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. Author manuscript; available in PMC: 2023 Aug 1.
Published in final edited form as: J Consult Clin Psychol. 2022 Aug;90(8):638–646. doi: 10.1037/ccp0000749

Mechanisms Linking Distal Minority Stress and Depressive Symptoms in a Longitudinal, Population-Based Study of Gay and Bisexual Men: A Test and Extension of the Psychological Mediation Framework

Micah R Lattanner 1,*, John E Pachankis 2, Mark L Hatzenbuehler 1
PMCID: PMC9896512  NIHMSID: NIHMS1864930  PMID: 36066865

Abstract

Objective:

Gay and bisexual men have significantly higher rates of depression than heterosexual men. The minority stress theory (Meyer, 2003) proposed that distal minority stressors, like interpersonal discrimination, contribute to this disparity. The psychological mediation framework (Hatzenbuehler, 2009) posited several psychosocial mechanisms through which distal minority stress creates elevations in depression among sexual minorities. Despite accumulating support for this framework, there are a number of limitations to existing research, including largely relying on cross-sectional designs; focusing on a small subset of mechanisms and moderators; and using non-probability samples.

Method:

We recruited a sample of gay and bisexual men (N = 502) obtained from a population-based dataset of U.S. adults. Participants completed validated measures of distal minority stress (i.e., interpersonal discrimination), psychosocial mechanisms (i.e., rumination, emotional clarity, and social support), identity-related moderators (i.e., identity centrality, stigma consciousness, and sexual orientation identity), and depressive symptoms at baseline, six-month follow-up, and 1-year follow-up.

Results:

Rumination (b=0.38, 95% CI [0.13, 0.84]), lack of emotional clarity (b=0.43, 95% CI [0.11, 0.83]), and lack of social support (b=0.21, 95% CI [0.04, 0.45]) each individually mediated the prospective relationship between interpersonal discrimination and depressive symptoms, controlling for initial symptoms, age, and education. These indirect effects were not moderated by identity-related characteristics or sexual identity.

Conclusion:

Our study provides some of the strongest empirical evidence for the psychological mediation framework to date and suggests targets for interventions focused on reducing the mental health consequences of minority stress for sexual minority men.

Keywords: depression, minority stress, stigma, psychological mediation framework, sexual minority men

Evidence consistently indicates that gay and bisexual men are at greater risk for depressive symptoms and major depressive disorder than heterosexual men (e.g., Cochran et al., 2017). Stigma—defined as the co-occurrence of labeling, stereotyping, separating, status loss, and discrimination in a context in which power is exercised (Link & Phelan, 2001)—is the most frequently hypothesized risk factor explaining this population disparity. Two foundational stigma theories have received the most scholarly attention: the minority stress theory (Meyer, 2003) and the psychological mediation framework (Hatzenbuehler, 2009).

The minority stress theory (Meyer, 2003) posited that the excess stressors to which sexual minorities are exposed because of their stigmatized identities contribute to psychopathology among this group and explain their higher burden of adverse mental health outcomes as compared to heterosexuals. The theory proposed two classes of minority stressors: 1) external stressful events and conditions, such as experiences of interpersonal discrimination, categorized as distal minority stressors; and 2) internal responses to stigma, such as self-stigma and rejection sensitivity, categorized as proximal minority stressors. Robust evidence from a range of methods and samples demonstrates associations between both types of minority stressors and mental health outcomes (including depression) among sexual minority populations in general, and gay and bisexual men in particular (e.g., Sarno et al., 2020; Timmins et al., 2020; Meyer & Frost, 2013).

Although the minority stress theory made important advances in understanding the causes of sexual orientation disparities in mental health, it did not address the specific mechanisms through which stigma-related stressors contribute to psychopathology among sexual minorities. In fact, Meyer (2003) called for the identification of such mechanisms as a critical next step for research: “To understand causal relations, research…needs to explain the mechanisms through which stressors related to prejudice and discrimination affect mental health” (p. 689). To address this gap, Hatzenbuehler (2009; Figure 1) developed the psychological mediation framework, which theorized that the distal minority stressors (e.g., interpersonal discrimination) identified in Meyer’s (2003) model render sexual minorities more vulnerable to a variety of universal cognitive (e.g., rumination), affective (e.g., lack of emotional clarity), and social/interpersonal (e.g., lack of social support) risk factors for poor mental health. In turn, these psychosocial mechanisms are hypothesized to serve as mediators of the relationship between distal minority stress and adverse mental health outcomes among sexual minorities.

