likely than White heterosexuals to encounter a prejudice-related qualifying event, and among LGBs, Black and Latino LGBs were no more likely than White LGBs to experience this type of event. We then used qualitative analysis of participants’ brief narratives to examine prejudice events that precipitated Relaxed Criterion A1 PTSD among 8 participants. Two themes emerged: (a) the need to make major changes and (b) compromised sense of safety and security following exposure to the prejudice event.

Keywords: lesbian, gay, and bisexual, PTSD, Criterion A1, prejudice, discrimination

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994) indicates that posttraumatic stress disorder (PTSD) can be diagnosed following specific events whose threshold is defined in Criterion A1—events must involve actual or threatened death or serious injury, such as physical and sexual assault, military combat, and natural and manmade disasters (Breslau et al., 1998). However, there is consistent evidence that experiencing events that do not meet Criterion A1 is associated with a clinical condition identical to PTSD. Research has shown that individuals have met criteria for PTSD based on their symptom report following events that do not meet Criterion A1. That is, individuals reported at least one reexperiencing symptom (Criterion B), at least three avoidance symptoms (Criterion C), and at least two hyperarousal symptoms (Criterion D) that lasted for at least one month. Researchers have studied PTSD using Non-Criterion A1 events such as bullying (Van Hooff, McFarlane, Baur, Abraham, & Barnes, 2009), the expected death of a loved one (Gold, Marx, Soler-Baillo, & Sloan, 2005; Mol et al., 2005); financial problems (Solomon & Canino, 1990); miscarriage (Van Hooff et al., 2008); moving (Solomon & Canino, 1990); non-life-threatening medical problems (Gold et al., 2005; Mol et al., 2005); intimate relationship problems (Gold et al., 2005; Mol et al., 2005; Van Hooff et al., 2008); and work problems (Mol et al., 2005).

There is concern that removing Criterion A1 would lead to inflated prevalence of PTSD and also minimize the suffering of individuals exposed to life-threatening events (McNally, 2003). In our previous study (Authors, 2011), the prevalence of PTSD increased from 8.3 to 25.2% when allowing qualifying events that did not meet Criterion A1 to qualify for a diagnosis. To prevent inflated prevalence, Gold and colleagues (2005) proposed constructing another DSM category to address the symptom profile that emerges following acute, but non-traumatic, stressors. In fact, the DSM-5 Work Group has proposed a new category, trauma and stress-related disorders, which would include adjustment disorders (APA, 2010b). A new adjustment disorder specifier, with PTSD-like symptoms, would also be used when PTSD symptoms are present, but Criterion A1 is not met. However, using this specifier is conceptually problematic because it does not explain why the same set of symptoms emerges following exposure to traumatic and non-traumatic events (Authors, 2011). The conceptual problems surrounding Criterion A1 were discussed in our previous study (see Authors, 2011). Because debate continues on this unresolved issue, more research is needed to clarify the types of events that should be considered potentially traumatic.

Sexual Orientation and PTSD

Adding to the concerns about qualifying events is the question of how valid Criterion A1 is across populations. To date, studies such as those cited above have not examined the effect of relaxing Criterion A1 on sexual minority populations. This is an important area for research, because sexual minorities are exposed to more stressful events than their heterosexual counterparts (Meyer, Schwartz, & Frost, 2008) and may therefore be at risk for PTSD. This gap in the extant literature led us to compare prevalence of PTSD between lesbian, gay, and bisexual individuals (LGBs) and heterosexual individuals (see Authors, 2011).

In that study, we calculated prevalence of PTSD by including all qualifying events, regardless of whether they met Criterion A1. We referred to this as Relaxed Criterion A1 PTSD, whereas DSM-IV PTSD referred to diagnosis of PTSD using only Criterion A1 qualifying events. We found that Non-Criterion A1 events precipitated PTSD among LGBs. In addition, Latino LGBs had higher prevalence of Relaxed Criterion A1 PTSD than White LGBs. However, there was no difference in prevalence of DSM-IV or Relaxed Criterion A1 PTSD between heterosexuals and LGBs. This pattern of findings, where higher rates of PTSD existed only in some populations, is consistent with Gilman et al.’s (2001) finding that women with same-sex partners had higher prevalence of DSM-IV PTSD than women with opposite-sex partners. However, our findings were not consistent with Roberts, Austin, Corliss, Vandermorris, and Koenen (2010), who found that LGBs were at higher risk for DSM-IV PTSD than heterosexuals.

