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. Author manuscript; available in PMC: 2021 Jan 1.
Published in final edited form as: Psycholog Relig Spiritual. 2019 Aug 15;12(3):261–268. doi: 10.1037/rel0000284

Religious Coping and Depressive Symptoms Among Black Americans Living with HIV: An Intersectional Approach

Jonathan Mathias Lassiter 1,3, Tonia Poteat 2
PMCID: PMC7678441  NIHMSID: NIHMS1044429  PMID: 33224430

Abstract

This exploratory quantitative study examined the association between religious coping and depressive symptoms among a sample of 216 Black Americans living with HIV (BALWH) in the Southeastern United States. Descriptive analyses and multiple linear regression were used to determine statistically significant associations between religious coping styles and depressive symptoms, and to investigate the potential of sexual orientation and gender to moderate the associations between religious coping styles and depressive symptoms. Negative religious coping, but not positive religious coping, significantly predicted depressive symptoms. Sexual orientation, but not gender, significantly moderated the association between positive religious coping and depressive symptoms so that the relationship was only significant for heterosexual BALWH. Implications of these findings for future research and clinical work with BALWH are discussed.

Keywords: African American, depression, sexual minority, religious coping, heterosexual, intersectionality

INTRODUCTION

Religion is a particularly strong force in the lives of Black Americans (Abrams, 2000; Taylor, Thornton, & Chatters, 1987). Black American churches have historically been the center of community life and religious coping has often been utilized as a vehicle to survive and overcome adversity. Religious coping is a combination of individual, and sometimes collective, religion-based cognitive and behavioral coping strategies that people utilize to persist in the face of life stressors (Pargament, Smith, Koenig, & Perez, 1998). However, most research investigating the role of religious coping in Black Americans’ lives has been conducted with samples in which participants are treated as a monolith and their experiences are deemed to be similar. Few studies have examined Black Americans’ differences in religious coping along gender lines (Hawthorne, Youngblut, & Brooten, 2016). Furthermore, a large majority of religion-focused studies among Black Americans’ do not assess or report the sexual orientations of the sample and thus participants are assumed to be heterosexual or their sexual orientation is deemed unimportant (Lassiter, Saleh, Starks, et al., 2017; Shilo, Yosse, & Savaya, 2016). Similarly, little of the research in this area has been done with Black Americans living with HIV (BALWH; Dalmida, Koenig, Holstad, & Wirani, 2013; Lee, Nezu, & Nezu, 2014). This is a significant oversight as BALWH must often navigate life stressors such as gendered racism, homonegativity, and HIV-stigma that negatively impact their mental health (Follins & Lassiter, 2017) and religious coping may constitute an important contributor to their psychological well-being. It is imperative that this gap in the scholarly literature be addressed so that clinicians and researchers may better develop counseling and intervention strategies that take these unique factors into account and better serve BALWH across sexual orientation and gender. Thus, the current study explores the associations between religious coping and mental health outcomes for BALWH as well as the moderating relationship of sexual orientation and gender on these relationships. In this way, the authors take an intersectional approach that highlights heterogeneity in Black communities and honors the unique experiences of Black Americans across sexual orientation and gender.

The Mental Health of Black Americans Living with HIV

BALWH must often navigate unique barriers to health. Researchers have found that intersectional oppression due to the co-occurrence of racial, sexual orientation, and HIV stigma were associated with high levels of depressive symptoms in Black same-gender-loving men living with HIV (Bogart et al., 2011). Similar results have been found among Black American women living with HIV (Vyavaharkar et al, 2011), bisexual men (Friedman et al., 2014), and heterosexual men (Brinkley-Rubinstein, 2015). These findings are concerning given that psychological distress has been associated with lower social support, lower levels of adherence to antiretroviral medications, and other poor HIV outcomes (Blashill, Perry, & Safren, 2011; Rueda et al., 2016). Given the detrimental impact of these interlocking stressors on the mental health of BALWH, there is a need to identify culturally-relevant factors that may mitigate such harmful effects. Religious coping may be such a resource.