Figure 1.

Figure 1.

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Conceptual Model of Psychosocial Mechanisms Linking Interpersonal Discrimination to Depressive Symptoms among Gay and Bisexual Men.

There is accumulating evidence for various aspects of the psychological mediation framework. For instance, both cross-sectional (e.g., Timmins et al., 2020; Schwartz et al., 2016) and prospective (e.g., Sarno et al., 2020) studies have found evidence that rumination mediates the association between distal minority stress and depressive symptoms. While these studies have produced important insights, a number of conceptual and methodological questions about the psychological mediation framework remain.

With respect to methodology, most studies of the psychological mediation framework have used cross-sectional designs (e.g., Timmins et al., 2020; Schwartz et al., 2016), which are limited when testing mediation processes that, by definition, unfold over time. Additionally, all of the studies testing the framework have used non-probability samples. This sampling approach not only restricts generalizability, but also potentially limits internal validity, given that community-based samples of sexual minorities may over- or under-represent certain characteristics that influence mental health (e.g., Salway et al., 2019).

In addition to these methodological issues, there are at least two important conceptual questions regarding tests of the framework. First, the few longitudinal studies that do exist have assessed only a small number of universal psychosocial mediators outlined in the framework. In the current study, we focus on three putative cognitive, affective, and social mediators, including: 1) rumination, defined as repeated and enduring negative thoughts about the self and aversive experiences (Watkins & Roberts, 2020); 2) lack of emotional clarity, a difficulty in emotion regulation that involves challenges in understanding experienced emotions (Kauffman, et al., 2016); and 3) lack of social support, the perception that supportive resources are not available or received (Lakey & Cohen, 2000). Each of these are established risk factors for depression (Watkins & Roberts, 2020; Moriya & Takahashi, 2013; Cohen & Willis, 1985) and are hypothesized to result from distal minority stressors. For instance, experiencing interpersonal discrimination, an aversive form of identity-based interpersonal stress, can lead to rumination by activating repetitive self-focused thoughts about one’s devalued identity and about the event itself (Hatzenbuehler, 2009). Sexual minorities report lower emotional awareness than heterosexuals (Hatzenbuehler et al., 2008), which is hypothesized to result from emotion avoidance tendencies that develop in response to stigmatizing environments (Burton et al., 2018). Finally, experiencing discrimination can cause social withdrawal and isolation, disrupting access to supportive interpersonal relationships (Hatzenbuehler et al., 2009).

Second, although Hatzenbuehler (2009; Figure 2) originally called for research to identify identity-related characteristics that may moderate the mediation effects proposed in the psychological mediation framework, we are unaware of systematic attempts to do so. Consequently, we examined three identity-related characteristics—including identity centrality, stigma consciousness, and sexual orientation identity—based on evidence that they shape experiences of, and/or responses to, minority stress. Specifically, experiences of minority stress are hypothesized to influence mental health most strongly for individuals whose social identities are more central (i.e., identity centrality; Quinn & Chaudoir, 2009) to their self-concept and for those who expect to be stereotyped or discriminated against based on their stigmatized identity (i.e., stigma consciousness; Figueroa & Zoccola, 2015). In addition, sexual orientation identity (i.e., gay vs. bisexual) may moderate associations between minority stressors and mental health. For example, gay men and women report a stronger connection with the sexual minority community than bisexual men and women (Balsam & Mohr, 2007), which may buffer gay men and women from experiencing mental health problems following exposure to discrimination. Consequently, the mediational processes studied herein may be conditional upon these identity-related moderators.

Figure 2.

Figure 2.

Figure 2.