Non-Life-Threatening Prejudice Events and PTSD

Our previous study (Authors, 2011) did not examine the effect of prejudice on Relaxed Criterion A1 PTSD among LGBs. Examining whether traumatic stress is associated with non-life-threatening prejudice events is an important area for investigation. Scholars have argued that experiencing non-life-threatening prejudice events, particularly those involving prejudice, such as racism, can precipitate PTSD (Bryant-Davis & Ocampo, 2005; Helms, Nicolas, & Green, 2010; Loo et al., 2001). For example, racism-related events—regardless of whether they involve threat to life or physical integrity—are considered cognitive/affective assaults on an individual’s racial identification, and thus they “strike the core of one’s selfhood” (Bryant-Davis & O’Campo, 2005, p. 480). In addition, individuals exposed to racism-related events can manifest feelings of shame and/or self-blame, and they may also use denial as way to cope with the experience (Bryant-Davis & Ocampo, 2005).

Clinical literature frequently addresses the role of shame and its relationship to PTSD following exposure to a broad range of traumatic events, including gender violence, accidents and injury, child abuse, and political violence and dislocation (Budden, 2009). According to Budden, shame comprises “painful self-consciousness of or anxiety about negative judgment, unwanted exposure, inferiority, failure, and defeat” (p. 1033). He theorizes that this has the potential to threaten the social self and also precipitate the posttraumatic symptoms that emerge “in the field of social relations and collective meanings” (p. 1032). For these reasons, the DSM-5 PTSD Work Group has proposed adding an additional criterion, “negative alterations in cognitions and mood,” and shame is listed as one of the pervasive negative emotional states that may follow traumatic exposure (APA, 2010a).

Similar to racial/ethnic minority groups, LGBs frequently encounter non-life-threatening prejudice events and therefore may be at risk for PTSD-like disorder. For example, using a national probability sample, Herek (2009) found that 46% of gay men, 44% of lesbians, 34% of bisexual women, and 24% of bisexual men had faced verbal abuse two or more times since the age of 18. In addition, 18% of gay men, 16% of lesbians, 7% of bisexual women, and 4% of bisexual men reported they had faced employment and housing discrimination.

The traumatic effects of non-life-threatening sexual orientation prejudice have also been discussed by scholars. For example, Brown (2003) argued that coming out can be traumatic for some LGBs, particularly when the experience involves the loss of longstanding sources of social support (e.g., one’s family or religious community). Brown, drawing from the work of Janoff-Bulman (1992), asserted that this loss is potentially traumatic because it shatters a person’s three basic assumptions about the world—benevolence of the world, meaningfulness of the world, and sense of self-worth.

Some evidence supports that Non-Criterion A1 prejudice events are associated with PTSD-related symptoms among LGBs. D’Augelli, Grossman, and Starks (2006) found higher levels of PTSD symptoms among gay and bisexual youth who experienced verbal harassment. In addition, Szymanski and Balsam (2011) found heterosexist discrimination (e.g., being treated unfairly by a friend or boss or being rejected by a family member or friend) as well as sexual orientation bias-crimes were associated with PTSD symptoms among a convenience sample of 247 self-identified lesbians.

The Current Study

The goals of this study were two-fold. First, it provided a test for minority stress theory by comparing prejudice-related qualifying events between White heterosexuals and White LGBs and among White, Black, and Latino LGBs. According to minority stress theory, LGBs encounter chronic stress, motivated by prejudice and discrimination, which, in turn, causes higher prevalence of psychiatric disorders (Meyer, 2003). Additionally, research has shown that the double minority status of Black and Latino LGBs is likely to confer excess stress exposure (Meyer et al., 2008), as they face prejudice and discrimination from both majority and minority group contexts (Herek & Garnets, 2007). We thus hypothesized that (a) LGBs would be more likely than heterosexuals to report a prejudice-related qualifying event and that (b) Black and Latino LGBs would be more likely than White LGBs to report a prejudice-related qualifying event.

Second, based on previous theoretical discussion on the potentially traumatic effects of non-life-threatening prejudice events (e.g., Brown, 2003; Bryant-Davis & Ocampo, 2005), we used qualitative analysis to obtain a deeper understanding of the similarities and differences between Criterion A1 and Non-Criterion A1 prejudice events associated with Relaxed Criterion A1 PTSD, as well as the consequences of these events.

