Journal of Gay & Lesbian Mental Health

ISSN: 1935-9705 (Print) 1935-9713 (Online) Journal homepage: http://www.tandfonline.com/loi/wglm20

Multiple Minorities as Multiply Marginalized:

Applying the Minority Stress Theory to LGBTQ
People of Color

Kali Cyrus MD, MPH

To cite this article: Kali Cyrus MD, MPH (2017): Multiple Minorities as Multiply Marginalized:
Applying the Minority Stress Theory to LGBTQ People of Color, Journal of Gay & Lesbian Mental
Health, DOI: 10.1080/19359705.2017.1320739

To link to this article: http://dx.doi.org/10.1080/19359705.2017.1320739

Accepted author version posted online: 20

Apr 2017.

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REVIEW ARTICLE

Multiple Minorities as Multiply Marginalized: Applying the Minority Stress Theory to

LGBTQ People of Color

Kali Cyrus, MD, MPH

Received 15 March 2017

Revised 7 April 2017

Accepted 12 April 2017

CONTACT Kali Cyrus, MD, MPH kali.cyrus@yale.edu

Abstract

The evidence is now overwhelming that discrimination negatively impacts both the physical and

mental health of minority groups. Members of multiple-minority groups, such as lesbian, gay,

bisexual, transgender, queer people of color (LGBTQ-POC), are more likely to be exposed to

experiences of stigmatization, discrimination, and fear of rejection. However, whether the stress

of having these unfavorable experiences translates into increased risk for negative health

outcomes is unanswered by the literature. Research to date attempts to address the relationship of

stress as a minority and health outcomes through examining the role of microaggressions,

exploring the concepts of risk and resilience, and most notably the creation of the minority stress

model. The model analyzes the complex relationship between external (discrimination/prejudice)

and internal (self-doubt/rumination) stressors that shape the experience of multiple-minority

groups, which helps us understand the lived experiences of LGBTQ-POC. LGBTQ-POC are

adversely affected by cumulative discrimination and social exclusion including racism from

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LGBTQ community, and homophobia and heterosexism within in their racial/ethnic community.

In this way they are a multiply marginalized group, which has implications not only for their risk

of mental illness, but also to their access to mental health care, and the quality of care they

receive. Using the minority stress model as a frame of reference, we will discuss current

approaches to capturing the toll that stress as an LGBTQ-POC has on mental health

consequences.

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Multiple Minorities as Multiply Marginalized: Applying the Minority Stress Theory to

LGBTQ People of Color

There is a substantial body of literature noting the higher prevalence of depression, anxiety,

substance use disorders, and even suicide amongst lesbian, gay, bisexual, transgender, and queer

(LGBTQ), particularly among youth (Haas et al., 2011). Less, although growing, is research

about LGBTQ individuals from racial/ethnic backgrounds and unique challenges faced due to the

intersection of gender, sexual orientation, and race/ethnicity. One imagines that living as a

member of multiple marginalized groups within a society creates a dynamic and likely stressful

emotional experience fueled by the systemic interaction of oppression, domination, and

discrimination within a society. However the literature to date is equivocal about the additive

stress due to membership of multiple minority groups, which raises many questions related to

possible protective mechanisms at play. What follows is a review of the pertinent findings in this

area to date and future directions.

Defining ―Minority Stress‖

In order to fully deconstruct the stress of living as an individual who is a member of multiple

marginalized minority groups, it is best to outline definitions of key terms.

General definitions per Oxford Dictionaries:

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Minority: A small group of people within a community or country, differing from the

main population in race, religion, language, or political persuasion (―Minority,‖ 2017).

Marginalize: Treat (a person, group, or concept) as insignificant or peripheral

(―Marginalize,‖ 2017).

Intersectionality: The interconnected nature of social categorizations such as race, class,

and gender as they apply to a given individual or group, regarded as creating overlapping

and interdependent systems of discrimination or disadvantage (―Intersectionality,‖ 2017).

Stress: A state of mental or emotional strain or tension resulting from adverse or

demanding circumstances (―Stress,‖ 2017).

