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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: J Sex Res. 2021 Aug 19;59(5):610–620. doi: 10.1080/00224499.2021.1963649

Sexual Shame & Emotion Dysregulation: Key Roles in the Association between Internalized Homonegativity and Sexual Compulsivity

Jorge Cienfuegos-Szalay 1,2, Raymond L Moody 1,2, Ali Talan 1, Christian Grov 3, H Jonathon Rendina 1,2
PMCID: PMC8976551  NIHMSID: NIHMS1733893  PMID: 34410183

Abstract

Sexual minority men (SMM) are at increased risk for mental health problems due to effects of sexual minority stigma (e.g., internalized homonegativity (IH)). Both IH and emotion dysregulation are contributors to sexual compulsivity; however, the role of feelings of sexual shame have not been examined in this association. A sample of 982 HIV-negative SMM completed online surveys (MAge = 42.4, SD = 13.74). Path analyses indicated significant direct effects of IH on sexual shame (β = 0.44, p < .001), emotion dysregulation (β = 0.19, p < .001), and sexual compulsivity (β = 0.22, p < .001). Modeled simultaneously, the association between sexual shame and sexual compulsivity (β = 0.26, p < .001) was significant, as was the association between emotion dysregulation and sexual compulsivity (β = 0.27, p < .001). Finally, an indirect effect of IH on sexual compulsivity through both sexual shame (p < .001) and emotion dysregulation (p < .001) was significant, and the association between IH and sexual compulsivity was reduced to non-significant (β = 0.01, p = 0.74). Targeting feelings of sexual shame and emotion dysregulation in clinical interventions may help reduce the negative health impact of sexual compulsivity among SMM.

Keywords: internalized homonegativity, minority stress, sexual shame, sexual compulsivity, emotion regulation

Introduction

Increased attempts have been made to understand what factors impact, maintain, or exacerbate sexual compulsivity among sexual minority men (SMM). In prior literature, sexual compulsivity has been broadly operationalized in terms of behavior, including excessive use of pornographic material, excessive masturbation, multiple sexual encounters with anonymous partners, and condomless sexual intercourse (Kafka, 2010; Satinsky et al., 2008). However, for the purpose of this study we defined sexual compulsivity as any sexual behaviors, urges or fantasies that are considered frequent, repetitive, and of an intensity to the point where they are considered hard to control, and consequently interfere with work, personal relationships and other vocational pursuits (Black, 2000; Parsons et al., 2017; Reid, Harper, & Anderson, 2009). This definition aligns with the previous proposed criteria for Hypersexual Disorder for the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; Kafka, 2010) as well as the International Classification of Diseases 11th Revision’s (ICD-11) definition of Compulsive Sexual Behavior Disorder (World Health Organization, 2018), with the noted exception that we did not include a timeframe for which the individual must be experiencing said urges.

Epidemiological data suggest there is a prevalence of sexual compulsivity in 1%−6% of the U.S. population. These studies, however, have used different definitions for sexual compulsivity and were limited by small samples (Klein, Rettenberger, & Briken, 2014; Kraus et al., 2018; Kuzma & Black, 2008), with recent evidence suggesting there are higher rates than what has been previously estimated. For example, Dickenson et al. (2018) found that over 8% of participants in a nationally representative U.S. sample reported clinically significant levels of sexual compulsivity. This study utilized the Compulsive Sexual Behavior Inventory-13, the only existing screening instrument with an established clinical cutoff to identify those who meet criteria based on the ICD-11’s Compulsive Sexual Behavior Disorder. Results also demonstrated men (10.3%) reported more clinically significant levels than women (7%; Dickenson et al., 2018); other data suggests rates are higher for SMM relative to their heterosexual counterparts (Baum & Fishman, 1994; Missildine et al., 2005). Among SMM, sexual compulsivity has been associated with several psychosocial and behavioral health problems, ranging from interpersonal conflicts and psychological distress (Parsons, Grov, & Golub, 2012), to physical risks such as increased exposure to sexually transmitted infections (Dodge et al., 2008; Grov, Parsons, & Bimbi, 2010; Muench & Parsons, 2004) and substance use (Stavro et al., 2013; Woolf-King et al, 2013).