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Direct and Indirect Effects of Interpersonal Discrimination on Depressive Symptoms among Gay and Bisexual Men via Rumination, Lack of Emotional Clarity, and Lack of Social Support

Our study sought to address these limitations of prior research on the psychological mediation framework (Hatzenbuehler, 2009). Doing so requires a unique data structure that 1) selects a sample of sexual minorities from a population-based dataset; 2) assesses distal minority stressors (i.e., interpersonal discrimination); 3) simultaneously measures universal psychosocial risk factors for psychopathology (e.g., emotion regulation), identity-related moderators (e.g., identity centrality), and mental health outcomes (i.e., depressive symptoms); and 4) includes multiple assessments across time, in order to permit tests of mediational processes. Because this type of data structure does not currently exist, we recruited a longitudinal sample of gay and bisexual men obtained from a population-based dataset of U.S. adults. This sample presents an unprecedented opportunity to identify psychosocial mechanisms linking stigma-related stressors to depressive symptoms, and to explore identity-related characteristics that may magnify or attenuate the indirect effect of these stressors on depression via psychosocial mechanisms.

Methods

Participants and Procedure

Data come from the Ipsos KnowledgePanel®, an online panel that is representative of the adult U.S. population. KnowledgePanel® employs an address-based sampling methodology, which provides a statistically valid sampling method using a published sample frame of residential addresses that covers approximately 97% of U.S. households. Ipsos includes a measure of sexual orientation identity (“Do you consider yourself to be: (1) heterosexual or straight, (2) gay/lesbian, (3) bisexual, (4) other?”) in their demographics packet, enabling researchers to recruit a sample of gay and bisexual men obtained from a larger sample with a known probability of selection. One thousand and fifty-eight respondents in the KnowledgePanel® identified as gay and bisexual men. In order to obtain our targeted sample size of 500, all 1,058 respondents (age 18+, English- and/or Spanish language speakers) were invited to participate, yielding a final sample size of 502 gay and bisexual men who were invited to become part of the National Study of Stigma and Sexual Health, a 2-year longitudinal study focused on stigma and HIV risk. The inclusion criteria for the parent study were: age 18+, identify as a gay or bisexual male, and English- or Spanish-speaking. There were no exclusion criteria. Participants who were enrolled in the study completed a 30-minute survey and behavioral assessments every 6 months.

At baseline (Wave 1), 502 gay and bisexual men were enrolled; we retained 85.3% (N = 428) at 6 months (Wave 2) and 83.1% (N = 417) at 1-year follow-up (Wave 3). Loss-to-follow-up at Wave 3 was not statistically associated either with depressive symptoms at baseline or with the mediators (assessed at Wave 2) or moderators (assessed at baseline). Of the primary demographic characteristics tested (i.e., age, race/ethnicity, household income, education, or urbanicity), only younger age was associated with attrition (p=0.02). Participants in the analytic sample (Table 1) were, on average, 53.37 years of age (SD = 14.79); a majority had completed a bachelor’s degree or higher (53.6%), were currently employed (63.4%), and were white (76.5%). The study received Institutional Review Board approval from Harvard University.

Table 1.

Descriptive Statistics of Demographic Characteristics and Primary Variables

Variable N (%) or Mean (SD) Range
Age, Mean (SD) 53.37 (14.79) 18–91
Gender Identity, N (%)
 Cisgender 485 (96.6)
 Transgender 6 (1.2)
 Non-Binary 3 (0.6)
 Other 6 (1.2)
 Refused or Missing 2 (0.4)
Sexual Orientation, N (%)
 Gay 371 (73.9)
 Bisexual 131 (26.1)
Race/Ethnicity, N (%)
 American Indian or Alaska Native 3 (0.6)
 Asian 8 (1.6)
 Black or African American 33 (6.6)
 Native Hawaiian or other Pacific Islander 1 (0.2)
 White 384 (76.5)
 Hispanic / Latino 59 (11.8)
 Other 10 (2.0)
 Don’t Know 3 (0.6)
 Refused 1 (0.2)
Metropolitan Statistical Area, N (%)
 Metro 457 (90.9)
 Non-metro 45 (9.1)
Education, N (%)
 Less than high school 10 (2.0)
 High school 49 (9.8)
 Some college 174 (34.7)
 Bachelor’s degree or higher 269 (53.6)
Distal Minority Stress Experiences – Wave 1 (N=502)
 Interpersonal Discrimination 1.20 (0.44) 1.00 – 4.75
Universal Psychosocial Mechanisms – Wave 2 (N=428)
 Rumination 1.87 (00.74) 1.00 – 4.00
 Lack of Emotional Clarity 1.73 (0.83) 1.00 – 5.00
 Lack of Social Support 1.96 (0.82) 1.00 – 4.00
Moderators – Wave 1 (N=502)
 Identity Centrality 2.52 (0.93) 1.00 – 4.00
 Stigma Consciousness 2.51 (0.50) 1.30 – 3.80
Dependent Variable – Wave 3 (N=417)
 Depressive Symptoms 8.13 (6.69) 0.00 – 28.0
Covariate – Wave 1 (N=502)
 Depressive Symptoms 7.74 (6.35) 0.00 – 29.00
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Measures