Religious Coping Among Black Americans

Black Americans consistently report high levels of religious coping (Chatters, Taylor, Jackson, & Lincoln, 2008; Park, Holt, Le, Christie, & Williams, 2017). Religious coping is a multidimensional coping resource that entails utilizing religious beliefs or practices to navigate stressors in one’s environment (Pargament et al., 1998). Accordingly, religious coping could be conceptualized as one of the various psychological, social, and behavior mechanisms through which religion is linked to health (Cheadle, Dunkel, & Schetter, 2017). Religious coping research has made the distinction between religious coping styles and religious coping strategies (Pargament et al., 1998). This study explored both.

Religious coping styles are characterized as predominating patterns of responding to life stressors with a particular set of religiously-informed strategies. If the religiously-informed strategies that one predominately uses are based in a positive view of the sacred and understanding of one’s self as working in collaboration with the sacred to overcome negative life challenges (e.g., believing the sacred will aid in time of need; Pargament et al., 1998), then the religious coping style can be characterized as positive religious coping. Those who mainly use strategies that are based in a view of the sacred as malevolent or uncaring and believe negative life events are meant as punishment from or abandonment by the sacred (e.g., one’s sacred power is allowing demonic forces to cause health problems; Pargament, Koenig, & Perez, 2000) can be understood as having a negative religious coping style. Researchers found that endorsing a positive religious coping style was associated with better mental health outcomes (e.g., fewer depressive symptoms, higher levels of positive affect, self-esteem, and meaning in life) among Black Americans (Park et al., 2017). Furthermore, endorsing a negative religious coping style was related to negative mental health outcomes (e.g., higher depressive symptoms and negative affect, lower self-esteem and meaning in life; Park et al., 2017). These two forms of religious coping styles have distinct implications for one’s health.

Religious coping strategies are individual religiously-informed ways of navigating stressors. They may include cognitive reframing or meaning-making techniques (e.g., believing one’s higher power is using a stressor to teach a valuable lesson) interpersonal responses (e.g., seeking social support from religious community members), and physical behaviors (e.g., praying, attending a religious service) that one may use when confronting an obstacle (Pargament, Feuille, & Burdzy, 2011). Each strategy has its own religious function (e.g., meaning making, closeness to the sacred; Pargament et al., 2000) and unique associations with health outcomes. However, most published religious coping research has focused on overall styles. Thus, information about the specific coping strategies used by Black Americans is not well understood. More research is needed to comprehend which religious coping strategies are commonly used by Black Americans. These discoveries may help clinicians and researchers better incorporate religious coping in their work with Black Americans. The present study aimed to illuminate the prevalence of both religious coping styles and strategies among BALWH.

Intragroup Differences in Religious Coping among Black Americans

The ways in which religious coping may be associated with mental health among Black Americans differentially across gender and sexual orientation have not been largely studied. In addition, research on the role of religious coping among BALWH is still in its nascent stage. Yet, some studies have begun to analyze intragroup religious coping. In regards to gender, some studies have found that Black American women utilize religious coping more than Black American men (Chatters et al., 2008; Hawthorne et al., 2016). Studies with HIV-positive people (mixed sexual orientation or presumed heterosexual samples) confirmed that positive religious coping style was associated with positive mental health outcomes, whereas negative religious coping style was associated with poor mental health outcomes (Dalmida et al., 2013; Lee et al., 2014). However, again, investigations of the link between religious coping and the mental health of BALWH is sparse. The present study aimed to address this gap in the scientific literature. Studies investigating the relationship between religious coping and sexual minority people’s mental health found patterns of associations that complicated previous findings among solely or predominately heterosexual samples. For example, Lassiter, Starks, Grov, and colleagues (2017) found that general religious coping – they did not make a distinction between positive or negative religious coping – was positively associated with depressive symptoms and rejection sensitivity and negatively associated with resilience and social support among sexual minority men. In another study with Jewish sexual minority men (Shilo et al., 2016), researchers found that while negative religious coping was associated with poor mental health outcomes, positive religious coping was only significantly related to positive mental health outcomes in the presence of other protective factors (e.g., social support from sexual minority peers). Furthermore, Brewster and her colleagues (2016) have found that negative religious coping was not significantly associated with mental health outcomes at all for a sample of 143 sexual minority people. Positive and negative religious coping styles may have a paradoxical impact on sexual minority people’s mental health given the homonegative overtones of many Abrahamic (i.e., Judaism, Islam, Christianity) religions (Meladze & Brown, 2015). Overall, these findings suggest that the relationships between religious coping and mental health can be nuanced for people with marginalized identities. Intersectionality theory (Bowleg, Huang, Brooks, Black, & Burkholder, 2003; Crenshaw, 1989) interrogates the ways in which interlocking individual identities (e.g., race, gender, health status) interact with structural factors (e.g., racism and white supremacy, sexism and patriarchy, HIV stigma) to influence one’s unique lived experiences. Intersectionality theorists would suggest that the relationship between religious coping and mental health would be different for diverse groups of Black Americans. Particularly, it is reasonable to believe that the intersecting marginalized identities and societal circumstances of BALWH are likely to impact the ways in which religious coping relates to their mental health.