Minority Stress Theory

A growing body of research supports minority stress theory as a possible explanation for the disproportionate rates of sexual compulsivity among SMM (Chaney & Burns-Wortham, 2018; Pachankis et al., 2015; Rendina et al., 2017; Rooney, Tulloch, & Blashill, 2018). According to this theory, sexual minority individuals may be exposed to unique forms of stress given the prejudice and stigma associated with their non-heterosexual identity (Hatzenbuehler, 2009; Meyer, 2003). Minority stressors are chronic, socially-based, and have been conceptualized to occur along a continuum of distal to proximal stressors (Meyer, 2003; Wong et al., 2014). Distal minority stressors are events from the social environment (e.g., prejudice, discrimination, violence) and the most explicit sources of minority stress (Meyer, 1995, 2003), often manifesting early in a sexual minority individual’s life (Hatzenbuehler, McLaughlin, & Nolen-Hoeksema, 2008) and with a likelihood of continuing to negatively impact mental and physical health into adulthood (Meyer, 2003). These external events have been consistently linked to negative health outcomes, including depression, anxiety and high-risk sexual behaviors (Arbona & Jimenez, 2014; Balsam, Rothblum, & Beauchaine, 2005; Frost & Bastone, 2008; Frost, Lehavot, & Meyer, 2015; Landolt et al., 2004). Chronic exposures to these external stressors often lead to the marginalization of SMM and contribute to the development of proximal stressors (Meyer, 1995, 2003; Pachankis, Goldfried, & Ramrattan, 2008).

Proximal stressors may appear through an individual’s self-perceptions and appraisals of their stigmatized sexual minority identity (Meyer, 2003), and manifestations include the internalization of stigmatized views against homosexuality (i.e., internalized homonegativity), expectations of rejection (i.e., rejection sensitivity) and concealment of sexual identity due to fear of harm from others (Meyer, 1995; Meyer & Frost, 2013). Internalized homonegativity—often referred to as internalized homophobia (Meyer & Dean, 1998) or internalized heterosexism (Szymanski, Kashubeck-West, & Meyer, 2008)—has been identified as the most proximal stressor to the self (Meyer, 2003). This phenomenon has been defined as a form of internal stress where a sexual minority individual directs negative societal values towards the self even in the absence of events of discrimination or prejudice (Meyer, 1995; Meyer & Dean, 1998; Newcomb & Mustanski, 2010). Among SMM, internalized homonegativity has been associated with depression and anxiety (Newcomb & Mustanski, 2010), substance use (Moody et al., 2018; Puckett et al., 2017), feelings of shame (Allen & Oleson, 1999), and sexual compulsivity (Dew & Chaney, 2005; Pachankis et al., 2015). Therefore, considering how internalized homonegativity has been specifically associated with both sexual risk behavior and sexual compulsivity among SMM (Dew & Chaney, 2005; Pachankis et al., 2015), exploring the mechanisms underlying this association may prove useful, particularly for the development of clinical and behavioral interventions for this population.

Sexual Shame

Although evidence is limited, feelings of shame may play a key role (Rendina et al., 2018). Commonly categorized as a self-conscious emotion, shame negatively influences an individual’s thoughts, behaviors, and overall well-being (Tracy & Robins, 2004). Self-conscious emotions arise when one evaluates their role in regards to a personal attribute or specific situation (Tracy & Robins, 2006), and shame specifically produces global feelings of personal failure in response to an individual not achieving their own goals or expectations (Hequembourg & Dearing, 2013; Rendina et al., 2018). Internalized homonegativity may be interpreted as a unique manifestation of shame related to holding a sexual minority identity, wherein the sexual minority individual is constantly receiving messages they are undesirable or unwanted for not holding a heterosexual identity (Allen & Oleson, 1999). Among SMM, feelings of shame have been suggested as a vital component in both the appearance and maintenance of sexually compulsive behaviors (Christensen et al., 2013), and shame may even be the defining symptom of sexual compulsivity rather than the sexual behavior itself (Pachankis et al., 2015; Rendina et al., 2019). More specifically, feelings of shame specifically directed at one’s sexual feelings, thoughts, and behaviors (i.e., sexual shame) as opposed to their identity as a sexual minority individual have been suggested to be sufficient to drive sexually compulsive behavior (Pachankis et al., 2015; Rendina et al., 2019). Furthermore, emotion regulation models of sexual compulsivity have highlighted how individuals may learn that they may reduce the shame associated to a sexual behavior, if only temporarily, by engaging in the behavior itself (Kafka, 2010; Pachankis et al., 2015; Rendina et al., 2019).

