Abstract
Background:
Sexual minority adults are at greater risk for cardiovascular disease (CVD) risk factors than heterosexual adults. There is a dearth of research identifying factors that are associated with CVD risk among sexual minorities. This study examined the associations between distal and proximal minority stressors and CVD risk. We also tested a sense of mastery as one mechanism that might explain the link between minority stressors and CVD risk.
Methods:
Participants were 670 sexual minority adults, (53.6% male; 76% White), ages 18 to 76 years (M = 41.19, SD = 14.73) obtained from a non-probability sample. Using an online survey, participants self-reported family history of CVD risk, physiological conditions (diabetes mellitus, high cholesterol, hypertension), and health behaviors (e.g., tobacco use, diet, exercise) that confer or protect against CVD risk. A weighted CVD risk index was computed. Linear and logistic regressions were conducted to test the effects of minority stressors on the CVD risk index and its specific indicators and to examine mediation.
Results:
Minority stressors were associated with a sense of mastery, and mastery was associated with lower CVD risk index scores. Proximal and distal minority stressors were not directly associated with the overall CVD risk index but were associated with some specific risk indicators. Mediation analyses revealed that both distal and proximal minority stressors were indirectly associated with the CVD risk index through mastery.
Conclusions:
Research and interventions should aim to reduce CVD risk factors and target minority stressors and mastery to improve the cardiovascular health of sexual minorities.
Keywords: sexual minorities, minority stress, internalized heterosexism, sense of mastery, cardiovascular disease risk
INTRODUCTION
Cardiovascular disease (CVD) is one of the leading causes of death in the U.S.(1). CVD and its related risk factors disproportionately impact subgroups of the U.S. population, particularly sexual minority (e.g., lesbian, gay, bisexual) adults. Population-based research has documented sexual orientation disparities in CVD and its risk factors; specifically sexual minority adults have higher rates of CVD and greater CVD risk factors than heterosexual adults (2-5). Despite these findings, a recent systematic review has found that there are limited and mixed sexual orientation differences in CVD diagnoses but there is evidence for disparities in CVD risk factors (6). Specifically, sexual minority adults are more likely than heterosexuals to have CVD risk factors such as tobacco and illicit drug use and poor mental health (6). Exacerbating their CVD risk, sexual minority women are also more likely to be overweight or obese and consume alcohol than heterosexual women (6-8). Although these disparities are health priorities (9), there is a dearth of research elucidating unique factors that are associated with CVD risk among sexual minority adults.
In addition to general adverse life experiences, the minority stress model posits that sexual minority individuals face unique and adverse stressors (e.g., heterosexist discrimination) related to their stigmatized sexual identity (i.e., minority stressors); consequently, these experiences have pernicious effects on their health (10, 11). Minority stressors are distal (i.e., external such as experiences of discrimination or victimization) or proximal (i.e., internalization of sexual stigma as part of one’s sense of self, such as internalized heterosexism) (10). Although research over the past two decades has identified the negative effects of minority stressors on mental health, limited literature has focused on the deleterious effects of minority stressors on physical health (12-14), including CVD risk. Stressful life events elevate young sexual minority individuals’ cardiometabolic risk over time (14). However, there is limited literature examining the associations between minority stressors and CVD risk factors and the psychological mechanisms linking these associations. Identifying mechanisms is crucial to informing future CVD interventions with sexual minorities, which are greatly lacking.
According to the psychological mediation framework, an adaptation of the minority stress model, minority stress may lead to poor health outcomes through compromised psychological stress response mechanisms (15). One psychological mechanism that could elucidate the associations between minority stressors and CVD risk factors is a sense a mastery, which is the perception of having control over one’s life (16). Sense of mastery is associated with improved cardiometabolic health and reduced risk for CVD among the general population (17). It is posited to attenuate the effects of general stress on CVD and may a protective psychological that is associated with health promoting behaviors (17). For example, a higher sense of mastery is associated with lower metabolic risk for individuals who lived near a large proportion of fast-food restaurants, suggesting that sense of mastery may interact with the environment to affect whether or not people follow health recommendations or engage in health behaviors (18). Moreover, a sense of mastery can serve as a psychological resource to defend against minority stressors; however, psychological resources may disintegrate with frequent sexual minority-specific stressors and facilitate poor health (15). Minority stress can disempower and deplete sexual minority individuals’ sense of control (19, 20); in fact, minority stress is associated with lower sense of mastery among sexual minorities (15, 21).
Despite the documented relationships between minority stressors and a lower sense of mastery and sense of mastery and lower CVD risk, the mediating effect of sense of mastery on the associations between distal and proximal minority stressors and CVD risk have not been tested. In this study, we examined the associations between distal (i.e., heterosexist harassment, rejection, and discrimination) and proximal (i.e., internalized heterosexism) minority stressors and CVD risk among a large sample of sexual minority adults who have not yet established CVD. We tested sense of mastery as a mechanism that might explain the link between minority stressors and CVD risk.
METHODS
Procedures
Participants were from a larger study of minority stress and health outcomes among sexual minority adults (author citation) conducted in the United States. A non-probability sample of sexual minority participants was recruited by contacting online sexual minority-specific listservs and an online panel of research participants. Informed consent was obtained from all individual participants included in the study. Then participants completed an online survey, and received monetary incentives described elsewhere. The primary study’s inclusion criteria were being 18 years of age or older and identifying as a sexual minority. To ensure the quality of data, responses were screened for duplicate IP addresses, but none were found. Additionally, 87 participants who identified as heterosexual or exclusively heterosexual on the sexual orientation demographic questions were screened out of the survey, leaving a total sample of 718 participants. All procedures performed in studies involving human participants were in accordance with the ethical standards of the first author’s Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Measures
Distal minority stress.
The 14-item Heterosexist Harassment, Rejection, and Discrimination Scale (22) assessed distal minority stress over the past year (e.g., “How many times have you been treated unfairly by your co-workers, fellow students, or colleagues because you are a gay, lesbian, or bisexual person?”; α = .95). Item response options were on a 6-point frequency scale, ranging from 1 (the event has never happened to you) to 6 (the event happened almost all the time). Higher scores indicate greater experiences of distal minority stress.
Proximal minority stress.
The 5-item Revised Internalized Homophobia Scale (20) assessed the internalized heterosexism dimension of proximal minority stress (e.g., “I wish I weren’t lesbian/gay/bisexual.”; α = .89). Response options were on a 5-point Likert scale from 1 (disagree strongly) to 5 (agree strongly). Higher scores indicate greater proximal minority stress.
Sense of mastery.
The 7-item Mastery Scale (16) assessed participants’ sense of mastery (e.g., “Sometimes I feel that I'm being pushed around in life.”; α = .86). Item response options were on a 4-point Likert scale, ranging from 1 (strongly agree) to 4 (strongly disagree). Higher scores indicate a greater sense of mastery. This scale has sound psychometric properties and has related to effective stress resistance (23).