Study Aims

Given the scarcity of research that focuses on people with intersecting marginalized identities and exposure to interlocking systems of oppression in the religion-health scholarship, we take an exploratory approach in our analyses and refrain from hypothesis testing. Thus, the first aim was to identify the types and prevalence of religious coping strategies and styles used by BALWH (as a group and as subgroups based on sexual orientation and gender). The second aim was to assess the associations between religious coping styles and depressive symptoms. Finally, we evaluated the moderating relationships of sexual orientation and gender on the associations between religious coping styles and depressive symptoms.

METHODS

Participants

This secondary analysis was performed using a subset of baseline data from the “Get Busy Living” study, a randomized controlled study that aimed to examine the efficacy of a motivational interviewing intervention that was developed to enhance medication adherence among people living with HIV (DiIorio et al., 2008). Participants were recruited by nurse educators from a large urban HIV/AIDS clinic in Atlanta, Georgia. The clinic serves a large population of Black American and low-income patients. The original study and the secondary analyses, which are the focus of this paper, received ethical approval and oversight from the Institutional Review Board at Emory University, a large private research institution in Atlanta, Georgia.

Nurse educators screened clinic patients for eligibility. Inclusion criteria were: being at least 18 years of age; living with HIV infection; having been recently prescribed a multi-drug antiretroviral therapy regimen or having had a recent change in their regimen; and having been referred to the nurse educator for psychoeducation about adherence. Additional criteria included being able to speak English and having access to a telephone and video recorder. All participants indicated their willingness and ability to participate in the study and signed informed consent documents.

Procedures

Participants completed a series of questionnaires using the Computer Assisted Self-Interview with audio (ACASI) at baseline and at 12-month follow-up. The ACASI is often used to collect data on sensitive and possibly stigma-inducing information, such as HIV, and is commonly used with participants from marginalized groups, (Rao, Molina, Lambert, Cohn, 2016; Macalino, Celentano, Latkin, Strathdee, & Vlahov, 2002). The current paper presents the results from secondary analyses of data collected at baseline assessment only. All identifiers were removed from the data before it was obtained for secondary analyses.

Measures

Sociodemographic characteristics were assessed. These included: age, income, sexual orientation, and gender. A measure of social support was also included as social support has been found to be significantly associated with depressive symptoms in previous studies (see the systemic review by Gariepy, Honkaneimi, & Quesnel-Vallee, 2016) and the authors thought it was important to control for its association to better understand the unique association between religious coping and depressive symptoms. The constructs of interest were: positive religious coping, negative religious coping, and depressive symptoms.

Religious coping.

The Brief Religious Coping Scale (Brief RCOPE; Pargament et al., 2011) was used to measure religious coping styles and strategies. Religious coping styles were measured by the two subscales – positive religious coping style and negative religious coping style, composed of seven items each – which comprise the measure. Religious coping strategies were measured by individual items in each subscale that accounted for religious coping strategies such as benevolent religious reappraisal and punishing god reappraisal. Participants were asked to rate their frequency of religious coping utilization during times of stress by selecting a response option ranging from 1 (not at all) to 4 (a great deal) to scale items such as I “looked for a stronger connection with God,” “sought God’s love and care,” and “sought help from God in letting go of my anger.” Religious coping styles were calculated by summing the seven items on each subscale. Religious coping strategy scores were computed by taking the mean rating of each item on each subscale. Higher scores indicate more frequent use of a particular coping style or strategy. The Cronbach alphas for the positive and negative religious coping subscales were .88 and .85, respectively.

Depressive symptoms.

The 20-item Center for Epidemiologic Studies Depression Scale (Radloff, 1977) was used to assess participants’ experience of depressive symptoms in the past seven days, with responses from 0 (rarely/none of the time) to 3 (most of the time). All item scores were summed for the scale score. Possible range of scores is 0 to 60, with higher scores indicating the presence of more depressive symptoms. Cronbach’s alpha for responses from this sample was .91.