Similar to sexual compulsivity, shame has been positively associated with internalized homonegativity (Brown & Trevethan, 2010), depression and anxiety (Gilbert, 2000), substance use-related disorders (Harder, 1995; Luoma et al., 2012), low self-esteem (Gruenewald et al., 2004), and HIV risk transmission behaviors (Sikkema et al., 2009) among SMM. Although the literature on internalized homonegativity, shame, and sexual compulsivity demonstrates a considerable overlap in detrimental effects on the mental and physical well-being of SMM, few empirical studies have given attention to the influence sexual shame may have on this association (Rendina et al., 2018). Preliminary data suggests, however, that negative self-views are crucial in both shame and internalized homonegativity (i.e., feelings of undesirability, unworthiness; Johnson & Yarhouse, 2013; Reid et al., 2009). Clinical case studies have also highlighted feelings of shame around sexual behaviors as a potential factor for the development of sexual compulsivity (Del Giudice & Kutinsky, 2007; Shepherd, 2010). Therefore, assessing the potential links between sexual shame and internalized sexual minority stigma seems necessary to further understand sexual compulsivity in SMM.

Emotion Regulation

In addition to feelings of sexual shame, there is an existing body of literature that suggests difficulties in emotion regulation are a core component of the development of both sexual compulsivity (Bancroft, 2008; Jerome, Woods, Moskowitz, & Carrico, 2016) and psychopathology in general (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Sheppes, Suri, & Gross, 2015). These difficulties are likely exacerbated by chronic exposure to minority stressors (Pachankis et al., 2015; Parsons et al., 2017). Emotion regulation refers to a set of processes and strategies used to modify or maintain the intensity of emotions individuals experience in order to produce appropriate responses to environmental demands (Aldao, 2013; Bookhout, Hubbard, & Moore, 2018; Gross, 2002). These multi-component and ongoing internal processes can be triggered by internal or external emotional factors and are accompanied by physiological, experiential, and behavioral responses, often simultaneously (Berke, Reidy, & Zeichner, 2018; Gross, 1998). The goal of successful emotion regulation is not to eliminate negative emotions but rather to successfully adapt to and transition between different emotional states until a desirable emotional state is reached (Wadlinger & Isaacowitz, 2011).

Difficulties in regulating emotions can therefore be described as difficulties with discerning, coping with, or expressing emotions, and are central components of several internalizing and externalizing psychological disorders like anxiety and depression (Aldao et al., 2010), substance use (Sher & Grekin, 2007), internet gaming disorder (Yen et al., 2017), and pathological gambling (Williams et al., 2012). Additionally, much like the effects of internalized homonegativity, difficulties in emotion regulation may commence early in one’s life and tend to follow an individual as they progress into adulthood (Aldwin et al., 2011). Considering SMM suffer disproportionately from both internalizing (Cochran, Sullivan, & Mays, 2003; Gilman et al., 2001) and externalizing disorders (Burgard, Cochran, & Mays, 2005; Drabble, Midanik, & Trocki, 2005), and show greater deficits in emotion regulation in comparison to their heterosexual peers (Hatzenbuehler, McLaughlin, & Nolen-Hoeksema, 2008), shedding light on the mechanisms that may underlie the association between internalized homonegativity and sexual compulsivity in order to potentially reduce SMM’s disparate rates of negative health outcomes is crucial.

The purpose of the current study was to investigate the potential role sexual shame and emotion dysregulation have in the association between internalized homonegativity and sexual compulsivity in a sample of 982 SMM across the U.S. We hypothesized 1) a significant and positive association between internalized homonegativity and sexual compulsivity; 2) the indirect effect of internalized homonegativity on sexual compulsivity through both sexual shame and emotion dysregulation separately would be significant; and 3) the combined indirect effect of internalized homonegativity on sexual compulsivity through both sexual shame and emotion dysregulation would be significant.

Method

Data used for these analyses were collected as part of the 24-month assessment of the One Thousand Strong study (Grov et al., 2016), a U.S. national cohort of 1,071 HIV-negative SMM in the U.S. prospectively followed for a three-year period. Of these, 985 (92%) completed the 24-month assessment; three participants were excluded due to their HIV-positive status, leaving a total sample of 982 for the current study. Participants were recruited through Community Marketing and Insight’s (CMI) panel of over 22,000 SMM. Recruitment methods used targeted sampling to ensure adequate representation of same-sex households based on age, race/ethnicity, and U.S. geography. To be eligible for the study, potential participants had to currently reside in the U.S., be at least 18 years old, be biologically male and currently identify with a male gender, identify as gay, bisexual, or queer, report sexual contact with another man in the past year, self-identify as HIV-negative, be willing to complete self-administered at-home rapid HIV antibody testing and self-administered testing for STIs (urethral and rectal chlamydia/gonorrhea), be able to complete assessments in English, have access to the Internet in order to complete at-home assessments, have access to any device capable of taking a digital photo (e.g., camera phone, digital camera), have a mail address that is not a P.O. Box, and report residential stability (i.e., have not moved more than twice in the past 6 months). Additional details on recruitment and enrollment are described elsewhere (Grov et al., 2016). Enrolled men confirmed their HIV status with a HIV-negative test result at baseline. Cross-sectional data from the 24-month follow-up were used for these analyses. All study procedures were approved by the Institutional Review Board of the City University of New York.