CVD risk factor index.
Using a novel, evidence-informed index created for this study, CVD risk factors were measured by participants’ self-report on 9-items based on prior research on cardiovascular health risk factors (24) and research on health risk factors among sexual minority individuals (6, 25). Validated existing measures of CVD risk classification were adapted to create the index used in the present study because existing risk estimation calculators are not appropriate for the present sample due to the sample’s mean age and the dichotomous response options of the questions; existing calculators, such as the American College of Cardiology and American Heart Association’s Atherosclerotic CVD Risk Calculator, are more appropriate for older samples and when lipid and blood pressure values are available. The items assessed family history of early heart disease, physiological conditions, and health behaviors that confer or protect against CVD risk. Participants were asked if they had any of the following conditions (“Have you ever been told by a doctor, nurse, or other health professional that you have any of the following?”): high blood cholesterol levels; hypertension; heart attack, stroke, or heart failure; and diabetes mellitus. Participants were also asked “Do you currently or have in the past…?” the following: use tobacco or cigarettes; eat food high In saturated fats, salt, or sodium; exercise regularly; use alcohol excessively; or have excess body fat. Responses were either “No” or “Yes”. Based on the CVD risk factors literature (24, 26-28), we weighted each item based on its severity and likelihood of conferring CVD risk to compute a CVD risk index using the following weights: 3 for diabetes mellitus; 2 for high cholesterol, hypertension, tobacco use, or family history of early CVD; 1.5 for excess body fat; 1 for diet high in saturated fat or sodium or and excessive alcohol use; and −1 for regular exercise. Points were summed to determine the CVD risk index. The item regarding heart attack, stroke, or heart failure was not included in this index, but was used to exclude participants with established CVD since the intention of this study was to evaluate risk for developing CVD in individuals without evidence of established CVD at the time of assessment. Higher scores on this index indicate greater CVD risk, but scores do not indicate absolute or relative CVD risk. While self-reported presence of CVD risk markers may not be suitable for formal CVD risk estimation, previous literature suggests that self-reported data is still useful in determining general CVD risk (29); this may be especially true for evaluating health behaviors associated with CVD risk (e.g., physical activity) rather than the outcomes of certain behaviors or physiological processes (e.g., hypercholesterolemia) (30).
Statistical Analysis
We excluded participants with established CVD since the intention of this study was to evaluate CVD risk for individuals without evidence of established CVD at the time of assessment. As such, 48 participants were excluded due to personal history of heart attack, stroke, or heart failure1. We first examined correlations among the variables and then conducted linear and logistic regressions to test for mediation. We used the PROCESS Macro v2.13 in SPSS 22 to test the mediating effect of mastery on the associations between distal and proximal minority stressors and CVD risk index as well as each individual CVD risk indicators with the exception of family history of heart disease. The macro conducted a bias-corrected bootstrapping procedure with 1,000 samples and 95% Confidence Interval (CI) (31, 32). Age, gender, race, education, income, and relationship status were accounted for in the models. Due to the small number of transgender (n = 20) and separated/divorced (n = 16) participants, they were not included in the regression models but were retained in the sample for descriptive purposes.
RESULTS
The final analytic sample was 670 participants. Participants were adults ages 18 to 76 years (M = 41.19, SD = 14.73). Participant demographics and descriptives are presented in Table 1. The mean CVD index score for the sample was 3.94 (SD = 3.02; Range: −1 to 13.5). We tested sociodemographic differences in the CVD index and found differences in education, with participants with some high school education, degree, or GED had higher index scores than participants with a bachelor’s degree; however, effect sizes were small (see Table 1).
Table 1.
Sample demographics and descriptives of cardiovascular disease (CVD) risk index (N = 670).
| Total Sample | Risk Index | Test Statistic | |
|---|---|---|---|
| % (n) | Mean (SD) | ||
| Gender | F(2) = 2.85, p = .06, η2p = .01 | ||
| Male | 53.6 (359) | 4.08 (3.17) | |
| Female | 43.4 (291) | 3.87 (2.84) | |
| Transgender | 3 (20) | 2.38 (2.31) | |
| Sexual Orientation | F(4) = 1.70, p = .15 | ||
| Lesbian | 22.1 (148) | 3.56 (2.69) | |
| Gay | 44.3 (297) | 4.11 (3.14) | |
| Bisexual | 25.2 (169) | 4.22 (3.20) | |
| Queer | 5.7 (38) | 3.21 (2.34) | |
| Other | 2.7 (18) | 3.14 (2.61) | |
| Race | F(6) = 0.75, p = .61 | ||
| Asian American/Pacific Islander | 4 (27) | 3.09 (3.59) | |
| Black or African American | 6.6 (44) | 2.84 (2.99) | |
| Biracial or Multiracial | 3.6 (24) | 3.73 (2.89) | |
| Hispanic or Latino/a | 6.4 (43) | 3.69 (3.08) | |
| Native American | 1 (7) | 3.93 (2.03) | |
| White | 76 (509) | 4.11 (2.97) | |
| Other | 1.9 (13) | 3.11 (2.65) | |
| Education | F(4) = 4.96, p < .001, η2p =.03; HS/GED > Bachelor’s | ||
| Some high school | 1.9 (13) | 5.42 (3.33) | |
| High school (HS) degree or equivalent (GED) | 26.6 (178) | 4.44 (3.02) | |
| Associates degree | 14.2 (95) | 4.43 (3.07) | |
| Bachelor’s degree | 31.8 (213) | 3.42 (3.04) | |
| Master’s degree or higher | 24.8 (166) | 3.70 (2.84) | |
| Income | F(1) = 0.87, p = .35, | ||
| ≤ $24,999 | 36.6 (245) | 4.13 (3.06) | |
| ≥ $25,000 | 61.9 (415) | 3.84 (2.99) | |
| Relationship Status | F(4) = 0.48, p = .75, | ||
| Single (not dating) | 35.2 (236) | 4.04 (3.23) | |
| Dating | 12.4 (83) | 3.26 (2.77) | |
| Partnered/Committed Relationship | 31.5 (211) | 3.94 (2.79) | |
| Married | 17.6 (118) | 4.09 (3.11) | |
| Separated/Divorced | 2.7 (16) | 5.25 (3.15) | |
| Cardiovascular Disease Risk Factors | |||
| Diabetes mellitus | 6.4 (43) | ||
| High cholesterol | 29.1 (195) | ||
| Hypertension | 17.5 (117) | ||
| Tobacco/cigarette use | 48.5 (325) | ||
| Family history of early CVD | 34.8 (233) | ||
| Excess body fat | 54.9 (368) | ||
| Diet high in saturated fat, salt, or sodium | 71.0 (476) | ||
| Excessive alcohol use | 25.8 (173) | ||
| Not engaged in regular exercise | 35.5 (238) |
Correlations indicated that both distal and proximal minority stressors were associated with a lower sense of mastery (r = −.31 and −.27, respectively, p < .001). A sense of mastery was associated with lower CVD risk index scores (r = −.11, p < .01). Distal and proximal minority stressors were not correlated with the CVD risk index (r = −.05, p = .23; r = .02, p = .54, respectively). Linear regressions indicated that distal and proximal minority stressors were associated with a lower sense of mastery (β = −.29 and −.21, respectively, p < .001), while accounting for sociodemographic variables.