A more specific definition of minority stress is provided by Meyer’s seminal article in 2003:

Minority stress: that stigma, prejudice, and discrimination create a hostile and stressful

social environment that causes mental health problems (Meyer, 2003, p.1).

It is evident from these basic definitions (taken individually or together) that the subject of this

discussion, the multiple minority, represents not only a distinct, but also complicated position

within a society. While these definitions convey a negative impression of regarding the

interaction of stress, intersectionality, and minority status, there is a more comprehensive

approach to viewing their relationship. Meyer’s work in 2003 attempts to capture how having

intersectional, minority, identities relates to experiences of stress and downstream consequences.

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This article posits a model that depicts stress, coping, and their influence on mental health

outcomes. The model captures the impact of multiple general environmental factors, such as

socioeconomic status, and an individual’s minority status such as sexual orientation. These

factors influence access to resources and effective coping mechanisms (Diaz, Ayala, Bein, Jenne,

& Marin, 2001). In addition to general stressors like losing a job, minority individuals are

subjected to special stressors like discrimination in employment or antigay violence. These

experiences are likely to lead to hypervigilance, personal identification with minority status, or

worse such as negative self-perceptions like internalized homophobia. Notably, the minority

identity could also be a source of strength if it associated with opportunities for support that can

offset the impact of stress. (Branscombe, Schmitt, & Harvey 1999; Crocker & Major,

1989; Miller & Major, 2000)

Intuitively, it seems logical that in addition to being a sexual or gender minority, having a

minority racial/ethnic background would lead to worse health outcomes as the stress of being a

minority in multiple identity groups would accumulate. In fact, there are many studies

confirming this, including one that showed that there are higher levels of inflammatory

biomarkers linked to chronic conditions including hypertension or cancer, for African Americans

or individuals with higher amounts of perceived discrimination (Stepanikova, Bateman, & Oates,

2017). Additionally, Krieger et al. (2008) describe the impact of accumulating health hazards

which varies with the power of the population affected. Through online surveys, within their

cohort they found that Black and Latino populations under the poverty line are likely to be

exposed to occupational hazards (i.e. dust, fumes) and social hazards (i.e. racial discrimination,

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workplace abuse) (Krieger et al., 2008). These authors found that exposure to the social hazard

of sexual harassment was linked to elevated systolic blood pressure (SBP), and that elevated SBP

was also linked to response to unfair treatment. However the limitations of Krieger et al.’s

(2008) work is notable for a smaller than expected sample size, the difficulty in isolating the

effect of exposure to a hazard to blood pressure from physiological mechanisms, and notably that

sexual harassment was highest amongst White women, a group expected to have less exposure to

racial discrimination).

Lastly, recent work by Merieish & Bradford (2014) is notable given their focus on

intersectionality when collecting data from surveys administered to over 3000 individuals in the

waiting room of a clinic serving gender and sexual minorities. After examining differences

between a heterosexual and homosexual sample and within sexual minority groups of a racially

diverse sample, they found that sexual minority women of color have higher substance abuse

rates than heterosexual women of color or White sexual minorities (Merieish & Bradford, 2014).

However, this work is limited by the convenience of the sample which may lead to difficulty

generalizing to other populations, and the endorsement of substance abuse was defined in

dichotomous terms in a cross sectional nature (Merieish & Bradford, 2014). Despite the findings

of these studies, the literature does not consistently show a higher prevalence of mental health

disorders or generally worse health outcomes among those with intersecting minority identities,

like LGBTQ-POC. This contradiction of findings suggests there are other factors at play, or more

interestingly, the existence of a protective mechanism from psychological stress as a member of

multiple marginalized minority groups.