Methods

Sample and Recruitment

The current study used data from Project Stride, which examined associations among stress, identity, and mental health among self-identified LGBs and heterosexuals living in New York City (Meyer, Frost, Narvaez, & Dietrich, 2006). Between February 2004 and January 2005, venue-based sampling was used to recruit participants from non-gay establishments (e.g., book stores, coffee shops, and art galleries), gay-oriented settings (e.g., bars and gay pride events), and public spaces (e.g., parks and city streets). Outreach workers visited a total of 274 venues across 32 different zip codes. Snowball sampling was also used to recruit participants who were less likely to be found in public places.

At each of the venues, outreach workers completed a brief screening form to determine study eligibility. Respondents were eligible for interviews if they: (a) self-identified as male or female and were assigned that sex at birth; (b) self-identified as LGB or heterosexual; (c) self-identified as White, Black, or Latino; (d) were between the ages of 18 and 59; (e) lived in New York City for two years or more; and (f) were able to engage in conversational English. Case quota sampling was used to ensure approximately equal numbers of participants with respect to gender (male or female), sexual orientation (LGB or heterosexual), race/ethnicity (White, Black, or Latino), and age group (18–30 or 31–59). Trained interviewers contacted eligible selected respondents and invited them to participate in the study. Participants engaged in a comprehensive in-person interview using computer-assisted and paper-and-pencil instruments.

The cooperation rate for the study was 79%, and the response rate was 60% (American Association for Public Opinion Research, 2005: COOP2 and RR2). Response and cooperation rates did not differ with respect to gender, race, or sexual orientation (χ2s ≤ 0.78, ps ≥ .38). Respondents were from 128 different New York City zip codes, with no more than 3.8% of the sample living in any one zip code.

Participants

Of the 524 participants in the initial sample, 16 had missing information or were not assessed for PTSD. Thus, the sample for the current study consisted of 382 LGB and 126 heterosexual respondents (N = 508) with a mean age of 32.13 (SD = 9.22). The participants included an equivalent number of White heterosexuals (25%), White LGBs (25%), Black LGBs (25%), and Latino LGBs (25%), and equivalent numbers of men and women. Most participants (81%) had more than a high school education, and 19% had a high school diploma or less. The majority of participants (84%) were employed, but 16% were unemployed. Slightly more than half (53%) had negative net worth, that is, owing money after calculating how much one would owe or have left after converting all assets to money and paying all debts.

Measurement Instruments

Stressful life events

The Life Events Questionnaire (LEQ; Meyer et al., 2006) is a semi-structured interview designed to elicit information about 47 stressful events experienced by individuals throughout the lifespan (Kman, Palmetto, & Frost, 2006). Interviewers asked participants whether they had experienced each one of the 47 events. There were two types of events: extreme or life-threatening (e.g., sudden death of a loved one, war, terrorist attack, natural and manmade disasters, seeing an injured or dead body, life-threatening illness, and sexual abuse/assault) and those not considered traumatic by the DSM-IV (e.g., relationship/marriage dissolution, expected death of a loved one, financial and work problems, homelessness, non-life-threatening illness, miscarriage, and harassment). Affirmative responses were carefully probed in order to formulate a brief event narrative. The event narratives included specific details about the event as well as the consequences of the events.

Event descriptions were extracted from the interviews and rated by two independent raters using a rating system adapted from Dohrenwend, Raphael, Schwartz, Stueve, and Skodol (1993). Raters assessed “life-threat” and “threat to physical integrity” on a scale ranging from (0) no chance of threat to (5) threat is certain and great. The average score of the two raters was computed to determine a final rating. Stressful events that received threat to life and physical integrity ratings between 3 and 5 were coded as life-threatening, and, as a result, considered Criterion A1 events. Events that received ratings below 3 were coded as non-life-threatening, and thus were considered Non-Criterion A1 events. Ratings between 3 and 5 were used to categorize stressful events as life-threatening. These ratings suggest the probability of serious threat is at least 50% or higher, as opposed to ratings below 3, which were used to classify events having “no chance of threat” to “possible threat.” Certain events that were rated as non-life-threatening (e.g., seeing an injured or dead body, childhood sexual abuse, life-threatening illness of a significant other) qualify as potentially traumatic (i.e., Criterion A1 events) according to the DSM-IV. Therefore, we classified them as Criterion A1 events in order to maintain consistency with the DSM-IV.