Distal Minority Stress and CVD Risk Outcomes
As presented in Table 2, distal minority stress was not associated with the CVD risk index (β = .03, p = .50). A sense of mastery was associated with lower CVD risk index scores (β = −.11, p < .01) and greater likelihood of reporting regular exercise (Adjusted Odds Ratio [AOR] = 1.98 (95% CI = 1.46, 2.69). Mediation was supported as the indirect effect of distal minority stress on the CVD risk index was significant through a sense of mastery2, indicating that distal minority stress was associated with a lower sense of mastery and in turn a lower sense of mastery was associated with greater scores on the CVD risk index.
Table 2.
Effects of Distal Minority Stress on cardiovascular disease risk factors among a sample of sexual minority adults.
| CVD Risk Index | High cholesterol | Diabetes Mellitus | ||||||
|---|---|---|---|---|---|---|---|---|
| Variables | B (SE) | β | B (SE) | β | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) |
| Age | .06 (.01) | .31*** | .06 (.01) | .31*** | 1.08 (1.06, 1.09)*** | 1.08 (1.06, 1.09)*** | 1.05 (1.02, 1.08)*** | 1.05 (1.02, 1.08)*** |
| Gender | −.04 (.25) | −.01 | −.03 (.25) | .00 | 1.02 (0.68, 1.54) | 1.02 (0.68, 1.54) | 1.88 (0.90, 3.95) | 1.87 (0.89, 3.92) |
| Race | −.34 (.28) | −.05 | −.26 (.28) | −.04 | 0.88 (0.54, 1.45) | 0.89 (0.54, 1.46) | 2.50 (1.18, 5.29)** | 2.66 (1.23, 5.69)* |
| Education | −.92 (.28) | −.14** | −.87 (.28) | −.13** | 0.89 (0.57, 1.41) | 0.90 (0.57, 1.42) | 0.47 (0.23, 0.98)* | 0.49 (0.24, 1.00) |
| Income | −.52 (.27) | −.08 | −.45 (.27) | −.07 | 0.93 (0.60, 1.44) | 0.93 (0.60, 1.45) | 0.56 (0.27, 1.15) | 0.59 (0.29, 1.22) |
| Relationship | .26 (.24) | .04 | .26 (.24) | .04 | 1.28 (0.86, 1.91) | 1.28 (0.86, 1.91) | 1.58 (0.79, 3.15) | 1.59 (0.79, 3.17) |
| Distal Stress | .10 (.15) | .03 | −.02 (.15) | .00 | 1.22 (0.95, 1.56) | 1.20 (0.93, 1.56) | 1.15 (0.75, 1.78) | 1.07 (0.68, 1.67) |
| Mastery | −.53 (.20) | −.11** | 0.95 (0.69, 1.32) | 0.71 (0.41, 1.22) | ||||
| Hypertension | Diet high in saturated fat, salt, or sodium | Excess Body Fat | ||||||
| Variables | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | ||
| Age | 1.04 (1.03, 1.06)*** | 1.04 (1.03, 1.06)*** | 1.00 (0.98, 1.01) | 1.00 (0.98, 1.01) | 1.03 (1.02, 1.04)*** | 1.03 (1.02, 1.04)*** | ||
| Gender | 2.14 (1.31, 3.50)** | 2.14 (1.31, 3.51)** | 1.02 (0.70, 1.49) | 1.03 (0.70, 1.50) | 0.53 (0.37, 0.76)** | 0.53 (0.37, 0.77)** | ||
| Race | 1.27 (0.73, 2.18) | 1.32 (0.77, 2.30) | 0.78 (0.51, 1.18) | 0.81 (0.53, 1.24) | 0.89 (0.60, 1.32) | 0.93 (0.62, 1.38) | ||
| Education | 0.80 (0.48, 1.33) | 0.81 (0.49, 1.36) | 0.68 (0.44, 1.05) | 0.69 (0.44, 1.07) | 0.80 (0.54, 1.19) | 0.82 (0.54, 1.22) | ||
| Income | 0.63 (0.39, 1.04) | 0.67 (0.40, 1.10) | 1.03 (0.69, 1.55) | 1.07 (0.71, 1.61) | 0.67 (0.46, 0.99)* | 0.70 (0.47, 1.03) | ||
| Relationship | 1.00 (0.63, 1.56) | 0.99 (0.63, 1.56) | 1.21 (0.84, 1.74) | 1.22 (0.85, 1.75) | 1.38 (0.98, 1.93) | 1.38 (0.98, 1.95) | ||
| Distal Stress | 1.12 (0.83, 1.50) | 1.04 (0.77, 1.41) | 0.82 (0.66, 1.01) | 0.77 (0.61, 0.96)* | 0.95 (0.77, 1.17) | 0.89 (0.72, 1.11) | ||
| Mastery | 0.73 (0.50, 1.05) | 0.77 (0.56, 1.04) | 0.75 (0.56, 1.00) | |||||
| Engaged in regular exercise | Tobacco/cigarette use | Excessive alcohol use | ||||||
| Variables | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | ||
| Age | 0.98 (0.97, 0.99)** | 0.98 (0.97, 0.99)** | 1.01 (1.00, 1.021) | 1.01 (1.00, 1.021) | 0.98 (0.96, 0.99)** | 0.98 (0.96, 0.99)** | ||
| Gender | 1.09 (0.75, 1.58) | 1.07 (0.73, 1.56) | 0.68 (0.48, 0.96)* | 0.68 (0.48, 0.96)* | 1.23 (0.83, 1.83) | 1.23 (0.82, 1.83) | ||
| Race | 1.25 (0.81, 1.92) | 1.13 (0.73, 1.74) | 0.80 (0.54, 1.18) | 0.79 (0.54, 1.18) | 0.70 (0.44, 1.10) | 0.69 (0.44, 1.10) | ||
| Education | 2.02 (1.36, 3.00)** | 1.97 (1.31, 2.94)** | 0.48 (0.32, 0.71)*** | 0.48 (0.32, 0.70)*** | 1.39 (0.88, 2.20) | 1.39 (0.88, 2.19) | ||
| Income | 1.78 (1.20, 2.62)** | 1.64 (1.10, 2.44)* | 1.09 (0.75, 1.58) | 1.08 (0.74, 1.57) | 1.22 (0.79, 1.88) | 1.21 (0.79, 1.88) | ||
| Relationship | 0.99 (0.69, 1.41) | 0.98 (0.68, 1.40) | 0.87 (0.62, 1.21) | 0.87 (0.62, 1.21) | 0.86 (0.59, 1.25) | 0.86 (0.59, 1.25) | ||
| Distal Stress | 0.77 (0.62, 0.95)* | 0.88 (0.70, 1.10) | 0.97 (0.79, 1.19) | 0.97 (0.77, 1.21) | 0.91 (0.71, 1.15) | 0.92 (0.71, 1.18) | ||
| Mastery | 1.98 (1.46, 2.69)*** | 1.04 (0.79, 1.37) | 1.05 (0.77, 1.45) | |||||
Note. Gender: 0 = female versus 1 = male; Race: 0 = White versus 1 = racial/ethnic minority; Education: 0 = ≤ H.S./GED versus 1 = ≥ Associates degree; Income: 0 = ≤ $24,999 versus 1 = ≥ $25,000; Relationship status: 0 = single/dating versus 1 = partnered/committed relationship). AOR = adjusted odds ratio; CI = confidence interval.