Social support.

The Personal Resource Questionnaire 85 Part 2 (PRQ; Weinert, 1987) was used to assess social support. Specifically, participants were asked to report how much social support they felt they had in their lives at the time of the interview. The scale contains 25 items that were scored on a Likert scale from 1 (strongly disagree) 7 to (strongly agree). Examples of the scale items include: “There is someone I feel close to who makes me feel secure,” “I belong to a group in which I feel important,” and “I can’t count on my relatives and friends to help me with my problems.” First, negatively worded items (i.e., items 4, 7, 10, 16, and 24) were reverse coded and then all scores were averaged to calculate the mean, which served as the final scale score. A higher score indicates a higher level of social support. The Cronbach alpha for this sample was .92.

Data Analysis

All data preparation and analyses were conducted with SPSS 25. Descriptive statistics were generated for the following sociodemographic characteristics: age, gender, sexual orientation, and income. In addition, descriptive statistics were obtained for social support, religious coping styles (i.e., positive and negative), religious coping strategies, and depressive symptoms. Next, linear regression was used to 1) explore the associations between depressive symptoms and religious coping styles among the full sample, and 2) examine the moderating relationship of sexual orientation and gender on the associations between religious coping styles and depressive symptoms. All analyses controlled for age, income, gender, sexual orientation, and social support. All assumptions for the various statistical tests were evaluated and determined to be met, except for normality for the depressive symptoms variable. A square root transformation of the depressive symptoms variable was performed to correct this.

RESULTS

Sample Characteristics

The sample was comprised of 216 participants. Overall, participants had an average age of 41.2. There were comparable numbers of people who identified as heterosexual (53.2%) and as members of sexual minority communities (46.8%). There were more men (67.1%) than women (32.9%) in the sample. In terms of identities along intersections of gender and sexual orientation, 6.5% of the sample identified as sexual minority women, 40.3% of the sample identified as sexual minority men, 26.4% of the sample identified as heterosexual women, and 26.8% endorsed being heterosexual men. The incomes of participants were low with most (64.9%) reporting making $750 or less per month. Participants endorsed experiencing depressive symptoms that were close to the clinical levels (M = 14.1, range 0 – 60, clinical cutoff = 16). See Table 1 for details.

Table 1.

Descriptive Statistics for Sociodemographic, Religious Coping, and Psychosocial Variables

Total
Sample		 Sexual
Minority
Women		 Sexual
Minority
Men		 Heterosexual
Women		 Heterosexual
Men

N = 216
n (%) = 14
(6.5)
n (%) = 87
(40.3)
n (%) = 57
(26.4)
n (%) = 58
(26.8)
N (%) N (%) N (%) N (%) N (%) x2 (df) p
Monthly Incomea
 $0 – $500 55 (25.5) 4 (28.6) 22 (28.9) 17 (32.1) 12 (23.5) .96 (3) ns
 $501 – $750 85 (39.4) 8 (57.1) 31 (40.8) 20 (37.7) 26 (51.0) 3.15 (3) ns
 $751 – $950 20 (9.3) 0 (0.0) 9 (11.8) 3 (5.7) 8 (15.7) 4.64 (3) ns
 $951 – $1150 12 (5.6) 0 (0.0) 5 (6.6) 5 (9.4) 2 (3.9) 2.36 (3) ns
 $1151 – $6000 22 (10.2) 2 (14.3) 9 (11.8) 8 (15.1) 3 (5.9) 2.39 (3) ns
M (SD) M (SD) M (SD) M (SD) M (SD) F (df) p
Age
(range = 22 – 60)		 41.2 (7.0) 41.2 (6.4) 40.0 (6.9) 41.1 (7.6) 43.1 (6.7) 2.38 (3, 212) ns
Social Support
(scale range = 1 – 7)		 5.3 (0.9) 5.2 (0.7) 5.2 (0.9) 5.3 (0.9) 5.2 (0.9) 0.17 (3, 211) ns
Positive religious
coping style
(scale range = 7 – 28)		 22.7 (4.9) 24.2 (3.1)a,b 21.5 (5.1)a 24.2 (4.3)b 22.5 (5.1)a,b 3.18 (3, 151) < .05
Negative religious
coping style
(scale range = 7 – 28)		 10.7 (4.6) 14.6 (6.2)a 10.7 (4.4)a,b c 10.3 (4.5)b,c 10.1 (4.4)b,c 2.73 (3, 149) < .05
Depressive Symptoms
(scale range = 0 – 60)		 14.1 (9.8) 19.2 (12.7) 13.7 (10.1) 13.3 (8.2) 14.4 (9.7) 1.47 (3, 212) ns
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Note.