In addition, raters assessed whether the event involved prejudice. Prejudice involvement was rated as either involving prejudice or not involving prejudice. The prejudice-related event was further coded based on the type of prejudice involved (sexual orientation, race/ethnicity, gender, age, physical appearance, socioeconomic status, religion, or other).

The consistency of the two ratings was used to determine inter-rater reliability. Of all the possible Project Stride event ratings (N = 77,085), only 2% were discrepant between the two raters, indicating a high degree of inter-rater reliability. Weekly rater meetings were used to resolve discrepancies of 1.5 for “life-threat” and “threat to physical integrity” (Meyer et al., 2006).

PTSD

A modified version of the Computer Assisted World Mental Health Composite International Diagnostic Interview (WMH-CIDI; Kessler & Ustun, 2004) was used to assess PTSD symptom criteria B through F. This is a highly standardized lay-administered interview used to assess current and lifetime psychiatric diagnoses based on DSM-IV criteria. Kessler et al. (2005) found good concordance between diagnoses from the WMH-CIDI and the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 2002) among a probability sample of National Comorbidity Survey Replication participants.

Interviewers began the WMH-CIDI for PTSD by asking participants whether they had experienced upsetting memories or dreams, felt emotionally distant from other people, and had trouble sleeping or concentrating following any of the 47 stressful experiences elicited by the LEQ. An affirmative response prompted interviewers to ask which one experience caused the most severe problems. This was considered the participant’s qualifying event. Participants reporting more than one experience were asked to choose the event that caused the most distress.

In addition to having a qualifying event, respondents also had to meet Criterion A2 by endorsing one or more of the following: feeling terrified or very frightened, helpless, or shocked or horrified at the time of the qualifying event. Participants who met Criterion A2 were then required to link symptoms associated with criteria B-D to the qualfying event. Finally, symptoms had to be present for at least one month (Criterion E), and participants had to report moderate, severe, or very severe levels of distress associated with the event (Criterion F).

Analytic Approach

Because all heterosexual participants were White, it was not possible to test the combined effects of race and sexual orientation. To examine the effect of sexual orientation while controlling for race, chi-square was used to test whether White LGBs were more likely than White heterosexuals to experience a prejudice-related qualifying event. To examine the effect of race while controlling for sexual orientation, chi-square was used to test whether Black and Latino LGBs were more likely than White LGBs to experience a prejudice-related qualifying event. For all analyses, a criterion of α = .05 was used for two-tailed statistical significance.

We used the Duquesne method as outlined by Moustakas (1994) to compare Criterion A1 and Non-Criterion A1 prejudice events. This method consists of the following steps: (a) collect verbal protocols (life narratives) that describe the experience; (b) read carefully to get a sense of the entire experience; (c) extract significant statements; (d) eliminate irrelevant repetition; (e) identify central themes; and (f) integrate these meanings into a single description (Creswell, 1998; McLeod, 2001). Coding of the narratives was completed in an iterative process between two of the authors (EA and AG) to identify and note emerging themes. These authors performed the coding, and then discussed the codes with the other authors (IM and JM) to confirm, reject, or rename them.

Results

Of the 508 participants, 280 (55.1%) reported an event that caused upsetting memories or dreams, emotional distance from other people, or difficulty sleeping or concentrating. Participants who reported such symptoms after a stressful event were assessed for a diagnosis of PTSD even if the qualifying event did not meet Criterion A1. LGBs were no more likely than heterosexuals to report a qualifying event, χ2 (df = 1, N = 508) = 3.05, p = .081; among LGBs, White, Black, and Latino LGBs did not differ with respect to reporting a qualifying event, χ2 (df = 2, N = 382) = 3.18, p = .204.

Consistent with the minority stress hypothesis, sexual orientation was associated with reporting a prejudice-related qualifying event—White LGBs (9.1%) were more likely than White heterosexuals (0%) to report such events, χ2 (df = 1, N = 127) = 3.98, p = .046 (Yates correction used). However, Black and Latino LGBs were no more likely than White LGBs to report such events (9.7%, 7.4%, and 9.1%, respectively).