p < .05
p < .01
p < .001.
Distal minority stress was not directly associated with most of the individual CVD risk factors, except for diet and exercise. Specifically, distal minority stress was associated with a lower likelihood to report a diet high in saturated fat, salt, or sodium and lower likelihood to report regular exercise. Mediation analyses indicated that distal stress was only indirectly associated with less reporting of regular exercise through sense of mastery, indicating that distal minority stress was associated with a lower sense of mastery and in turn a lower sense of mastery was associated with less reporting of regular exercise. Indirect effects are reported in Table 4.
Table 4.
Indirect effects of distal and proximal minority stressors on the weighted CVD risk index and the individual CVD risk factors via sense of mastery.
| Distal Minority Stress | ||||||
|---|---|---|---|---|---|---|
| Full Sample | Women | Men | ||||
| b (SE) | 95% CI | b (SE) | 95% CI | b (SE) | 95% CI | |
| CVD Risk Index | .12 (.05) | .029, .214 | .03 (.07) | −.104, .182 | .19 (.08) | .058, .368 |
| High cholesterol | .01 (.03) | −.062, .083 | .03 (.07) | −.097, .181 | .01 (.05) | −.098, .096 |
| Diabetes mellitus | .08 (.07) | −.054, .231 | .04 (1.03) | −.275, .390 | .12 (.08) | −.033, .311 |
| Hypertension | .07 (.04) | −.012, .154 | .04 (.08) | −.119, .214 | .09 (.06) | −.014, .216 |
| Tobacco/cigarette use | −.01 (.03) | −.076, .053 | −.03 (.05) | −.124, .079 | .00 (.05) | −.112, . 087 |
| Excessive alcohol use | −.01 (.04) | .084, .057 | −.03 (.06) | −.156, .078 | .01 (.05) | −.089, .130 |
| Diet high in saturated fat, salt, or sodium | .06 (.04) | −.013, .129 | −.01 (.06) | −.139, .124 | .11 (.06) | .018, .238 |
| Excess body fat | .06 (.04) | −.001, .140 | .08 (.06) | −.023, .198 | .07 (.05) | −.018, .177 |
| Engaged in regular exercise | −.15 (.04) | −.235, −.079 | −.12 (.05) | −.224, −.014 | −.18 (.07) | −.329, −.070 |
| Proximal Minority Stress | ||||||
| Full Sample | Women | Men | ||||
| b (SE) | 95% CI | b (SE) | 95% CI | b (SE) | 95% CI | |
| CVD Risk Index | .10 (.04) | .017, .189 | .02 (.05) | −.079, .133 | .18 (.07) | .054, .338 |
| High cholesterol | .02 (.03) | −.050, .094 | .02 (.05) | −.089, .131 | .03 (.05) | −.065, .141 |
| Diabetes mellitus | .03 (.07) | −.106, .165 | .01 (.48) | −.305, .255 | .07 (.09) | −.102, .245 |
| Hypertension | .05 (.04) | −.030, .144 | .02 (.07) | −.102, .204 | .08 (.06) | −.023, .195 |
| Tobacco/cigarette use | −.01 (0.03) | −.074, .059 | −.03 (.04) | −.120, .054 | .01 (.05) | −.085, .095 |
| Excessive alcohol use | −.03 (.03) | −.090, .043 | −.04 (.05) | −.137, .058 | .00 (.05) | −.095, .107 |
| Diet high in saturated fat, salt, or sodium | .04 (.03) | −.027, .109 | −.02 (.05) | −.121, .076 | .09 (.05) | −.003, .208 |
| Excess body fat | .06 (.03) | .006, .137 | .06 (.05) | −.020, .172 | .08 (.05) | −.006, .191 |
| Engaged in regular exercise | −.14 (.04) | −.221, −.076 | −.10 (.05) | −.214, −.014 | −.18 (.07) | −.331, −.077 |
Note. The ninth risk factor used to create the weighted CVD risk index is family history of heart disease. We did not examine this item separately because its associations with minority stressors are not conceptually meaningful.
Proximal Minority Stress and CVD Risk Outcomes
Proximal minority stress was not associated with the CVD risk index (β = .07, p = .09; see Table 3). A sense of mastery was associated with lower CVD risk index scores (β = −.10, p < .05), lower odds of reporting excess body fat (AOR = 0.74, 95% CI = 0.55, 0.98), and greater likelihood to report regular exercise (AOR = 1.98, 95% CI = 1.46, 2.68). Mediation was supported as the indirect effect of proximal minority stress on CVD risk index was significant through a sense of mastery2, indicating that proximal minority stress was associated with a lower sense of mastery and in turn a lower sense of mastery was associated with greater scores on the CVD risk index.
Table 3.