Measures

Data were collected using a computer-assisted self-interviewing (CASI) software at 24 months following enrollment via Qualtrics. We included measures of demographic characteristics, internalized homonegativity, sexual compulsivity, and sexual shame.

Demographics.

Participants reported their current age, race and ethnicity, level of education, income, and sexual orientation. Participants also reported their zip code, which was used to create a population density rank-ordered variable based on census data.

Internalized Homonegativity.

Internalized homonegativity was assessed using a modified 9-item version of the Meyer (1995) Internalized Homophobia Scale. This scale measures internalized stigma in regards to having a non-heterosexual orientation. Respondents were asked how much they agreed or disagreed with statements regarding their feelings related to their sexual orientation on a 4-point Likert-type scale, which ranged from 1 (strongly disagree) to 4 (strongly agree). Sample items are: “I have tried to stop being attracted to men in general” and “I wish I weren’t gay/bisexual”. Responses to all nine items were averaged and higher scores indicate greater internalized homonegativity (Cronbach’s α = 0.86).

Sexual Compulsivity.

Sexual compulsivity was assessed using the Sexual Compulsivity Scale (SCS) (Kalichman & Rompa, 2001), a 10-item 4-point Likert-type scale which ranges from 1 (not at all like me) to 4 (very much like me). The SCS measures the impact of sexual thoughts on daily functioning and the inability to control sexual thoughts and/or behaviors. Examples of items found in this scale are “My high level of desire to have sex has disrupted my daily life” and “I feel my sexual thoughts & feelings are stronger than I am.” Total scoring ranges from 10–40, with higher scores indicating greater levels of sexual compulsivity, and has demonstrated good convergent, criterion-related, and divergent validity (Cronbach’s α: 0.89; Grov, Parsons, & Bimbi, 2010; Kalichman & Rompa, 2001; Rendina et al., 2012).

Sexual Shame.

Sexual shame was assessed using a subscale of the Sexual Shame and Pride Scale (SSPS; Rendina et al., 2018). The sexual shame subscale is an 8-item Likert-type scale, which ranges from 1 (not at all like me) to 6 (exactly like me). Examples of items found in this scale are “Shortly after sex, I am often ashamed of what I have just done” and “I would be ashamed if people knew the kinds of things I have done sexually”. Total scoring ranges from 8–48, with higher values indicating higher levels of sexual shame (Cronbach’s α: 0.90). For the purposes of this study the mean score was calculated for each participant. The Sexual Shame subscale has demonstrated convergent and predictive validity (Rendina et al., 2018).

Difficulties in Emotion Regulation.

Difficulties in emotion regulation were assessed using the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), a 36-item, 5-point Likert-type scale which ranges from 1 (almost never) to 5 (almost always). This scale measures emotion dysregulation through six distinct subscales. The first, nonacceptance of emotional responses, contains items such as “When I’m upset, I become angry with myself for feeling that way”. The second assesses difficulties in engaging in goal-directed behaviors, and contains items such as “When I’m upset, I have difficulties getting work done”. The third assesses impulse control difficulties, and contains items such as “When I’m upset, I become out of control”. The fourth captures a lack of emotional awareness, and contains items such as “I pay attention to how I feel” (reverse-coded). The fifth subscale gathers information on the access a person might have to their emotion regulation strategies and contains items such as “When I’m upset, I believe that I will remain that way for a long time”. The final subscale captures an individual’s lack of emotional clarity, and contains items such as “I have difficulty making sense out of my feelings”. Scores can range from 36 to 180, with higher values indicating greater difficulties in emotion regulation (Cronbach’s α: 0.93). The DERS has demonstrated good construct and predictive validity (Fowler et al., 2014; Gratz & Roemer, 2004)

Analysis Plan

Utilizing SPSS 27, we examined descriptive statistics among demographic characteristics and conducted ANOVAs to assess for significant differences across internalized homonegativity, emotion regulation, sexual shame, and sexual compulsivity. We then assessed correlations between our variables of interest and age. Finally, we conducted path analyses utilizing MPlus version 8. A path analysis allowed us to assess the potential mechanisms, both direct and indirect, through which an independent variable produces an effect on a dependent variable. We conducted a series of regressions, with each adjusted for age, race, income, education, and sexual orientation. The maximum likelihood estimation was used with 5,000 bootstrap draws.