Of the 19 LGB participants who experienced a prejudice-related qualifying event, 6 identified as White, 7 as Black, and 6 as Latino. Fifteen participants experienced an event that was categorized as Non-Criterion A1, whereas 4 experienced a Criterion A1 prejudice event. Six participants experienced events involving racial prejudice (of which 2 participants were White), and 13 experienced events involving sexual orientation prejudice. Five of the 19 participants reported more than one type of prejudice involvement. One respondent experienced both racial and ethnic prejudice; another respondent experienced sexual orientation prejudice in addition to prejudice related to physical appearance; 3 participants who experienced prejudice based on sexual orientation and physical appearance also reported prejudice based on their social class. As shown in Table 1, prejudice events were associated with Relaxed Criterion A1 PTSD among 8 participants. The table also shows the number of Criterion B, C, and D symptoms endorsed by each participant.

Table 1.

Sexual Orientation, Racial Prejudice Events, and Number of Criterion B, C, and D Symptoms Associated with Relaxed Criterion A1 PTSD

Event Type Category Prejudice Race Gender Criterion B Criterion C Criterion D
Physical Assault Criterion A1 SO Black Male 4 5 5
Physical Assaulta Criterion A1 SO Black Male 4 6 3
Physical Assault Non-Criterion A1 Racial White Male 4 5 4
Physical Assaulta Non-Criterion A1 SO Black Female 4 4 5
Physical Assaulta Non-Criterion A1 SO Latino Male 3 4 3
Harassment Non-Criterion A1 SO Latino Male 2 6 3
Unemployment Non-Criterion A1 SO White Female 5 7 4
Childhood Abuse Non-Criterion A1 SO Latino Male 5 3 4
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Note. SO = Sexual Orientation.

a

Also includes prejudice based on physical appearance and social class. Each participant also met Criterion A2, had symptoms for at least one month (Criterion E), and reported moderate, severe, or very severe levels of distress (Criterion F).

Prejudice Events Descriptions and Themes

Table 2 shows the similarities and differences between the Criterion A1 and Non-Criterion A1 prejudice events associated with Relaxed Criterion A1 PTSD. Two specific themes emerged: (a) the need to make major changes following the event; and (b) compromised sense of safety and security following the event.

Table 2.

Similarities and Differences Between Criterion A1 and Non-Criterion A1 Prejudice-Related Events Associated with Relaxed Criterion A1 PTSD

Similarities Differences
Criterion A1 Non-Criterion A1
Events were prejudice-related Severe physical injury No severe physical injury or life-threat
Significant life changes made following the event Clear-cut avoidance symptoms following the event among all participants Clear-cut avoidance symptoms following the event among some participants
Safety or security was felt to be compromised Perpetrators not known Perpetrators known in most cases (e.g., peers, relative, partner, co-workers)
Experienced emotional distress Alone when assaults occurred In the presence of others (e.g., relative, friend) when event occurred
21 and 33 years old when event occurred All but 1 participant was 19 years old or younger when event occurred
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All 8 participants had to make significant changes following the event. One respondent who experienced severe (i.e., Criterion A1) physical assault moved from Central America to the U.S. following the attack. The other participant who experienced severe physical assault had to change his daily travel patterns and also decrease the amount of time he spent outside of the house. Those who experienced Non-Criterion A1 events (i.e., harassment, non-life-threatening childhood physical abuse, unemployment, and non-life-threatening physical assault) also made major life changes following the events, such as moving, switching schools, asking parents for money, and altering well-established routines.

Unlike the 6 participants who experienced Non-Criterion A1 events, the 2 participants experiencing Criterion A1 physical assault suffered extremely violent attacks that led to severe physical pain, injury, and/or hospitalization. Both participants also avoided the areas where the attacks occurred as well as venues that might place them at risk for another sexual orientation bias attack. The participant who moved from Central America to the U.S. was attacked by six men from his neighborhood who knew he was gay. He reported the men stabbed and beat him. Following the attack, he needed six stitches and took pain medication for two to three weeks. The participant reported the crime to the police, but “they knew I worked for the government, [so they] didn’t put my sexuality on report.” As a result of the attack, he stopped going out, because “I was scared to be in my neighborhood.”

The other participant experiencing Criterion A1 physical assault was attacked by a male who thought he was flirting with him. He reported:

[I] had a street fight with a drunk looking for a fight. We talked normally at first and then realized something was wrong with him. He commented that I was gay, asked if I was trying to pick him up. He assumed it. I said no, and I tried to walk away. He grabbed my arm and swung. Got a busted lip, scraped side of my face…[After the incident I] avoided that part of [the neighborhood]. Curtailed me going out…made me more cautious in my interactions and activities.