Effects of Proximal Minority Stress on cardiovascular disease risk factors among a sample of sexual minority adults.
| CVD Risk Index | High cholesterol | Diabetes Mellitus | ||||||
|---|---|---|---|---|---|---|---|---|
| Variables | B (SE) | β | B (SE) | β | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) |
| Age | .07 (.01) | .32*** | .07 (.01) | .32*** | 1.08 (1.06, 1.09)*** | 1.07 (1.06, 1.09)*** | 1.06 (1.03, 1.09)*** | 1.06 (1.03, 1.09)*** |
| Gender | −.08 (.25) | −.01 | −.04 (.25) | −.01 | 0.98 (0.65, 1.47) | 0.98 (0.65, 1.48) | 1.72 (0.82, 3.63) | 1.73 (0.82, 3.64) |
| Race | −.36 (.28) | −.05 | −.28 (.28) | −.04 | 0.89 (0.54, 1.45) | 0.90 (0.55, 1.48) | 2.39 (1.11, 5.16)* | 2.46 (1.3, 5.34)* |
| Education | −.88 (.28) | −.13** | −.86 (.28) | −.13** | 0.92 (0.58, 1.45) | 0.92 (0.58, 1.45) | 0.50 (0.24, 1.03) | 0.50 (0.24, 1.04) |
| Income | −.56 (.27) | −.09* | −.48 (.27) | −.08 | 0.93 (0.60, 1.43) | 0.93 (0.60, 1.46) | 0.48 (0.23, 1.01) | 0.50 (0.24, 1.04) |
| Relationship | .28 (.24) | .05 | .28 (.24) | .05 | 1.27 (0.85, 1.88) | 1.27 (0.85, 1.88) | 1.71 (0.85, 3.43) | 1.71 (0.85, 3.44) |
| Proximal Stress | .24 (.14) | .07 | .14 (.15) | .04 | 1.06 (0.83, 1.35) | 1.04 (0.81, 1.34) | 1.78 (1.25, 2.54)** | 1.72 (1.19, 2.50)** |
| Mastery | −.47 (.20) | −.10* | 0.91 (0.66, 1.25) | 0.85 (0.49, 1.48) | ||||
| Hypertension | Diet high in saturated fat, salt, or sodium | Excess Body Fat | ||||||
| Variables | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | ||
| Age | 1.05 (1.03, 1.06)*** | 1.05 (1.03, 1.07)*** | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 1.03 (1.02, 1.04)*** | 1.03 (1.02, 1.04) | ||
| Gender | 2.04 (1.25, 3.33)** | 2.06 (1.26, 3.38)** | 1.06 (0.73, 1.55) | 1.08 (0.74, 1.56) | 0.54 (0.38, 0.77)** | 0.55 (0.39, 0.79) | ||
| Race | 1.23 (0.71, 2.14) | 1.28 (0.74, 2.23) | 0.77 (0.51, 1.17) | 0.80 (0.53, 1.22) | 0.89 (0.60, 1.33) | 0.94 (0.63, 1.40) | ||
| Education | 0.83 (0.49, 1.39) | 0.84 (0.50, 1.40) | 0.66 (0.43, 1.03) | 0.67 (0.43, 1.03) | 0.79 (0.53, 1.17) | 0.79 (0.53, 1.19) | ||
| Income | 0.60 (0.36, 0.99)* | 0.63 (0.38, 1.04) | 1.04 (0.70, 1.57) | 1.08 (0.72, 1.63) | 0.68 (0.46, 1.00) | 0.72 (0.49, 1.06) | ||
| Relationship | 1.01 (0.64, 1.60) | 1.01 (0.64, 1.60) | 1.23 (0.86, 1.77) | 1.23 (0.86, 1.77) | 1.36 (0.97, 1.92) | 1.37 (0.97, 1.93) | ||
| Proximal Stress | 1.34 (1.03, 1.74)* | 1.27 (0.99, 1.67) | 0.95 (0.77, 1.18) | 0.92 (0.74, 1.14) | 0.91 (0.74, 1.11) | 0.85 (0.69, 1.05) | ||
| Mastery | 0.78 (0.54, 1.12) | 0.83 (0.61, 1.12) | 0.74 (0.55, 0.98)* | |||||
| Engaged in regular exercise | Tobacco/cigarette use | Excessive alcohol use | ||||||
| Variables | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | ||
| Age | 0.98 (0.97, 0.99)** | 0.98 (0.97, 0.99)** | 1.01 (1.00, 1.02) | 1.01 (1.00, 1.02) | 0.98 (0.96, 0.99)** | 0.98 (0.96, 0.99)** | ||
| Gender | 1.18 (0.81, 1.70) | 1.11 (0.76, 1.62) | 0.69 (0.48. 0.97)* | 0.68 (0.48. 0.97)* | 1.24 (0.84, 1.85) | 1.23 (0.83, 1.83) | ||
| Race | 1.26 (0.82, 1.93) | 1.13 (0.73, 1.75) | 0.80 (0.54, 1.19) | 0.80 (0.54, 1.18) | 0.69 (0.43, 1.09) | 0.68 (0.43, 1.08) | ||
| Education | 1.92 (1.30, 2.86)** | 1.92 (1.28, 2.87)** | 0.47 (0.32, 0.70)*** | 0.47 (0.32, 0.70)*** | 1.39 (0.88, 2.19) | 1.38 (0.88, 2.18) | ||
| Income | 1.86 (1.26, 2.75)** | 1.68 (1.13, 2.51)* | 1.09 (0.75, 1.59) | 1.09 (0.75, 1.59) | 1.22 (0.79, 1.88) | 1.20 (0.77, 1.85) | ||
| Relationship | 0.98 (0.68, 1.39) | 0.98 (0.67, 1.40) | 0.87 (0.62, 1.21) | 0.87 (0.62, 1.21) | 0.87 (0.60, 1.27) | 0.87 (0.60, 1.27) | ||
| Proximal Stress | 0.77 (0.62, 0.94)* | 0.88 (0.70, 1.09) | 0.96 (0.79, 1.17) | 0.97 (0.79, 1.19) | 1.04 (0.84, 1.29) | 1.06 (0.85 1.33) | ||
| Mastery | 1.98 (1.46, 2.68)*** | 1.04 (0.79, 1.37) | 1.12 (0.81, 1.54) | |||||
Note. Gender: 0 = female versus 1 = male; Race: 0 = White versus 1 = racial/ethnic minority; Education: 0 = ≤ H.S./GED versus 1 = ≥ Associates degree; Income: 0 = ≤ $24,999 versus 1 = ≥ $25,000; Relationship status: 0 = single/dating versus 1 = partnered/committed relationship). AOR = adjusted odds ratio; CI = confidence interval.
p < .05
p < .01
p < .001.
Proximal minority stress was directly associated with greater odds of reporting diabetes mellitus and hypertension and lower odds of reporting regular exercise. It was not associated with the other individual CVD risk factors. Mediation analyses indicated that proximal stress was indirectly associated with more reporting of excess body fat and less reporting of regular exercise through sense of mastery. Indirect effects are reported in Table 4.
Exploratory Analyses for Women and Men
Additional exploratory analyses were conducted and stratified by women and men. For women, results for the effects of distal and proximal stress on CVD risk outcomes are reported in Supplemental Tables 1 and 2, respectively. For men, results for the effects of distal and proximal stress on CVD risk outcomes are reported in Supplemental Tables 3 and 4, respectively. Consistent with the aggregated sample results, distal minority stress was not associated with greater CVD risk index scores for women and men. A sense of mastery was associated with lower CVD risk index scores for men but not women, and it was associated with a greater likelihood of reporting regular exercise for women and men. Mediation was supported as the indirect effect of distal minority stress on the CVD risk index was significant through a sense of mastery for men but not women. Indirect effects are reported in Table 4.
