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Stigma Health. Author manuscript; available in PMC 2021 November 01.
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Published in final edited form as:

Stigma Health. 2020 November ; 5(4): 488–491. doi:10.1037/sah0000210.

Visible and Concealable Stigmatized Identities and Mental

Health: Experiences of Racial Discrimination and Anticipated
Stigma
Diane M. Quinn1, Gabriel Camacho1, Bradley Pan-Weisz2, Michelle K. Williams1
1Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut
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2Department of Psychology, California State University, Long Beach, Long Beach, CA

Abstract
Experiencing and anticipating discrimination because one possesses a visible (e.g., race) or
concealable (e.g., mental illness) stigmatized identity has been related to increased psychological
distress. Little research, however, has examined whether experiencing and anticipating
discrimination related to possessing both a visible and concealable stigmatized identity (e.g., a
racial/ethnic minority with a history of mental illness) impacts mental health. In the current study,
we test two hypotheses. In the first, we examine whether experienced discrimination due to a
visible stigma (race/ethnicity) and anticipating stigma due to a concealable stigma (e.g., substance
abuse) each predict unique variance in depressive symptomatology. In the second, we examine
whether experienced discrimination due to a visible stigma is related to greater anticipated stigma
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for a concealable stigma, which in turn is related to more depression. A total of 265 African
American and Latinx adults who reported concealing a stigmatized identity at least some of the
time completed measures of racial/ethnic discrimination, anticipated stigma of a concealable
stigmatized identity, and depressive symptomatology. Results of a simultaneous linear regression
revealed that increased racial/ethnic discrimination and anticipated stigma independently predicted
greater depressive symptomatology (controlling for each other). A mediation analysis showed that
the positive association between increased racial/ethnic discrimination and higher depressive
symptomatology was partially mediated by greater anticipated stigma. These results demonstrate
that a person can experience increased psychological distress from multiple types of stigma
separately, but also may anticipate greater stigma based on previous experiences of racial
discrimination, which in turn relates to increased distress.
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Keywords
Visible Stigma; Concealable Stigma; Anticipated Stigma; Discrimination; Depression

Experiences of racial and ethnic discrimination are related to increased psychological and
physical distress (Pascoe & Smart Richman, 2009; Schmitt, Branscombe, Postmes, &
Garcia, 2014). Likewise, research on people with concealable stigmatized identities (CSIs) –

Correspondence Information: Diane M. Quinn, Department of Psychological Sciences, University of Connecticut, 406 Babbidge
Rd, U-1020, Storrs, CT, 06269-1020. Telephone: (860) 486-4936. diane.quinn@uconn.edu.
 Quinn et al. Page 2

identities that are not immediately apparent such as mental illness or substance abuse – has
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shown that greater anticipation of stigma if the identity were to be revealed is related to
reports of greater psychological and physical distress (Ikizer, Ramírez-Esparza & Quinn,
2017; Quinn & Chaudoir, 2009). However, people possess multiple identities, and some may
be visible while others are concealable. There are increasing calls within psychology to
address how multiple identities impact each other (Bowleg, 2008; Else-Quest & Hyde, 2016;
Rosenthal, 2016) to shape people’s health outcomes (Hatzenbuehler, Phelan, & Link, 2013).
Yet, research rarely brings together experiences of both visible (e.g., race) and concealable
(e.g., mental illness) stigmatized identities.

In the current work, we examined experiences of stigma in a sample of American adults who
are racial/ethnic minorities (African American or Latinx) and who reported concealing a
stigmatized identity at least some of the time. Thus, everyone in the sample possessed both a
visible and concealable stigmatized identity. We measured people’s experiences of racial/
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ethnic discrimination, their level of anticipated stigma about their CSI, and their depressive
symptomatology as a measure of mental health.

The current work was guided by two hypotheses. First, supporting work on the additive
effects of possessing multiple disadvantaged statuses (e.g., Grollman, 2014), we predicted
that both experienced racial/ethnic discrimination and anticipated CSI stigma would predict
unique variance in depression. That is, more experiences of racial/ethnic discrimination and
more anticipated stigma would each predict higher levels of depressive symptomatology,
controlling for the other. Second, we hypothesized that greater experiences of racial/ethnic
discrimination would be related to more anticipated CSI stigma, which in turn would predict
more depression. Our rationale is that experiencing discrimination of any kind will lead
people to be more alert and concerned for future discrimination. This theorizing is in line
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with research examining how experiences of racial discrimination lead people to expect
more racial discrimination in the future (e.g., Mendoza-Denton et al., 2002). This prediction
is tested in a mediation model with experienced racial/ethnic discrimination predicting
greater anticipated stigma which, in turn, predicts depression. In sum, we hypothesize that
experiences of racial/ethnic discrimination may be directly related to increased depression,
but they may also be related to increased depression indirectly through the greater
anticipation of CSI stigma. Note that these hypotheses are complementary and strive to
illuminate a more complex picture of the lived experience of people with multiple
stigmatized identities: A person can experience greater psychological distress from multiple
types of stigma separately, but also can anticipate greater stigma based on previous
experiences of discrimination with a different identity.
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Sample and Method.