Results

Table 1 presents the demographic characteristics of the sample, as well as a series of bivariate associations of the variables of interest. Ages in the sample ranged from 18 to 81 (M = 42.4, SD = 13.7). The majority of the sample identified as White (71.1%), while the remaining identified as Hispanic/Latino (12.3%), Black/African American (8%), Multiracial (3.3%) and Asian, Native Hawaiian or Alaskan Native, and Native American (5.3%). More than half of the sample reported an annual income of $30,000 or more (75.4%), 60.9% reported having at least a 4-year college degree, and 52.6% reported having a main partner.

Table 1.

Demographics across key variables.

n % Internalized Homonegativity Emotion Dysregulation Sexual Shame Sexual Compulsivity
M (SD) F(p) M (SD) F(p) M (SD) F(p) M (SD) F(p)
Race/Ethnicity
 Black/African American 79 8.04% 1.41 0.59 5.020 (.001) 68.06 23.52 2.051 (.085) 1.94 1.01 1.389 (.236) 14.75 5.01 1.125 (.343)
 Hispanic/Latino 121 12.32% 1.37 0.60 69.19 23.11 2.08 0.90 15.19 5.75
 White 698 71.08% 1.35 0.56 71.82 22.55 2.12 0.93 15.46 5.62
 Multiracial 32 3.26% 1.63 1.02 79.88 25.39 2.27 1.06 16.81 7.20
 Other 52 5.30% 1.67 0.85 74.46 26.33 2.29 1.11 16.33 6.66
Income
 Less than $30,000/year 242 24.64% 1.43 0.61 2.331 (.127) 77.15 24.60 18.497 (.000) 2.21 0.90 3.143 (.077) 15.69 6.04 .511 (.475)
 $30,000 or more/year 740 75.36% 1.36 0.61 69.78 22.25 2.08 0.96 15.38 5.60
Education
 No Bachelor’s Degree 384 39.10% 1.38 0.61 .001 (.979) 73.04 24.37 2.482 (.115) 2.07 0.97 1.530 (.216) 15.18 5.44 1.530 (.216)
 4-Year College Degree 598 60.90% 1.38 0.62 70.67 22.14 2.14 0.93 15.64 5.90
In a Relationship
 No 466 47.45% 1.42 0.66 3.661 (.056) 73.03 23.31 3.426 (.064) 2.23 0.98 14.321(.000) 15.61 5.43 0.640 (0.424)
 Yes 516 52.55% 1.35 0.56 70.30 22.77 2.00 0.90 15.32 5.95
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Examining bivariate associations between demographics and our variables of interest, men who identified their race as “other” reported significantly higher internalized homonegativity compared to both Latino and Multiracial men, as demonstrated through post-hoc analyses. No other significant findings were found among any demographic variables and internalized homonegativity. Men who reported an annual income of less than $30,000 reported greater difficulties in regulating their emotions compared to men who reported having an income of above $30,000, but no other significant findings were found between the remaining demographic characteristics and emotion dysregulation. Men in relationships reported less sexual shame when compared to men who reported being single. No other statistically significant associations were seen between the remaining demographic variables and either sexual shame or sexual compulsivity.

Table 2 presents the correlations between our variables of interest. Internalized homonegativity, sexual shame, emotion dysregulation, and sexual compulsivity were all found to be positively correlated with each other. In terms of age, significant negative correlations were seen with internalized homonegativity, sexual shame, and difficulties in emotion regulation, but not with sexual compulsivity. However, these negative correlations had a relatively weak effect size. In comparison, the associations seen among our variables of interest were within the range of moderate to strong effect sizes.

Table 2.

Means and correlations for key variables.

1 2 3 4 M SD
1. Age - - - - 42.36 13.74
2. Internalized Homonegativity −.144** - - - 1.38 0.61
3. Emotion Dysregulation −.189** .372** - - 71.60 23.06
4. Sexual Shame −.121** .453** .479** - 2.11 0.95
5. Sexual Compulsivity .003 .219** .373** .379** 15.46 5.71
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**.