Distal minority stress was not directly associated with most of the individual CVD risk factors, except for exercise for women. Specifically, distal minority stress was associated with a lower likelihood to report regular exercise among women. Mediation analyses indicated that distal stress was indirectly associated with less reporting of regular exercise through sense of mastery for women and men, and it was indirectly associated with a greater likelihood to report eating a poor diet through sense of mastery for men only. Indirect effects are reported in Table 4.
Proximal minority stress was not directly associated with the CVD risk index for women and men. Mediation was supported as the indirect effect of proximal minority stress on CVD risk index was significant through a sense of mastery for men but not women. Proximal minority stress was directly associated with greater odds of reporting diabetes mellitus for women and men, and lower odds of reporting regular exercise for women but not men; it was not associated with the other individual CVD risk factors. Mediation analyses indicated that proximal stress was indirectly associated less reporting of regular exercise through sense of mastery for women and men. Indirect effects are reported in Table 4.
DISCUSSION
Distal (e.g., discrimination) and proximal (i.e., internalized heterosexism) minority stressors were associated with a lower sense of mastery, and sense of mastery was related to lower scores on the CVD risk index. Both minority stressors were indirectly associated with CVD risk index scores through a lower sense of mastery; however, exploratory analyses stratified by gender indicated that these mediation findings were only evidenced among men and not women in the sample. Since this investigation uses an index that was not previously been validated, the associations were also evaluated for individual CVD risk factors. These findings indicated that both minority stressors were associated with less exercise and proximal stress was associated with greater excess body fat through lower mastery. Minority stressors were not directly associated with the CVD risk index and several of its individual indicators in this relatively healthy and young sample of sexual minority adults. Exploratory analyses revealed some gender differences in these associations, which requires further research. However, a consistent finding was that both distal and proximal minority stressors were indirectly associated with less reporting of regular exercise through sense of mastery for women and men.
Our results indicate that a sense of mastery plays a significant role in CVD risk among sexual minority adults. Consistent with prior findings, we found that minority stressors were associated with a lower sense of mastery (15, 33) across all participants and sense of mastery was associated with risk of CVD (17), both in terms of the overall CVD risk index and specific risk factors (i.e., excess body fat and regular exercise). We extend these findings to show that a lower sense of mastery mediated the associations among: both minority stressors and the CVD risk index for the aggregated sample and only for men; both minority stressors and regular exercise for the aggregated sample and for women and men separately; proximal minority stress and excess body fat for the aggregated sample; distal minority stress and eating a poor diet for men only. Due to the lack of control in experiencing minority stress (e.g., discrimination), minority stress can disempower sexual minority individuals (19, 20), possibly increasing CVD risk. Although future longitudinal research must examine how these associations unfold as well as gender differences, a sense of mastery may be an important modifiable CVD risk factor to target in interventions with sexual minority adults generally.
The lack of direct effects of minority stressors on CVD risk, in terms of both the overall risk index and individual CVD risk factors (with the exception of exercise for women), in the present study may be explained by the cross-sectional nature of the data. Cumulative experiences of minority stress over time may predict CVD risk development. Repeated experiences of minority stress might lead to more proximal suboptimal health behavior engagement and distal physiological dysregulation (e.g., autonomic, hormonal) that eventually translates into more severe health outcomes. In fact, research has demonstrated that many sexual minority individuals may have a dysregulated stress response, especially when exposed to minority stress and stigma (34). Retrospective recollections of discrimination may not accurately predict CVD risk; participants may not recall and under-report stigma and discrimination when asked retrospectively.
Our findings have implications for future sense of mastery research. Previous research has demonstrated that having a high sense of mastery and lower perceived constraints is associated with better self-reported health (35). Sense of mastery likely varies over time and decreases with greater disease burden and disability such as during advanced stages of CVD (e.g., congestive heart failure) (36). The present cross-sectional analysis does not allow for examination of variations in mastery in response to changes of health status or engagement in health-promoting behaviors; such investigation may yield sophisticated insights via ecological momentary assessment (EMA) methods, which include delivering surveys via smartphones to collect context-rich data. Future research utilizing EMA could detect changes in sense of mastery, engagement in CVD risk-reducing behaviors, and experience of minority stressors. These analyses raise additional questions about sense of mastery in subgroups of sexual minority adults. Various subgroups (e.g., lesbian women, transgender men, nonbinary individuals) may have specific needs that have implications for effective interventions, and the present analyses are meant to inspire future investigation of additional research questions. For example, sexual minority women may benefit from CVD risk reduction interventions that focus less on sense of mastery and more on other CVD risk behaviors, like engagement in regular exercise.
Perceptions of control, mastery, and health may be important for behavioral changes related to CVD risk that warrant further investigation. For example, sexual minority adults with low sense of mastery may disregard opportunities for CVD risk-reducing behavior change (e.g., exercise, smoking cessation). Future research should also evaluate the relationship between sense of mastery and intersectional minority identities. Clinical interventions for sexual minority adults with low sense of mastery and multiple marginalized identities may aim to increase mastery through training for healthcare providers on providing compassionate affirming care, facilitating community support, and fostering self-compassion (37). Examining interventions that can improve sense of mastery (directly or because of other health behavior change), self-efficacy (38), and health locus of control (39) may be potential areas for future research. It is important to note that most previous research has measured sense of mastery rather than intervened on it; as a potentially modifiable CVD risk factor in this population, future research should consider sense of master as a target in interventions for some sexual minority adults. Further research is necessary to determine the extent to which sense of mastery is modifiable and if improvements in sense of mastery can meaningfully reduce CVD risk.
Our results also have implications for clinical interventions for CVD risk reduction specifically in sexual minority adults. In our sample, participants most often endorsed: diets high in saturated fat, salt, or sodium (71.0%); excess body fat (54.9%); and tobacco or cigarette use (48.5%). Interventions targeting healthful diet (including access to healthful foods) and weight management should be targeted towards sexual minority adults of all ages but perhaps especially sexual minority college-aged adults due to high rates of poor diet within this population (40) and the establishment of CVD risk at this time period (41). Furthermore, sexual minority adults have higher rates of substance use (6), including tobacco, which requires both future research and expansive substance use reduction intervention offerings available to sexual minority adults. While this study’s results have implications for person-level CVD risk reduction, the impact of structural factors cannot be ignored in future research. Many interventions attempt to intervene on person-level factors (e.g., knowledge, motivation), but health disparities will only be reduced by targeting the structural environments (e.g., political, social, physical, economic) and minority stress that shape health behaviors (e.g., insufficient access to preventive medical care) and uphold health disparities (42).