The 3 participants who experienced Non-Criterion A1 physical assault were not subject to life- or physical-integrity threat, but their sense of safety and security was still compromised following the events. For example, one participant felt a sense of danger after being threatened by her girlfriend. The White participant who was diagnosed with Relaxed Criterion A1 PTSD after encountering a racially motivated Non-Criterion A1 physical assault in which he was chased by a group of black teenagers who hit him on the back. Following this event, he was worried about running into the teenagers again, and as a result avoided school and certain forms of public transportation.

Two participants experienced negative reactions from their mothers after they found out the participants were gay. These negative reactions compromised the safety and security of the participants during their teenage years. One participant, whose Non-Criterion A1 event was harassment, reported: “After mom found out that I was gay, she threw away and damaged my things. Called me ‘faggot’ and ‘cocksucker.’ Mom ripped up and destroyed my schoolbooks, CDs…threw out random things…” The participant who experienced non-life-threatening childhood physical abuse by his mother reported that the abuse was, for the most part, motivated by his sexual orientation. The respondent reported: “One time when it was bad enough that there were marks… I quit the swim team rather than show the marks.” Both participants responded to the hostility and aggression by moving out of their parents’ homes. The participant who developed Relaxed Criterion A1 PTSD from being unemployed had her financial security compromised after her employer “let her go,” in part, because she was “vocal about gay rights.” The participant spent a long time searching for jobs, had to pay for her own health insurance, and had to ask her mother for money to pay her mortgage, prompting major changes to her previously established way of life.

Discussion

As expected, LGB orientation was associated with experiencing a prejudice-related PTSD qualifying event. In fact, no heterosexuals experienced such an event. The finding that race/ethnicity was not associated with experiencing a prejudice-related PTSD qualifying event was unexpected in light of the previously reported finding that, unrelated to a PTSD diagnosis, Black and Latino LGBs are more likely to experience racial/ethnic prejudice events than White LGBs (Meyer et al., 2008). One possible reason for the current finding may be that Blacks and Latinos identified other PTSD qualifying events that caused more severe problems than those involving prejudice. For example, 25% of Latino LGBs were diagnosed with Relaxed Criterion A1 PTSD after experiencing childhood sexual or physical abuse, and 22.6% of Black LGBs were diagnosed with Relaxed Criterion A1 PTSD after experiencing the unexpected or expected death of loved one.

Our findings showed that 8 of the 19 participants who experienced a prejudice-related PTSD qualifying event met criteria for Relaxed Criterion A1 PTSD. Two participants experienced events categorized as Criterion A1, and 6 experienced events categorized as Non-Criterion A1. Thus, experiencing prejudice events that do not meet Criterion A1, such as harassment, termination from employment, non-life-threatening physical assault, or non-life-threatening childhood abuse can precipitate PTSD-like disorder among LGBs. Although physical assault and childhood physical abuse qualify as potentially traumatic events (i.e., Criterion A1 events) according to the DSM-IV, our analysis showed that the 4 cases in which they occurred were qualitatively different than the 2 physical assault cases that were categorized as Criterion A1. In these 4 cases participants did not experience life-threat or serious physical injury, whereas in the other 2 cases participants encountered life-threat as well as physical injury. One particpant reported he was stabbed, punched, and choked and required immediate medical attention, and the other participant reported a “busted lip.”

Regardless of whether events were categorized as Criterion A1 or Non-Criterion A1, the prejudice events associated with Relaxed Criterion A1 PTSD shared common themes—both types of events led to major life changes and compromised participants’ sense of safety or security. High magnitude events, regardless of whether they are life-threatening, can challenge one’s existing cognitive schemas or the way in which one views the world. Schema theories, such as the one proposed by Janoff-Bulman (1992), have provided researchers and clinicians with alternative ways to understand reactions to traumatic events (Cahill & Foa, 2007). Posttraumatic stress is not solely the result of experiencing fear and terror but also the shattering of one’s basic assumptions about the world (DePrince & Freyd, 2002). According to Brown (2003), losing one’s longstanding sources of social support after coming out can shatter these assumptions. In the current study, the mothers of 2 participants demonstrated extreme hostility and aggression toward their sons after finding out they were gay, which was experienced as a loss of support. Also, the way in which one perceives an event can play a role in precipitating PTSD-like disorder. The participant who lost her job may have not had her physical safety compromised, but the negative consequences of this event were enough to cause psychological pain, which can be experienced as traumatic (Carlson & Dalenberg, 2000).