Correlation is significant at the 0.01 level (2-tailed).

The results of our path analyses are presented in Figure 2. Adjusting for sociodemographic characteristics, these indicated significant associations between internalized homonegativity and sexual shame (β = 0.44, p < .001) as well as internalized homonegativity and emotion dysregulation (β = 0.19, p < .001). Furthermore, significant associations were seen between sexual shame and sexual compulsivity (β = 0.26, p < .001), sexual shame and emotion dysregulation (β = 0.38, p < .001), and emotion dysregulation and sexual compulsivity (β = 0.27, p < .001). There were significant indirect effects of internalized homonegativity on sexual compulsivity through both sexual shame (β = 0.11, p < .001) and emotion dysregulation (β = 0.05, p < .001) separately, as well as simultaneously (β = 0.04, p < .001). The total indirect effect of the model was significant (β = 0.21, p < .001). Additionally, the direct effect between internalized homonegativity and sexual compulsivity was not statistically significant (β = 0.01, p = 0.737), providing support of a full mediation effect.

Figure 2.

Figure 2.

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Direct and Indirect Effects of Internalized Homonegativity on Sexual Compulsivity.

Indirect Effects on Sexual Compulsivity

Internalized homonegativity via sexual shame β = 0.11***

Internalized homonegativity via emotion regulation β = 0.05***

Internalized homonegativity via sexual shame and emotion regulation β = 0.04***

Discussion

In recent years, increased efforts have been made to understand the underlying mechanisms in the association between minority stressors and sexual compulsivity. However, considerable gaps still remain in our understanding of how these two phenomena are connected. As an attempt to address these gaps, we assessed what roles sexual shame and emotion dysregulation had in the association between internalized homonegativity and sexual compulsivity in a cohort of nearly one thousand SMM in the U.S. Results of our path analyses demonstrated that the association between internalized homonegativity and sexual compulsivity can be almost entirely explained by both elevated feelings of sexual shame and difficulties in emotion regulation.

While there have been different conceptualizations as to how sexually compulsive behaviors develop (Barth & Kinder, 1987; Black, 2000; Black et al., 1997; Kafka, 2010, 2014), a core theme across all of these has been a need for the individual to regulate, manage, or escape negative emotional states. Though our data was cross-sectional, our research lends support to this hypothesis, and converges with prior studies that have demonstrated that deficits in emotion regulation abilities at least partially mediate the association between minority stressors and sexual compulsivity. For example, examining the link between emotion dysregulation, minority stressors, and sexual compulsivity among highly sexually active SMM, Pachankis et al. (2015) found that emotion dysregulation and internalized homonegativity were both significantly positively associated with sexual compulsivity. Further, internalized homonegativity had a stronger impact on deficits in emotion regulation abilities compared to other proximal minority stressors, such as expectations of rejection. In another study, Parsons et al. (2017) examined the feasibility of an emotion regulation intervention designed to improve mental health and reduce risky sexual behaviors among SMM with high levels of sexual compulsivity. The authors found that the intervention reduced sexual compulsivity and improved symptoms of depression and anxiety, as well as reduced overall substance use and HIV transmission risk behaviors.

Building upon this work, in the current study we considered sexual shame as a mechanism through which internalized homonegativity is associated with sexual compulsivity. Previous research has highlighted that shame plays an integral role in both minority stressors generally and internalized homonegativity specifically (Allen & Oleson, 1999; Brown & Trevethan, 2010). However, when assessing shame and its relation to sexual compulsivity, studies have done so in indirect ways, largely using measures of stigma associated to HIV status or sexual identity as a proxy (Rendina et al., 2012). Measuring the association of sexual shame with sexual compulsivity directly, Rendina et al. (2018) found sexual shame was significantly associated with, and strongly predicted, sexual compulsivity when measured three months later. Furthermore, the impact of internalized homonegativity and emotion dysregulation became non-significant when feelings of sexual shame were entered into the models (Rendina et al., 2018). Our findings provide additional evidence for this association and give credence to the hypothesis that feelings of sexual shame play a unique role in the association between internalized homonegativity and sexual compulsivity.

Previous research has identified distinct dimensions within shame that may affect SMM differently. For example, regarding sexual behaviors, Park et al. (2014) found that feelings of shame relating to sexual desire were negatively correlated with knowledge of safer sex practices and positively correlated with engaging in condomless anal sex. Our findings extend how sexual shame specifically may influence SMM in terms of engaging in risk behaviors. Although we did not examine sexual behaviors specifically, taken together with our findings this suggests that while shame may evoke global feelings of unworthiness and inadequacy, feelings of sexual shame may specifically serve as a reminder of how sexual minority individuals are violating society’s heteronormative values. This reminder may in turn increase distress, which then may lead SMM to engage in sexually compulsive behaviors as an attempt to alleviate said distress.