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Risk and Resilience

As described above, there appears to be contradictory dynamics exerting an influence in how

stress affects individuals who are sexual, racial, and gender minorities. Within the literature these

competing theories have been framed in a discussion of risk versus resilience. The risk

hypothesis states that LGBTQ-POC are exposed to excess stress through homophobia, racism,

and at times transphobia—which can be referred to as the double (or triple) jeopardy hypothesis

(Meyer, 2010). On the other hand, the resilience hypothesis states that because of experiences

with racism prior to coming out, Black LGBTQ individuals are protected against the effects of

stress related to homophobia and may have greater capacity to cope with the minority stress they

experience than do LGBTQ Whites (Meyer, 2010).

Delving into an examination of resilience, it is first worth mentioning that it is a concept that

cannot be directly observed but inferred by one’s adaptive functioning when exposed to risk and

its mechanism of operation varies in terms of timing and effect (Meyer, 2010). For example,

resilient individuals who feel a sense of competency may perceive less stress in certain

situations. Thus resilience may influence the appraisal of stress before a stressful event is even

encountered thereby allowing for a protective effect prior to exposure to the stressor (Lazarus &

Folkman, 1984). Resilience might also provide greater strengths or coping mechanisms to deal

with stress (Dohrenwend, 1998). Lastly, resilience may directly impact health outcomes through

having supportive social networks despite stress exposure (Balsam et al., 2015; Berkman &

Syme, 1979).

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The idea of resilience seems quite appealing when compared to the minority stress theory given

the consistent findings that LGBTQ-POC do not have higher rates of mental health disorders.

However, as Meyer (2010) points out, the resilience theory presupposes that LGBTQ-POC have

more resources than White counterparts to cope with stress which is generally not the case for

disadvantaged groups in the U.S., whereas the stress theory posits that not only do minority

populations have greater stress but less access to resources which is likely accurate for our

population group of interest. This conflict remains a key theme within this discussion which has

not been firmly settled. Schwartz & Meyer (2010) attempt to broach this gap by pointing out

methodological differences in studying these hypotheses, namely the use of between-group

versus within-group studies for interpreting results of social stress studies. Between-groups

research explores mental health prevalence by comparing LGBTQ individuals and their

heterosexual counterparts and within-groups work explores mental health outcomes of LGBTQ-

POC who are exposed to more prejudice (and stress) versus that of non LGBTQ-POC. Meyer

(2010) critiques the fact that these studies are typically carried out separately, rather than a

combined methodology. Therefore separate, rather than total, effect processes are investigated

and do not present the entire story. Thus, this field stands to gain significantly from the

emergence of creative investigative designs, including work focused on the intersectionality of

identities, which provides a promising avenue for future research directions (McCall, 2005).

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Migroaggressions and LGBTQ-POC

A more recent and interesting contribution to the literature has been the discussion of the role of

microaggressions in mediating psychological distress. Sue et al. (2007) define microaggressions

as brief, daily assaults on minority individuals, which can be social or environmental, verbal or

nonverbal, as well as intentional or unintentional. These authors note that perpetrators of

microaggressions are often unaware they engage in such communications when interacting with

minority individuals. Descriptions of microaggressions within the research have also been

reportedly linked to psychological distress, depression, and health related behaviors (Smith,

Allen, & Danley, 2007; Torres, 2009; Constantine, 2007).

The three main forms of microaggressions coined by Sue et al. (2007) are microassaults,

microinsults, and microinvalidations. Microassaults are overt verbal or nonverbal insults and

behaviors, for example saying the phrase ―that’s so gay‖ to refer to something bad or weird

(Nadal, 2013). Microinsults can be stereotypic statements or actions that may slight or demean a

person’s marginalized identity, such as making a joke that a gay man couldn’t possibly like

sports or a that a woman is ―too pretty to be a lesbian (Nadal, 2013).‖ Lastly, microinvalidations

include moments when LGBTQ people are told that their perceptions of discrimination are

unfounded and their realities of heterosexism or transphobia are refuted in their lives (Nadal,

2013; Sue et al., 2007). Through a series of qualitative explorations, Nadal et al. (2010, 2011)

outlined eight themes of microaggressions associated with LGBTQ individuals as presented in

Table I below.

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With the goal of elucidating the role of intersectional identities on microaggressions, Nadal et al.