To reduce participant burden while maximizing coverage of constructs relevant to the parent study, validated subscales were used when possible.

Interpersonal discrimination.

Distal minority stress experiences were assessed via interpersonal discrimination directed toward one’s sexual orientation (e.g., “During the last 6 months, about how often did you experience discrimination in public, like on the street, or in stores or in restaurants, because you were assumed to be gay or bisexual?”). These 4 items (α = 0.80) were obtained from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative survey of U.S. adults (Ruan et al., 2008), and were used in prior work to assess associations between sexual orientation-based discrimination and mental health (e.g., McLaughlin et al., 2010).

Mechanisms.

We examined the three classes of cognitive, affective, and social mechanisms featured in the psychological mediation framework (Hatzenbuehler, 2009). Rumination was measured with the brooding subscale (α = 0.88) of the Response Styles Questionnaire (Treynor et al., 2003), which has been used in prior research on the framework (e.g., Hatzenbuehler et al., 2009; Timmins et al., 2020). Lack of emotional clarity was measured with the emotional clarity subscale (α = 0.80) of the Difficulties in Emotion Regulation Scale-Short Form (Kaufman et al., 2016). Lack of social support was measured with the appraisal subscale (α = 0.82) of the Interpersonal Support Evaluation List-12 (Cohen et al., 1985).

Moderators.

We examined three identity-related moderators. Identity centrality was measured with the identity centrality subscale (α = .90) of the Lesbian, Gay, and Bisexual Identity Scale (Mohr & Kendra, 2011). Stigma consciousness (α = .72) was measured with the Stigma Consciousness scale, adapted for sexual orientation (Pinel, 1999). Sexual orientation identity was a dichotomous variable comparing gay versus bisexual men.

Dependent variable.

Participants completed the Center for Epidemiologic Studies Depression Scale-10, a reliable and valid measure of depressive symptoms (Andresen et al., 1994). We computed sum score of depressive symptoms at Wave 1 (α = 0.85) and Wave 3 (α = 0.86).

Covariates.

We considered several covariates, including neuroticism, relationship status, age, education, urbanicity, and ethnic minority status. Only age and education were significantly associated with both our independent (i.e., interpersonal discrimination) and dependent (i.e., depressive symptoms) variables. Thus, we controlled for age and education as predictors of Wave 1 interpersonal discrimination and of Wave 3 depressive symptoms. Further, Wave 1 depressive symptoms were associated with Wave 2 mediators and with Wave 3 depressive symptoms. As a result, to examine changes in depressive symptoms over time and to account for potential confounding of the mediation process by Wave 1 depressive symptoms, we also controlled for Wave 1 depressive symptoms as a predictor of Wave 2 mediators and of Wave 3 depressive symptoms.

Analytic Strategy

Correlations were first calculated to investigate associations among study variables (Table 2). We then examined our two research questions related to the psychological mediation framework (Hatzenbuehler, 2009), depicted in Figure 1. The first evaluated whether the prospective association between interpersonal discrimination and depressive symptoms was mediated by the cognitive (i.e., rumination), affective (i.e., lack of emotional clarity), and social (i.e., lack of social support) mechanisms. The second examined whether these mediating pathways were moderated by the three identity-related characteristics (i.e., identity centrality, stigma consciousness, and sexual orientation identity). All variables were modeled continuously. Indirect effects were estimated using bootstrapping resampling procedures (Efron & Tibshirani, 1986); indirect effects with confidence intervals that did not include 0 were considered statistically significant (MacKinnon et al., 2008). There was minimal missing data on study variables (i.e., less than 1%); therefore, full information maximum likelihood (FIML) estimation was used to address missing data. Statistical analyses were conducted using Mplus 8. The analytic code is provided in the online supplement.