Participants were 265 self-identified African American (40.4%) and Latinx (59.6%) adults
recruited to complete an in-person survey from three locations in and around Hartford,
Connecticut, between 2009-2011 in exchange for $ - $20 (see Quinn et al., 2014) for full
information on the recruitment procedure). All participants reported having at least one of
five possible CSIs. Participants answered the anticipated stigma measure based on their
reported CSI of substance abuse (26.4%), mental illness (25.3%), domestic violence

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(21.1%), childhood abuse (14.3%), or sexual assault (12.8%). If participants had multiple
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CSIs, they were asked to answer questions based on the identity that was most important to
them.

On average, participants were in their thirties (M = 34.90, SD = 11.50), male (60.4%), low
income (between $5,000 to $10,000 per year), and possessed a high school diploma or less
(68%). The in-person survey was completed in English or Spanish (21%). All study
procedures and measures were approved by an Institutional Review Board and the
institutional review board of the Department of Mental Health and Addiction Services
(DMHAS) of the State of Connecticut.

Measures.
As part of the survey, participants completed measures of racial/ethnic discrimination,
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anticipated stigma of the CSI, and depressive symptomatology.

Racial/ethnic discrimination was measured using the 9-item “day-to-day” discrimination

scale (Kessler, Mickelson, and Williams, 1999). The “day-to-day” discrimination scale
assesses the frequency of experiencing different forms of racial/ethnic discrimination (e.g.,
“People act as if you are inferior”) from 0 (Never) to 4 (Often), α = .92, (M = 2.41, SD
= .81).

Anticipated stigma of the CSI was measured using a 15-item anticipated stigma scale (Quinn
& Chaudoir, 2009) assessing the perceived likelihood of being mistreated if others were
aware of their CSI (e.g., “Friends avoiding you”) from 1 (Very Unlikely) to 7 (Very Likely),
α = .95, (M = 3.70, SD = 1.82).
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Depressive symptomatology was measured using the 20-item Center for Epidemiological
Studies-Depression scale (CES-D; Radloff, 1977). The CES-D assess the frequency of
symptoms over the last week (e.g., “I felt fearful”) from 0 (Rarely or None of the Time [Less
than 1 Day]) to 3 (Most or all of the Time [5–7 Days]), α = .87, (M = 1.21, SD = .58).

Sociodemographic characteristics were also measured and included as covariates in each

analysis. Specifically, age in years, gender (0 =Male, 1 = Female), household income (1 =
less than 5,000 to 12 = over 100,000), education (1 = Elementary School to 12 = Doctoral
Degree), and language in which the survey was completed (1 = English, 2 = Spanish) were
included as covariates.

Results.
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As predicted, at the bivariate level more racial/ethnic discrimination was associated with
more anticipated stigma of the CSI, r = .40, p <. 001 and higher depressive symptomatology,
r = .27 p < 001. Consistent with previous research, more anticipated stigma of the CSI was
associated with more depressive symptomatology, r = 31, p <. 001.

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Additive model.
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In order to examine whether racial/ethnic discrimination and anticipated stigma of the CSI
uniquely and directly predict depressive symptomatology, we conducted a hierarchical
multiple linear regression. Age, education, income, language, and gender were entered into
the first step of the model and accounted for approximately 11% of the variance in
depressive symptomatology, F (5, 248) = 7.15, p < .001. Including racial/ethnic
discrimination into the model resulted in a significant increase in the proportion of variance
accounted for in depressive symptomatology, ΔR2 .05, F (1, 247) = 14.35, p < .001, with a
total of about 15% of the variance in depressive symptomatology accounted for when
including racial/ethnic discrimination, F (6, 247) = 8.67, p < .001. Including anticipated
stigma of the CSI into the final model also significantly increased the proportion of variance
accounted for, ΔR2 = .03, F (1, 246) = 10.23, p= .002, with a total of 18% of the variance in
depressive symptomatology accounted for when including anticipated stigma, F (7, 246) =
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9,17, p < ,001, Importantly, in the final step of the regression, with all variables entered
simultaneously, both experienced racial/ethnic discrimination, ß =.15, p = .019, and
anticipated stigma, ß = .21, p = .002, were significant and unique predictors of depressive
symptomatology. Thus, as predicted, these results give support for an additive model of
stigma, with each type of stigma accounting for unique variance in depression.