a

=Some percentages are less than 216 due to missing data. Means with different subscripts differ significantly at p < .05 in the Bonferroni comparison.

Endorsement of Religious Coping Styles and Strategies

Overall, participants reported engaging a positive religious coping style significantly more than a negative religious coping style (t = 22.99, df = 152, p <.01). Heterosexual women reported engaging a positive religious coping style significantly more than sexual minority men (F = 3.18, df = 3, 151 p < .05). Sexual minority women reported engaging a negative religious coping style significantly more than heterosexual women and men (F = 2.73, df = 3, 149, p < .05). See Table 1. The top three endorsed positive religious coping strategies were spiritual connection, seeking spiritual support, and religious purification. The top three endorsed negative religious coping strategies endorsed were demonic reappraisal, punishing god reappraisal, and spiritual discontent (see Table 2).

Table 2.

Average Scores for Items Measuring Positive and Negative Religious Coping Strategies

Positive Religious Coping
 Negative Religious Coping
Item Number - Coping Strategy M (SD) Item Score Range Item Number - Coping Strategy M (SD) Item Score Range
1. Spiritual Connection 3.5 (0.7) 1 – 4 1. Spiritual Discontent 1.5 (0.9) 1 – 4
2. Seeking Spiritual Support 3.5 (0.8) 1 – 4 2. Punishing God Reappraisala 1.5 (0.9) 1 – 4
3. Religious Forgiving 3.1 (0.1) 1 – 4 3. Punishing God Reappraisal 1.6 (0.9) 1 – 4
4. Collaborative Religious Forgiving 3.2 (0.9) 1 – 4 4. Spiritual Discontent 1.4 (0.9) 1 – 4
5. Benevolent Religious Appraisal 3.1 (0.9) 1 – 4 5. Interpersonal Religious Discontent 1.4 (0.9) 1 – 4
6. Religious Purification 3.4 (0.8) 1 – 4 6. Demonic Reappraisal 1.9 (1.1) 1 – 4
7. Religious Focus 2.8 (1.1) 1 – 4 7. Reappraisal of God’s Power 1.3 (0.8) 1 – 4
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Note.

a

= Two items that represented this religious coping strategy was included in the subscale.

Multivariate Associations Between Religious Coping Styles and Depressive Symptoms

After controlling for sociodemographic characteristics and social support, negative religious coping style (B = .04, SE = .02, CI = .00 – .08, p < .05) significantly predicted depressive symptoms. Specifically, negative religious coping style was associated with higher levels of depressive symptoms. Positive religious coping style was not significantly associated with depressive symptoms (B = .00, SE = .02, CI = −.04 – .04, p = ns). See Model 1 in Table 3.

Table 3.

Multivariate Regression Analyses of Main Effects of Religious Coping Styles on Depressive Symptoms and Moderating Influences of Sexual Orientation and Gender

Depressive Symptoms
Predictor B (SE) 95% CI of B ß
Model 1
 Positive religious coping style .00 (.02) −.04 – .04 −.00
 Negative religious coping style .04 (.02) .00 – .08 .12*
Adjusted R2 .25
Model 2
 Positive religious coping style .07 (.04) −.01 – .14 .20
 Negative religious coping style .06 (.04) −.02 – .13 .16
 Positive religious coping style X sexual orientation −.11 (.05) −.20 – −.02 −.23**
 Negative religious coping style X sexual orientation .04 (.04) −.04 – .12 .08
 Positive religious coping style X gender −.05 (.05) −.15 – .05 −.08
 Negative religious coping style X gender −.07 (.04) −.15 – .01 −.14
Adjusted R2 .28
∆ R2 .03
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Note. N = 216. All models controlled for age, income, gender, sexual orientation, and social support.

*

p < .05.

**

p < .01.