These preliminary findings, whether evaluated via a risk index or on individual risk factors, suggest that more research is necessary to guide CVD prevention and intervention with sexual minorities. Such research can guide the need for tailored CVD risk reduction interventions with sexual minorities, particularly in early and middle adulthood before the cumulative effects of decades of poor health behaviors predispose them for CVD. Given some gender differences emerged in our specific CVD risk indicators (i.e., men were more likely than women to report hypertension; women were more than men likely to report excess body fat and tobacco use) and have been documented in the literature (e.g., obesity for sexual minority women), tailored interventions should also be implemented to target some unique risk indicators by gender.
Strengths and Limitations
This study includes numerous strengths and limitations. Our study is a relatively large examination of sexual minority adults’ health behaviors and health statuses that lead to CVD. The sample size of this study is particularly notable given that it included adults from a variety of sexual orientations, genders, and ages. This study also examines modifiable risk factors of CVD, and it finds that sense of mastery may be a relevant modifiable risk factor in this population.
The greatest limitation of the study is the way that participants were asked about CVD risk, the answer options available to them, and the CVD risk that could consequently be calculated. While self-reported CVD risk is widely used and research has documented its accuracy (29, 30), participants were asked to self-report diagnoses and health behaviors with dichotomized answer options and without a specified time frame, limiting the variance and nuance available for observation. Participants should also be asked the temporality, magnitude, severity, or frequency for each question so that more sensitive and specific CVD risk can be calculated for each risk factor. Furthermore, some items used the terms “excess” or “excessive” (in relation to body fat and alcohol intake), which is limited by personal subjectivity. The lack of specificity in this study limits the conclusions that can be drawn and may account for differences observed in this study compared to existing literature (e.g., lack of direct associations between minority stress and substance use). Future research should utilize gold-standard risk measures that are appropriate for the participants’ age and categorize degrees of risk rather than simplified (present or absent) options. This study’s risk scoring protocol was adapted from well-validated CVD risk indices to accommodate the dichotomized answer options, but gold standard risk scores were impossible to calculate. Most participants were under age 40, for whom CVD is much harder to predict; 10-year risk estimates will be substantially lower than in individuals closer to the age of CVD onset. We were also unable to use the risk calculators that require input of cardiometabolic metrics including blood pressure measurements and total cholesterol. Ideally, future research should collect objective measures of health whenever possible, or researchers should use validated risk calculators that use self- report data when objective measures of health are unavailable. For similar cases where cardiometabolic metrics are unavailable or unable to be collected, especially in younger or hard-to-reach samples, it may be beneficial to validate this or other calculators that do not rely on cardiometabolic metrics. Future studies evaluating sexual minority adults’ CVD risk or prevalence should consider recruiting a slightly older sample and using a validated CVD risk measure.
The current study utilized a cross-sectional design to answer a research question based on well- validated theories, but longitudinal designs are necessary. This is further compounded by temporal differences in the measures used for the mediational models. Nevertheless, the present study substantiates the value of examining CVD development in this population that is at increased risk for future CVD onset. We examined distal and proximal minority stressors separately; future work should examine the interplay of these stressors as well as potential mediating effects of proximal minority stress on the associations between distal minority stress and CVD risk. The sample was predominantly White. Future research should oversample racial and ethnic minorities; they may experience more complex effects of discrimination on CVD risk due to their intersectional minority identities. Although we accounted for several sociodemographic variables in our study, future work should account for additional factors, such as insurance coverage or healthcare utilization.
CONCLUSION
Health disparities in CVD risk for sexual minority populations is a public health problem that deserves further research and prevention. The present study demonstrates an indirect association for distal and proximal minority stress on composite CVD risk through a sense of mastery. This study is one of the first to examine the interplay between minority stress and CVD risk in a large sexual minority sample and to propose a potentially modifiable mechanism for this link: a sense of mastery. The study’s results provide evidence that further research is needed to explain how the experience of being a sexual minority in a heterosexist society uniquely contributes to CVD risk development. By combining classic risk reduction strategies with novel assessment methods, such as EMA, and culturally-sensitive, tailored interventions that recognize the inherent strengths and common struggles of sexual minority people, innovative programs may reduce the additional CVD risk that is conferred upon sexual minority individuals.
Supplementary Material
Acknowledgements:
This work was supported by the National Institute on Alcohol Abuse and Alcoholism (K08AA025011; PI: Mereish) and the National Heart, Lung, and Blood Institute (K23HL136845; PI: Goldstein) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Conflict of Interest Declaration: The authors declare that they have no conflict of interest.
We tested differences in sociodemographic and key variables between participants who were excluded due to endorsing a past heart attack, stroke, or heart failure versus participants who did not endorse any of these conditions and were included in this study. Results indicated that participants with these conditions had higher CVD risk index scores, F(1)=61.13, p < .001, η2p = .08, (M = 7.49, SD = 2.94 versus M = 3.94, SD = 3.02, respectively) and were older in age, F(1) = 49.19, p < .001, η2p = .06, (M = 56.02, SD = 12.40 versus M = 41.26, SD = 14.84, respectively), than participants who did not have these conditions. The two groups did not differ on any of the sociodemographic variables or on their scores of distal minority stress, proximal minority stress, or sense of mastery.
We also conducted the mediation analyses with the sample including participants with an established heart condition (i.e., heart attack, stroke, or heart failure) and found consistent patterns of results.