Mediation model.
In order to examine whether the relationship between experiences of racial/ethnic
discrimination and depression is partially mediated through a greater anticipation of stigma
around one’s CSI, we conducted a simple mediation analysis using 5,000 bootstrapped
confidence intervals to test the statistical significance of the indirect effect (Hayes, 2017). As
seen in Figure 1, results revealed that racial/ethnic discrimination indirectly predicted
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depressive symptomatology through its relationship with anticipated stigma of the CSI even
when accounting for the covariates, ß = .08, 95% CI [.03, .14]. Specifically, the more racial/
ethnic discrimination African American and Latinx adults experienced, the more likely they
believed that they would be mistreated if others were to become aware of their CSI, ß = .38,
p <.001, 95% CI [.26, .50], which in turn was associated with higher depressive
symptomatology, ß = .21, p = .002, 95% CI [.08, .33]. The direct effect of racial/ethnic
discrimination on depressive symptomatology remained significant even when accounting
for anticipated stigma of the CSI and all of the covariates, ß = .15, p =.02, 95% CI [.03, .28],
demonstrating that the indirect path through greater anticipated stigma was one way that
experiences of discrimination relate to depression but not the only way.

Discussion
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In the current work we considered how the experiences and beliefs related to visible and
concealable identities may work separately and together to impact mental health. Consistent
with past research on multiple disadvantaged statuses (e.g., Grollman, 2014), more
experienced racial/ethnic discrimination and more anticipated stigma regarding a CSI,
independently predicted greater depressive symptomatology. We also tested a novel
hypothesis that experiences of racial/ethnic discrimination may predict anticipated stigma
with a concealable stigmatized identity, which builds on past research about expectations of

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future discrimination (Mendoza-Denton et al., 2002). Our findings suggest that the
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relationship between experienced racial/ethnic discrimination and depressive

symptomatology was partially mediated by anticipated stigma of a CSI—specifically, more
experienced racial/ethnic discrimination predicted more anticipated stigma of a CSI, which,
in turn, predicted more depressive symptoms (i.e., worse mental health). That the mediation
was partial instead of full highlights that the relationships between multiple identities and
depression are working along both separate and enmeshed pathways.

Findings from the current research suggest that experiences of discrimination with a visible
stigmatized identity can sensitize a person to anticipate more stigma based on a concealable
identity. It could be that once someone has experienced discrimination because of their race/
ethnicity, they then come to expect poor treatment from others based on other social
identities. Although this theorizing is in line with research examining how experiences of
racial discrimination lead people to expect more racial discrimination in the future (e.g.,
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Mendoza-Denton et al., 2002), the current work is cross-sectional. We believe it is likely that
experiences of racial and ethnic discrimination occur before the acquisition of the
concealable stigmatized identities (Cheng, Cohen, & Goodman, 2015), but a longitudinal
study that includes both experiences of discrimination and anticipation of discrimination
based on multiple identities is needed to provide stronger evidence of a temporal pathway.

Another way to examine the relationship between multiple identities is to examine whether
they statistically interact. For example, people who have high levels of experienced racial
discrimination might report different levels of depressive symptomology depending on
whether they have high or low levels of anticipated stigma. That is, scores on one variable
may moderate the relationship between scores on the other variable and the outcome. We
tested for such a statistical interaction using Hayes (2017) PROCESS model and found it
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was not supported, b = .06, p = .30, 95% CI [−.05, .16].

People live with multiple identities. In order to understand how social identities affect
health, it is crucial for researchers to begin collecting information not only on whether a
person possesses multiple identities, but also their experiences of disadvantage related to
those identities. This study, focusing on measures of experienced and anticipated
discrimination of visible and concealable stigmatized identities is a small step in that
direction. Combined with a greater understanding of institutional and structural sources of
discrimination, researchers can get closer to a full picture of how stigma contributes to
health disparities (Hatzenbueler et al., 2013), and, ultimately, to know where the best places
to intervene to improve health are.
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Figure 1:
Standardized regression coefficients for the effect of racial/ethnic discrimination on
depressive symptomatology through anticipated stigma of a concealable stigmatized identity,
controlling for age, gender, household income, education, and language in which the survey
was completed. The total effect shown in parentheses. *p < .05, **p < .01, ***p < .001.
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