Table 2.

Bivariate correlations among study variables

1 2 3 4 5 6 7 8 9
1 Interpersonal Discrimination -
2 Rumination .20** -
3 Lack of Emotional Clarity .22** .51** -
4 Lack of Social Support .17** .30** .38** -
5 Identity Centrality .18** .02 -.09 −.09 -
6 Stigma Consciousness .25** .16** .07 .10* .16* -
7 Sexual Orientation −.10* .06 .07 .14** −.20** −.17** -
8 Wave 3 Depressive symptoms .26** .56** .50** .40** −.01 .24** .10* -
9 Wave 1 Depressive symptoms .20** .54** .46** .38** .05 .28** .04 .76 -
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Sexual orientation: gay/homosexual = 0; bisexual = 1.

*

p < .05.

**

p < .01.

Results

Interpersonal discrimination was prospectively associated with depressive symptoms at Wave 3, controlling for initial depressive symptoms, age, and education (b=1.95, 95% CI [.50, 2.95]; Figure 2A). Rumination (b=0.38, 95% CI [0.13, 0.84]), lack of emotional clarity (b=0.43, 95% CI [0.11, 0.83]), and lack of social support (b=0.21, 95% CI [0.04, 0.45]) each individually mediated the prospective relationship between interpersonal discrimination and depressive symptoms (Figures 2B-D), controlling for initial symptoms, age, and education. In a multiple mediation model, rumination (b=0.29, 95% CI [0.07, 0.67]) and lack of emotional clarity (b=0.28, 95% CI [0.02, 0.61]), but not lack of social support (b=0.14, 95% CI [−0.01, 0.34]), independently mediated the prospective relationship between interpersonal discrimination and Wave 3 depressive symptoms, controlling for initial symptoms, age, and education (Figure 2E).

The relationships between interpersonal discrimination and Wave 3 depressive symptoms, and between interpersonal discrimination and the three psychosocial mechanisms, were not moderated by identity centrality, stigma consciousness, or sexual orientation (each p >.05), indicating that mediating pathways are not moderated by the three proposed identity-related characteristics.

Discussion

Following the publication of Meyer’s (2003) influential minority stress theory, the field required a greater understanding of the mechanisms through which minority stressors affect mental health among sexual minority populations. Hatzenbuehler’s (2009) psychological mediation framework posited several cognitive, affective, and social mechanisms through which minority stressors were likely to contribute to psychopathology. While several previous studies have supported specific aspects of the psychological mediation framework, most have used cross-sectional designs (e.g., Timmins et al., 2020), have focused on a small subset of mediators and moderators (e.g., Sarno et al., 2020), and have relied on non-probability samples. We recruited a longitudinal sample of gay and bisexual men obtained from a probability-based dataset of U.S. adults, which enabled us to address these gaps in the literature. Our sample was assessed with validated measures of interpersonal discrimination, universal psychosocial mechanisms, identity-related moderators, and depressive symptoms at baseline, six month follow-up, and 1 year follow-up.

Rumination, lack of emotional clarity, and lack of social support all mediated the prospective relationship between interpersonal discrimination and depressive symptoms, controlling for depressive symptoms at Wave 1, age, and education. These findings replicate and extend prior work on the psychological mediation framework (e.g., Hatzenbuehler et al., 2009; Sarno et al., 2020; Timmins et al., 2020) by including a wider range of mediation processes in a longitudinal sample obtained from a population-based dataset. In the model examining all three hypothesized mediators simultaneously, rumination and emotional clarity, but not social support, were significant mediators, providing preliminary evidence that cognitive and affective processes, rather than social processes, might serve as the most robust pathways through which interpersonal discrimination leads to depression. Further, although Hatzenbuehler (2009; Figure 2) originally called for research to identify whether identity-related characteristics moderated the mediation effects proposed in the psychological mediation framework, we are unaware of systematic attempts to do so. We observed that the indirect effect of interpersonal discrimination on depressive symptoms via rumination, lack of emotional clarity, and lack of social support was not moderated by identity centrality, stigma consciousness, or sexual orientation identity. These findings indicate that the framework operates similarly across gay and bisexual men who identify more and less strongly with their sexual orientation identity and who have differing expectations regarding the likelihood that they will be stereotyped by others (i.e., stigma consciousness), underscoring the potentially wide applicability of the model. Nevertheless, future research should examine additional moderators proposed in the framework that were not tested herein (e.g., sex/gender, developmental influences).