Moderating Effect of Sexual Orientation and Gender on the Association Between Religious Coping Styles and Depressive Symptoms

Sexual orientation significantly moderated the relationship between positive religious coping style and depressive symptoms (B = −.11, SE = .05, CI - −.20 – −.02, p < .01). After conducting a simple slope analysis (see Figure 1), we found that higher levels of positive religious coping were associated with higher levels of depressive symptoms, but only for heterosexual BALWH. Sexual orientation did not moderate the association between negative religious coping style and depressive symptoms. Gender was not a significant moderator for the relationship between either of the religious coping styles and depressive symptoms.

Figure 1.

Figure 1.

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Moderating effect of sexual orientation on the association between positive religious coping and depressive symptoms.

DISCUSSION

This paper represents an expansion of the scholarly literature related to coping among people with HIV. Specifically, it added empirical information about the relationship between religious coping and mental health for BALWH. Compared to a normative range of average mean scores across 30 studies (Ms = 17 – 21; Pargament et al., 2011), the current sample scored higher (M = 22.7) on the positive religious coping subscale. The current sample’s negative religious coping style subscale score (M = 10.7) was within the normative range found across 30 studies (Ms = 8 – 14; Pargament et al., 2011). Overall, the sample’s scores on the positive religious coping subscale items suggests that BALWH used positive religious coping strategies “quite a bit” to “a great deal.” BALWH scores on the negative religious coping subscale indicate that they used negative religious coping strategies “not at all” to “somewhat.”

We discovered that BALWH used several different positive and negative religious coping strategies to help them navigate stressors. BALWH most often used spiritual connection – a coping strategy wherein one seeks to build a stronger relationship with the sacred in a way that connects them with a larger spiritual force and purpose (Pargament et al., 2000) – to grapple with negative life events. They also often sought spiritual support from the sacred (Pargament et al., 2000) – a coping strategy that emphasizes cultivating a feeling of love, care, and comfort between one’s self and the sacred – as a way to persevere in times of distress. BALWH highly endorsed seeking religious purification – asking for forgiveness from the sacred after engaging in behaviors they considered ungodly. Taken together, these positive religious coping strategies represent an understanding of the sacred as a source for renewal, strength, and connection with something greater than themselves in times of stress.

BALWH reported rarely using religious focus as a positive coping strategy and reappraisal of god’s power as a negative coping strategy. Religious focus consists of engaging in religious activities to shift focus from a stressor (Pargament et al., 2000). Reappraisal of god’s power is when one doubts the ability of the sacred to be effective in one’s life (Pargament et al., 2000). These findings suggest that BALWH do not use religious activities as a distraction from their stressful lives and seldom doubt the power of the sacred to help them cope with negative experiences. However, our findings suggest that demonic reappraisal was the most used negative religious coping strategy when trying to make sense of life stressors. Demonic reappraisal is attributing a stressor to the work of a demonic force (Pargament et al., 2000). Thus, it seems that BALWH believe that nefarious forces are active agents in their lives that contribute to negative experiences. Given that the forces that negatively impact the lives of BALWH are often chronic and invisible, in the sense that they are longstanding systemic and systematic forms of disenfranchisement (e.g., poverty [Badgett, Durso, & Schneebaum, 2013]; housing discrimination [U.S. Department of Housing and Urban Development, 2013]), exploitation (e.g., cultural appropriation [Spivey, 2017]), and other forms of structural oppression, it is logical that these experiences may be interpreted as the work of forces that are malevolent, beyond comprehension, and unable to be changed.

After controlling for sociodemographic characteristics and social support, we found that a negative religious coping style was related to BALWH experiencing more depressive symptoms. These findings are consistent with extant literature that found that negative religious coping was associated with psychological distress among heterosexual Black women living with HIV (Woods, Antoni, & Ironson, 1999) and general samples of Black Americans (Park et al., 2017). However, this was not the case when considering intersecting identities among BALWH.