We also examined whether, similar to proximal minority stressors, sexual shame impacted sexual compulsivity through emotion dysregulation. Sexual shame has been hypothesized to be the main mechanism through which self-regulatory problems for SMM appear because individuals fail to change their feelings of desire (e.g., wanting to engage in sexual contact with a person of the same sex) and simultaneously have to grapple with the internalization of this sexual desire as “bad” (Park et al., 2014). Additionally, as feelings of sexual shame are intrinsically linked with internalized homonegativity, when SMM internalize the stigma associated with their sexual orientation and experience sexual shame, this can be perceived as a threat to their identity and, in consequence, they may experience psychological distress from which they cannot escape (Hatzenbuehler et al., 2009; Major & O’Brien, 2005). With this threat to identity, sexual minority individuals are likely to experience involuntary emotional responses and have subsequent trouble managing these responses if they do not have the adequate psychological resources (Major & O’Brien, 2005; Meyer, 2003). Given that deficits in emotion regulation abilities play an important role in other compulsive disorders (Williams et al., 2012) and have been previously suggested as important psychological precursors to sexual compulsivity (Jerome, Woods, Moskowitz, & Carrico, 2016), it follows that they would at least partially explain the association between internalized homonegativity, sexual shame and the inability to control sexual urges, feelings or behaviors.

When examining differences among sociodemographic variables, SMM who reported their race as “other” had significantly higher levels of internalized homonegativity in comparison to Latino and Multiracial SMM. This could be due to several reasons. First, previous research has identified that sexual minorities of color may be in a “greater risk position” to experience heterosexist stigma because stigma against sexual minorities is higher amongst racial minorities in comparison to their White counterparts (Moradi et al., 2010). While we cannot ascertain the specific races these individuals identified as, our findings suggest that “other” racial minorities (e.g., Native Americans, Alaskan or Hawaiian Natives, Asians) may be more susceptible than Latino and Multiracial SMM in internalizing negative values about their sexual identity. Taking our findings into consideration, this speaks to the lack of research among racial and ethnic minorities pertaining to compulsive sexual behaviors. Racial and ethnic minorities may feel more psychological distress due to the additional stressors of holding multiple stigmatized identities. Future researchers should make efforts to take an intersectional approach when addressing these issues.

In terms of income, SMM who reported having an annual income of $30,000 or more reported higher levels of emotion regulation in comparison to SMM who earned $30,000 or less. This is consistent with previous literature, where higher levels of socioeconomic status have been associated with higher levels of not just emotion regulation, but overall healthy functioning (Côté, Gyurak, & Levenson, 2010). Additionally, men who reported being in a relationship seemed to experience lower levels of sexual shame. Men in relationships could potentially feel more comfortable with their sexual identity, and thus, experience fewer negative feelings towards their sexual behaviors (Frost & Meyer, 2009). Although it has been stated that the association between relationship status and mental health is bidirectional, stronger effects have been demonstrated when relationship status is the predictor and mental health is the outcome (Braithwaite & Holt-Lunstad, 2017). Previous research has also demonstrated that men who are open about their sexual orientation report better mental health outcomes and are more satisfied with their relationship quality (Frost & Meyer, 2009). Additionally, the social support provided by a partner within the context of an intimate relationship can act as a protective factor against negative health outcomes (Braithwaite & Holt-Lunstad, 2017). Future research could incorporate which stage of the coming out process a sexual minority individual finds themselves in, as this has been suggested as an influencing factor in their psychological health (Greene & Britton, 2012).

Clinical Implications

Elucidating potential mechanisms between minority stressors and sexual compulsivity is important, as SMM who report sexual compulsivity face greater physical and mental health risks. These risks include higher rates of condomless anal sex (Muench & Parsons, 2004), comorbidity with anxiety, mood, and substance use disorders (Brem, Shorey, Anderson, & Stuart, 2017; Raymond, Coleman, & Miner, 2003) and lower relationship quality (Starks, Grov, & Parsons, 2013). Our findings may help establish clinical guidelines and inform manualized treatments on how to address sexual compulsivity symptomology in SMM specifically. By identifying, acknowledging, and targeting internalized stigma among sexual minority individuals, and specifically addressing feelings of sexual shame and emotion dysregulation, it may be possible to reduce distress brought on by sexual compulsivity. Furthermore, as models of emotion regulation have demonstrated, when sexually compulsive behaviors are present feelings of sexual shame may be the appropriate treatment target relative to the sexual compulsive behavior itself (Pachankis et al., 2015). It is therefore necessary to develop cognitive-behavioral interventions that target negative self-views regarding one’s sexual orientation and sexual behaviors as well as deficits in emotion regulation abilities to potentially minimize the effects detrimental effects sexual compulsivity.