(2015) expanded their work to include the role of religion, ethnicity, race, sexuality, and gender.

Using unique qualitative approaches of Qualitative Secondary Analysis (QSA), and Consensual

Qualitative Research (CQR) they analyzed data from over 19 diverse focus groups (of varying

races, sexual orientations, gender identities, and religions) with a total of eighty participants

(Nadal et al., 2015). Through QSA methods, data is reanalyzed to explore an old question from a

new perspective and CQR requires researchers to independently and collaboratively analyze raw

data for similar answers amongst participants (Nadal et al., 2015). While this study is not

primarily aimed at LGBTQ-POC individuals, it highlights the importance of studying individuals

in a holistic manner, rather than based on separate identity categories. Additionally, LGBTQ-

POC may also present with a combination of these identities, which could influence their

exposure to stress, ability to cope, and mental health outcomes. Major themes and subthemes

from this work are presented in Table II below (Nadal et al. 2015).

With theories of minority stress, resilience, and microaggressions as a backdrop, Balsam and

colleagues (2011) created the LGBTQ-POC Microaggressions Scale to further explore the

unique challenges faced by this population, examine associated psychosocial and health

consequences, and serve as a tool for designing interventions. Using a series of three mixed

methods studies, Balsam et al. (2011) developed, validated, and administered a tool to capture

the types, frequency, and perceived stress of microaggressions experienced by LGBTQ-POC

with demographic trends. Using the results of focus groups and in depth interviews to develop

the scale, it was administered online to 900 individuals, then finalized after its last administration

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on the web to more than 1200 participants (Balsam et al., 2011). The 18-item self-report

questionnaire features three subscales that were consistent with research on microaggressions:

racism within LGBT communities, heterosexism within racial/ethnic communities, and

racial/ethnic discrimination in dating and close relationships. The results suggested that LGBTQ-

POC microaggressions may be linked to depression and that heterosexism in racial/ethnic

minority communities may be particularly harmful to the mental health of LGBTQ-POC. The

results also showed that racism, especially from loved ones, were associated with depression and

increased rates of perceived stress. Other findings were that LGBTQ Asian American

participants reported significantly more microaggressive experiences and distress and that

LGBTQ men of color reported significantly more microaggressive experiences/distress

compared to LGBTQ women of color. Lastly, overall, lesbians and gay men reported higher

experiences of LGBTQ racism and LGBTQ relationship racism compared to their bisexual male

and female counterparts. While Balsam et al.’s (2011) work creatively captures a mode of

measurement for microaggressions experienced within a multiply marginalized group, it has its

limitations. Although the sample size is robust, it insufficiently examined differences within

some racial/ethnic groups, does not determine the extent to which the sample represents

LGBTQ-POC in general, and does not identify how an individuals’ psychological distress

influences perceptions of microaggressions committed against them (Balsam et al., 2011).

Discussion

There is mounting evidence confirming that living as an LGBTQ-POC within society leads to

complicated ways of socializing with the world. What is unclear, however, is the extent to which

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the membership in multiple minority groups leads to worse physical or mental health outcomes.

Theoretical frameworks which attempt to explain the downstream health effects of living as an

LGBTQ-POC include the minority stress theory, risk and resilience, and examining

microaggressions. However, these concepts do not capture the complete story of how being the

―other‖ in multiple contexts relates to resiliency. Given that each approach seems intuitively

valid in its assertions, it is worth considering how the main tenets of each are interrelated. The

LGBTQ-POC itself is a small subset of the general population with remarkable diversity within

the group, thus the likelihood of discovering a ―one-size fits all‖ explanation to how stress is

perceived, interpreted, and affects mental health outcomes is no easy feat. Combining multiple

approaches and methods of investigation will be key to making sense of the complexity of the

LGBTQ-POC subjective experience. Uncoupling identities and exploring ways in which

intersectionality of not only gender, sexual orientation, race, but other identities like disability

status would provide greater insight into the heterogeneity that exists within each of these

groups. For example, while the literature has covered ground exploring differences between