Sexual orientation, but not gender, moderated the relationship between positive religious coping style and depressive symptoms. Among the heterosexual subsample, higher levels of positive religious coping were associated with higher levels of depressive symptoms. Given the correlative and cross-sectional nature of the data, this finding may be interpreted bidirectionally. It may be that having a positive religious coping style contributed to the heterosexual subsample experiencing more depressive symptoms. Alternatively, and more feasibly, heterosexual BALWH use of positive religious coping may increase as they feel more depressed. Related to this point, other researchers have found that experiencing negative events were related to increased use of positive religious coping (Bjorck & Thurman, 2007). Positive religious coping seems to be beneficial for heterosexual people during times of psychological distress but may be a stressor for depressed sexual minority BALWH due, in some part, to the homonegative context of many Abrahamic (i.e., Judaism, Islam, and Christianity) religions (Brewster, Velez, Foster, Esposito, & Robinson, 2016; Lassiter, Saleh, Grov, et al., 2017). Homonegativity in religious doctrine and settings may contribute to sexual minority BALWH having more tenuous relationships with religion compared to their heterosexual counterparts who are not often demonized for their sexual orientation. More research is needed to better understand how religious coping influences the health of sexual minority BALWH. As stated previously, gender was not a significant moderator in our analyses. It would be appropriate to reason that the relationship between religious coping and mental health would be stronger for women given that they have reported utilizing religious coping more than men in this sample and other studies (Chatters et al., 2008; Hawthorne et al., 2016). However, the higher rate of religious coping among women did not translate to a stronger relationship between religious coping and depressive symptoms among this subgroup in our sample. More research is needed to further explore the intersections of gender, BALWH, and psychological functioning.

Clinicians providing counseling for BALWH are encouraged to explore the topics of religious coping in their patients’ lives as it has been found to be culturally relevant for this population (Szaflarski, 2013). Counselors may find it beneficial to query about both the positive and negative aspects of religious coping styles and strategies. Conducting functional analyses of religious coping strategies may help patients determine which religious coping strategies are beneficial and which are deleterious, and subsequently develop more effective and salubrious religious coping strategies. Examining the ways in which an HIV diagnosis and other individual and structural distressing experiences may be interpreted as punishment or blessings from the sacred may also prove helpful in counselors gaining a better understanding of their patients’ mental health. Our findings suggest that the interplay of sexual orientation, religious coping, and mental health should also be considered. Clinicians and researchers may find it beneficial to query or assess their patients’ sexual identities and internalized homonegativity, and how these things intersect with mental health, coping with HIV, and relationships with the sacred. This should not be done in a forceful manner but conducted with an openness and curiosity so that patients may process these experiences in an affirming environment. Some BALWH may find it helpful to conduct this type of exploration in collaboration with their mental health providers and culturally-sensitive clergy members.

While there are several strengths to this study, there are some limitations that should be considered. First, it should be noted that the sample was limited to Black American people living with HIV in the southern region of the United States. Extension of the findings to groups dissimilar to the sample is cautioned. The data analyses described in this paper were cross-sectional. Therefore, no statements of causality can be made. Data about religious and spiritual denominational affiliation were not collected. This data may have provided more insight about the context of the sample’s religious coping. Future studies may benefit from collecting and analyzing this type of data in studies examining religion and health among BALWH. Finally, due to insufficient cases (N = 14) in the sexual minority women cell, a three-way interaction (i.e., gender X sexual orientation X religious coping) assessing the dual impact of gender and sexual orientation on the association between religious coping styles and mental health outcomes was not feasible. Future studies should aim to recruit sufficient sample and subsample sizes to further religion-health research with an intersectional focus.

CONCLUSIONS

Despite these limitations, this study provides nuanced information about the associations between religious coping and mental health for BALWH. BALWH are likely to use positive religious coping strategies that help them build a stronger spiritual connection with and receive support from the sacred. Yet when negative religious coping is activated, they tend to attribute life stressors to overwhelming forces beyond their control. The study provides evidence that having a negative religious coping style is detrimental to the mental health of BALWH regardless of sexual orientation and gender. Furthermore, experiencing more depressive symptoms was associated with more use of positive religious coping among heterosexual BALWH only. Researchers and clinicians who work with HIV-positive Black Americans may find it beneficial to assess both religious coping styles and individual religious coping strategies as well as issues of sexual orientation with their patients who are experiencing mental health problems or who may be at risk for developing them.

Acknowledgements

Dr. Lassiter’s effort was supported by a training grant (R25HD045810; PI: Tor Neilands) from the National Institute of Child Health and Human Development. Dr. Poteat’s time was supported by a NIH K award (5KL2TR001077-05; PI: Daniel Ford) to Johns Hopkins University’s Institute for Clinical and Translational Research.

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