In order to identify more LGBs with PTSD-like disorder, it would be helpful to remove Criterion A1. Doing so would allow researchers and clinicians to focus on the symptoms (i.e., reexperiencing, avoidance, and hypervigiliance) precipitated by the prejudice event, rather than whether it meets Criterion A1 (Brewin et al., 2009). Similar to Bryant-Davis and O’Campo (2003), Mascher (2003) argued that experiencing an event involving prejudice, regardless of severity, could cause PTSD symptoms such as hypervigilance, fear, anxiety, and relationship problems. The consequences of trauma involving prejudice can be enduring, and often times LGBs have little awareness of how exposure to this type of trauma impacts their current thoughts, feelings, and behavior (Mascher, 2003).

The current study had some important limitations. First, Project Stride used a nonrandom sample, which could under- or overestimate prevalence of mental disorder. However, sampling bias was reduced by avoiding venues such as 12-step groups and mental health clinics that over-represent individuals with psychiatric disorders. Second, Project Stride did not include samples of Black and Latino heterosexuals, which prevented an examination of differences in prejudice events on the basis of sexual orientation among non-Whites. This would be an important area of inquiry because the effect of sexual orientation on the experience of prejudice events may vary according to race/ethnicity. However, Project Stride was designed to test the hypothesis that Black and Latino LGBs would encounter more stressful experiences than White LGBs in the same way that Latino, Black, and White LGBs would encounter more stressful experiences than White heterosexuals. Moreover, Project Stride was conceptualized in such a way so that the burden of race/ethnicity was considered an added burden to sexual orientation minority status (Meyer, Schwartz, & Frost, 2008). Finally, the findings about the similarities between Non-Criterion A1 and Criterion A1 prejudice events, as the analysis are based on data from only 8 participants, and thus they must be considered preliminary at best.

Despite these limitations, the study had a number of strengths. The use of an independent rating system helped to ensure that qualifying events were acute stressful events; daily hassles and chronic strain were not assessed for a PTSD diagnosis in this study. An event was not an actual “event” unless raters determined it caused a change in the participant’s life. Raters also accounted for intracategory variability; that is, “the fact that a variety of types of experience are encompassed by each particular event category” (Dohrenwend, 2006, p. 478). Thus, our categorizations more likely reflect the actual nature of events (Dohrenwend, 2006), as compared with automatically designating certain events as life-threatening or extreme. Furthermore, to be diagnosed with PTSD participants had had to meet Criterion A2 and have the required number of Criteria B–D symptoms. In addition, these symptoms had to be present for at least one month (Criterion E), and participants had to report moderate, severe, or very severe levels of distress associated with the event (Criterion F). This is important to highlight, because the presence of PTSD symptoms following a stressful event is not necessarily indicative of disorder (Brewin, Lanius, Novac, Schynder, & Galea, 2009). PTSD reflects a failure of adaptation; thus it is the persistence of these symptoms as well as the level of impairment caused by these symptoms that is pathological (Brewin et al., 2009).

More studies that use objective measures of prejudice, such as this one, are needed to examine associations between acute non-life-threatening prejudice events and PTSD among diverse samples of LGBs. In addition, revising criterion A1 would compel more researchers to study the traumatic effects of prejudice-related events that do not meet Criterion A1. This has the potential to affect treatment outcomes, as the nature of PTSD differs from other stress-related psychiatric disorders, such as adjustment, mood, and other anxiety disorders. According to Shalev (1996), PTSD consists of multiple components, including hyperarousal, the development of conditioned fear responses, and altered cognitive schemas, thus making PTSD a “biopsychosocial trap in which one level of impairment prevents self-regulatory healing mechanisms from occurring at other levels” (p. 94). Currently, Criterion A1 limits PTSD research to the study of life-threatening or extreme events, unless researchers define their results a priori (Solomon & Canino, 1990), as this study did.

Acknowledgments

This research was supported by National Institute of Mental Health Grant R01MH066058-03, awarded to Ilan H. Meyer.

Footnotes

The manuscript is based on data also used in a dissertation by Edward J. Alessi.

Contributor Information

Edward J. Alessi, School of Social Work, Rutgers, The State University of New Jersey

James I. Martin, Silver School of Social Work, New York University

Akua Gyamerah, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University.

Ilan H. Meyer, The Williams Institute, UCLA School of Law

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