Limitations

The present study’s findings should be interpreted in light of several limitations. First, although this was a U.S. national sample, it was not meant to be representative of all SMM. Participants who were recruited through CMI’s LGBTQ panel were likely accustomed to answering questionnaires and participating in studies related to LGBTQ health. Participants were also recruited through email, and thus, generalizability is limited to individuals who have access to internet and email correspondence, although this is certainly the case for most Americans today (Perrin & Atske, 2021). Second, more than half of our sample identified as White and had a high income and almost our entire sample identified as gay or queer. This makes the generalizability of our findings difficult, as SMM who also hold racial, ethnic or other sexual identities may demonstrate different patterns in regards to sexual compulsivity. Additionally, SMM with lower income may experience additional debilitating factors, as low income among this group has been significantly associated with a higher likelihood of having detrimental health outcomes, such as higher rates of sexual risk behaviors and substance abuse (Baral, Sifakis, Cleghorn, & Beyrer, 2007; Harawa et al., 2008). Future research should focus on how marginalization in individuals with intersecting identities (e.g., race, ethnicity, sexual orientation) may interact with sexual behaviors and experiences of sexual shame.

The data for this study were also cross-sectional and thus causality cannot be inferred. Fourth, we assessed emotion dysregulation using the total score of the DERS. This precludes us from being able to identify which specific dimensions of emotion regulation play a significant role in the relationship between internalized homonegativity and sexual compulsivity. Additionally, while the DERS is widely used due to its clinical relevance and potential aid in helping establish psychological diagnoses, it has been criticized due to its psychometric limitations (Bardeen, Fergus, Hannan, & Orcutt, 2016). More specifically, the Awareness subscale has been found to share small correlations with the other five DERS scales (Bardeen, Fergus, & Orcutt, 2012) and has demonstrated a lower factor loading on a higher-order emotion regulation construct when compared to the remaining subscales (Bardeen et al., 2016; Fowler et al., 2014). Thus, when interpreting these findings, appropriate caution should be taken in extrapolating what type of emotion regulation difficulties play a role between minority stress processes and sexual compulsivity. Nonetheless, our results highlight the importance of exploring and targeting any difficulties in emotion regulation among SMM in order to potentially reduce negative psychological or behavioral outcomes, such as sexual compulsivity. And finally, our sample of SMM had relatively low scores in internalized homonegativity and sexual compulsivity. Therefore, these results may not accurately depict the experiences of SMM who meet clinical criteria for sexually compulsive behaviors.

Conclusions

We examined the association between a proximal minority stressor, internalized homonegativity, and sexual compulsivity. For SMM in particular, feelings of sexual shame and difficulties in regulating emotions contributed significantly to the association between internalized homonegativity and sexual compulsivity, both independently and simultaneously. These findings have important implications for SMM who report sexual compulsivity. While feelings of shame relating to a sexual minority identity have been reported previously (Johnson & Yarhouse, 2013), feelings of sexual shame may have a unique effect on the physical and mental health of SMM. Perhaps by addressing the different dimensions of shame brought on by internalizations of negative societal values (e.g., global feelings of shame attached to a sexual minority identity, feelings of shame attached to same-sex sexual behaviors), sexual compulsivity and other negative outcomes that SMM are at risk of may be significantly reduced. As a whole, understanding the mechanisms through which sexual compulsivity is related to proximal minority stressors are needed in order to target this successfully in behavioral and psychological interventions and reduce negative physical and mental health outcomes for SMM.

Figure 1.

Figure 1.

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Hypothesized Path Model

Acknowledgments

Funding details:

This work was supported in part by a diversity supplement from the Eunice Kennedy Shriver National Institute on Child Health and Human Development under Grant U19-HD089875–03S2; a Career Development Award from the National Institute on Drug Abuse under Grant K01-DA039030; and a research grant from the National Institute on Drug Abuse under Grant R01-DA036466.

Footnotes

Conflicts of Interest and Source of Funding

The authors have no competing interests to declare.

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