Black and Caucasian lesbians, what about exploring how the dynamic changes if the Black

woman was a Nigerian, Catholic, immigrant? Nadal et al. (2016) discuss the benefit of exploring

these ―what if’s‖ such as highlighting nuances too subtle to be captured by large population

studies. Investigating these complexities will likely require more nuanced approaches to

gathering information (i.e. mixed methods approaches such as combining epidemiological

studies with an ethnographic or grounded theory component). Additionally, there may be value

in exploring atypical settings (i.e. classroom settings, adolescents, places of worship) or multi-

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disciplinary collaboration (i.e. psychotherapists, teachers, pastors) who not only provide a very

different lens to viewing these issues but can intervene at various stages.

In the current sociopolitical context in which difference appears to be highlighted more than

ever, uncovering how this vulnerable population experiences the world as a minority is key to

designing interventions. Additionally, considering how the multiply marginalized achieve

―success‖ could add more depth and understanding to these issues. For example, exploring the

variations of resilience would help frame the concept of minority stress in encouraging terms

rather than that of a ―struggle.‖ It is clear that navigating society as an ―other‖ in various contexts

is extremely complex thus solely focusing on the difficulties, including microaggressions, leads

to an accidental neglect of dynamics that could explain the contradictory findings of insignificant

changes in mental health prevalence amongst LGBTQ-POC when faced with the increased stress

of discrimination.

Even though the field has made strides in highlighting the difficulties of living as a LGBTQ-

POC, there is more work to be done. The fact that there is a growing body of research to better

understand how to improve the experience of the marginalized is exciting, however as the

population expands and diversifies creative methods of investigation must continue to evolve as

well.

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Table 1

Major Theme Example of Microaggression

Use of heterosexist or transphobic Saying ―No homo!‖

terminology

Endorsement of heteronormative or gender- Expecting individuals to dress according to

conforming culture/behaviors traditional gender norms.

Assuming a universal LGBTQ experience Stereotyping all gay men as promiscuous.

Exoticization Assuming a bisexual person is interested in

having sex with a heterosexual couple.

Discomfort of the LGBTQ experience Telling an LGBTQ person that they are

―going to hell.‖

Denial of reality of Responding to an LGBTQ person

heterosexism/transphobia expressing experience of microaggression

with a reply like ―You’re being too

sensitive.‖

Assumption of sexual Assuming LGBTQ individuals are sexual

pathology/abnormality predators or have HIV (human immune-

deficiency virus).

Denial of individual Becoming defensive when a gay man

heterosexism/transphobia challenges you about heterosexist behavior.

Nadal, Rivera, and Corpus’ (2010) eight themes of microaggressions experienced by LGBTQ

individuals.

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Table 2

Major Theme Examples of Microaggression

Exoticization of Women of Color (a) Women of color as sexual objects, (b)

Biased compliments on appearance, (c)

Asian women as ―damsels in distress,‖ and

(d) Exclusion or isolation of multiracial

women

Gender-Based Stereotypes for Lesbians and (a) Assumption of All Gay Men as

Gay Men Feminine and (b) Assumption of All

Lesbian Women as Masculine.

Disapproval of LGBT Identity by Racial, E.g.: an LGBTQ-POC influenced by values

Ethnic, and Religious Groups of machismo in Latino culture and

religious values (Catholic, Christian) in

Latino culture

Assumption of Inferior Status for Women E.g.: a Filipina participant shared how

of Color Filipino women are often perceived as

nannies in real life or the media.

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Invisibility and Desexualization of Asian E.g.: How often does the Asian man win

American Men the girl in media depictions?

Assumption of Inferiority or Criminality of E.g.: Assuming that African American men

Men of Color can only be successful through athletics or

music.

Gender-Specific Expectations for Muslim E.g.: Presuming that Muslim women

Women and Men wearing a hijab are doing so out of

obligation rather than choice.

Women of Color as Spokesperson E.g.: Being asked by non POC to determine

whether something is offensive.

Themes of intersectional microaggressions identified by Nadal et al. (2015) through qualitative

analysis focus groups.

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