There are important etiologic as well as practical implications of these findings. With respect to etiology, the identification of mechanisms through which minority stressors affect psychopathology is an essential step towards uncovering causal relations between stigma and mental health. Practically, the identification of mechanisms suggests potential targets for interventions aimed at reducing the negative mental health sequelae of minority stress. A recent LGBQ-affirmative cognitive behavioral therapy intervention was designed by Pachankis and colleagues (2015; 2022) to reduce the mental health impact of minority stress by targeting the universal psychological mediation processes put forward by Hatzenbuehler’s framework (2009). Our study provides further support for this intervention approach of targeting cognitive, affective, and social sequelae of distal minority stress processes among sexual minority men. Further, the fact that the mediation processes examined herein were not moderated by several identity-related processes and characteristics suggests that interventions based on the psychological mediation framework may not need to be tailored along these dimensions.

We note several study limitations. First, because the parent study from which this cohort was created was focused on stigma and HIV risk, our analytic sample was comprised of gay and bisexual men. Sex/gender may moderate many of the processes that we examined. As such, it will be important to examine whether our findings generalize to sexual minorities across all genders. Second, our sample of gay and bisexual men is drawn from a larger panel that is nationally representative, which minimizes selection biases that can occur in non-probability samples of sexual minority individuals (Salway et al., 2019). However, in order to obtain our targeted sample size of 500 participants, we had to recruit all gay and bisexual men from the larger panel, and thus were unable to randomly select our sample. As such, our results may not generalize to the full population of gay and bisexual men. Third, our study focused on distal minority stress (i.e., interpersonal discrimination); future research should examine how both distal and proximal (i.e., concealment, rejection sensitivity, and internalized stigma) minority stressors interrelate with the universal psychological processes as outlined in the integrated psychological mediation framework (Figure 2; Hatzenbuehler, 2009). Fourth, although the scale of depressive symptoms has sound psychometric properties (Andresen et al., 1994), future studies should validate these findings with clinician-administered diagnostic interviews. Finally, the universal psychosocial mediators were first assessed in Wave 2. Although this permitted testing the temporal ordering of variables in our model, we were unable to control for effects of mediators at baseline. It is unlikely that these variables would change appreciably over this 6-month period, but future studies should include measures of psychosocial mediators across multiple assessment periods in order to more robustly test mediation.

Gay and bisexual men represent one of the highest-risk groups for depression (e.g., Cochran et al., 2017). Thus, the identification of mediating mechanisms underlying this elevated risk represents an important public health priority. Our study significantly contributes to this effort through a theory-driven examination of stigma, psychosocial mechanisms, and depressive symptoms among a longitudinal cohort of gay and bisexual men obtained from a probability-based sample. Our results can help guide the selection of optimal treatment targets in psychological interventions aiming to reduce the negative mental health consequences of distal minority stress in this population (e.g., Pachankis et al., 2015; in press).

Supplementary Material

Supplemental Material

Public Health Significance Statement.

Gay and bisexual men are one of the highest-risk groups for depression; thus, the identification of mechanisms that contribute to this population disparity represents an important public health priority. We recruited a sample of gay and bisexual men obtained from a population-based dataset of U.S. adults in order to better understand the psychosocial mechanisms through which interpersonal discrimination contributes to depressive symptoms. In documenting a variety of cognitive, emotional, and social mechanisms linking interpersonal discrimination and depressive symptoms among sexual minority men, our results can help guide the selection of optimal treatment targets in psychological interventions aiming to reduce the negative mental health consequences of minority stress in this population.

Acknowledgments

This work was supported by the National Institute of Mental Health (R01MH112384).

Footnotes

Data Transparency Statement

We have published three papers from the National Study of Stigma and Sexual Health dataset, none of which are focused on the topics covered in this manuscript.

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