REFERENCES
- 1.Benjamin Emelia J, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation. 2019;139(10):e56–e528. doi: 10.1161/CIR.0000000000000659 [DOI] [PubMed] [Google Scholar]
- 2.Conron KJ, Mimiaga MJ, Landers SJ. A population-based study of sexual orientation identity and gender differences in adult health. American journal of public health. 2010; 100(10):1953–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wu L, Sell RL, Roth AM, Welles SL. Mental health disorders mediate association of sexual minority identity with cardiovascular disease. Preventive Medicine. 2018; 108:123–8. doi: 10.1016/j.ypmed.2018.01.003 [DOI] [PubMed] [Google Scholar]
- 4.Fredriksen-Goldsen KI, Kim H-J, Barkan SE, Muraco A, Hoy-Ellis CP. Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American journal of public health. 2013; 103(10):1802–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Clark CJ, Borowsky IW, Salisbury J, et al. Disparities in long-term cardiovascular disease risk by sexual identity: The National Longitudinal Study of Adolescent to Adult Health. Preventive Medicine. 2015;76:26–30. doi: 10.1016/j.ypmed.2015.03.022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Caceres BA, Brody A, Luscombe RE, et al. A Systematic Review of Cardiovascular Disease in Sexual Minorities. Am J Public Health. 2017;107(4):e13–e21. doi: 10.2105/ajph.2016.303630 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Caceres BA, Brody AA, Halkitis PN, Dorsen C, Yu G, Chyun DA. Cardiovascular Disease Risk in Sexual Minority Women (18-59 Years Old): Findings from the National Health and Nutrition Examination Survey (2001-2012). Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018;28(4):333–41. doi: 10.1016/j.whi.2018.03.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Semiyen J, Curtis TJ, Varney J. Sexual orientation identity in relation to unhealthy body mass index: individual participant data meta-analysis of 93 429 individuals from 12 UK health surveys. Journal of Public Health. 2019. doi: 10.1093/pubmed/fdy224 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Graham R, Berkowitz B, Blum R, et al. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine; 2011. [PubMed] [Google Scholar]
- 10.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological bulletin. 2003;129(5):674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Brooks VR. Minority stress and lesbian women: Free Press; 1981. [Google Scholar]
- 12.Lick DJ, Durso LE, Johnson KL. Minority Stress and Physical Health Among Sexual Minorities. 2013;8(5):521–48. doi: 10.1177/1745691613497965 [DOI] [PubMed] [Google Scholar]
- 13.Mereish EH, Poteat VP. A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of counseling psychology. 2015;62(3):425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hatzenbuehler ML, Slopen N, McLaughlin KA. Stressful life events, sexual orientation, and cardiometabolic risk among young adults in the United States. Health Psychology. 2014;33(10):1185. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma “get under the skin”? The mediating role of emotion regulation. Psychological Science. 2009;20(10): 1282–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Pearlin LI, Schooler C. The structure of coping. Journal of health and social behavior. 1978:2–21. [PubMed] [Google Scholar]
- 17.Roepke SK, Grant I. Toward a more complete understanding of the effects of personal mastery on cardiometabolic health. Health Psychology. 2011;30(5):615. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Paquet C, Dubé L, Gauvin L, Kestens Y, Daniel M. Sense of Mastery and Metabolic Risk: Moderating Role of the Local Fast-Food Environment. Psychosomatic Medicine. 2010;72(3):324–31. doi: 10.1097/PSY.0b013e3181cdf439 [DOI] [PubMed] [Google Scholar]
- 19.Miller JB, Stiver IP. The healing connection: How women form relationships in therapy and in life. Boston: Beacon Press; 1997. [Google Scholar]
- 20.Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: Insights from a social psychological perspective. Journal of Counseling psychology. 2009;56(1):32. [Google Scholar]
- 21.Herek GM, Gillis JR, Cogan JC. Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of consulting and clinical psychology. 1999;67(6):945. [DOI] [PubMed] [Google Scholar]
- 22.Szymanski DM. Does internalized heterosexism moderate the link between heterosexist events and lesbians' psychological distress? Sex Roles. 2006;54(3-4):227–34. [Google Scholar]
- 23.Marshall GN, Lang EL. Optimism, self-mastery, and symptoms of depression in women professionals. Journal of Personality and Social Psychology. 1990;59(1):132–9. doi: 10.1037/0022-3514.59.1.132 [DOI] [PubMed] [Google Scholar]
- 24.Grundy SM, Pasternak R, Greenland P, Smith S, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Journal of the American College of Cardiology. 1999;34(4):1348–59. [DOI] [PubMed] [Google Scholar]
- 25.Aaron DJ, Markovic N, Danielson ME, Honnold JA, Janosky JE, Schmidt NJ. Behavioral risk factors for disease and preventive health practices among lesbians. American Journal of Public Health. 2001;91(6):972. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. bmj. 2017;357:j2099. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Rea TD, Heckbert SR, Kaplan RC, et al. Body mass index and the risk of recurrent coronary events following acute myocardial infarction. The American journal of cardiology. 2001;88(5):467–72. [DOI] [PubMed] [Google Scholar]
- 28.Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change, and coronary heart disease in women: risk within the'normal'weight range. Jama. 1995;273(6):461–5. [DOI] [PubMed] [Google Scholar]
- 29.Greenlund KJ, Zheng ZJ, Keenan NL, et al. Trends in Self-reported Multiple Cardiovascular Disease Risk Factors Among Adults in the United States, 1991-1999. Archives of Internal Medicine. 2004;164(2):181–8. doi: 10.1001/archinte.164.2.181 [DOI] [PubMed] [Google Scholar]
- 30.Dey AK, Alyass A, Muir RT, et al. Validity of Self-Report of Cardiovascular Risk Factors in a Population at High Risk for Stroke. Journal of Stroke and Cerebrovascular Diseases. 2015;24(12):2860–5. doi : 10.1016/j.jstrokecerebrovasdis.2015.08.022 [DOI] [PubMed] [Google Scholar]
- 31.Preacher K, Hayes A. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods. 2008;40(3):879–91. doi: 10.3758/BRM.40.3.879 [DOI] [PubMed] [Google Scholar]
- 32.Hayes AF. PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. 2012.
- 33.Meyer IH, Schwartz S, Frost DM. Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social science & medicine. 2008;67(3):368–79. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Hatzenbuehler ML, McLaughlin KA, Slopen N. Sexual orientation disparities in cardiovascular biomarkers among young adults. American journal of preventive medicine. 2013;44(6):612–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Lachman ME, Weaver SL. The sense of control as a moderator of social class differences in health and well-being. Journal of personality and social psychology. 1998;74(3):763. [DOI] [PubMed] [Google Scholar]
- 36.Jang Y, Chiriboga DA, Lee J, Cho S. Determinants of a sense of mastery in Korean American elders: a longitudinal assessment. Aging Ment Health. 2009;13(1):99–105. doi: 10.1080/13607860802154531 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Greene DC, Britton PJ. Predicting Adult LGBTQ Happiness: Impact of Childhood Affirmation, Self-Compassion, and Personal Mastery. Journal of LGBT Issues in Counseling. 2015;9(3): 158–79. doi: 10.1080/15538605.2015.1068143 [DOI] [Google Scholar]
- 38.Bandura A, Freeman W, Lightsey R. Self-efficacy: The exercise of control. Springer; 1999. [Google Scholar]
- 39.Wallston KA, Wallston BS. Health locus of control scales. Research with the locus of control construct. 1981;1:189–243. [Google Scholar]
- 40.Laska MN, VanKim NA, Erickson DJ, Lust K, Eisenberg ME, Rosser BRS. Disparities in Weight and Weight Behaviors by Sexual Orientation in College Students. American journal of public health. 2015; 105(1): 111–21. doi: 10.2105/AJPH.2014.302094 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Goldstein CM, Xie SS, Hawkins MAW, Hughes JW. Reducing Risk for Cardiovascular Disease: Negative Health Behaviors in College Students. Emerging Adulthood. 2014;3(1):24–36. doi: 10.1177/2167696814536894 [DOI] [Google Scholar]
- 42.Brown AF, Ma GX, Miranda J, et al. Structural Interventions to Reduce and Eliminate Health Disparities. American Journal of Public Health. 2019;109(S1):S72–S8. doi: 10.2105/AJPH.2018.304844 [DOI] [PMC free article] [PubMed] [Google Scholar]
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