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Roles of Spirituality in Lesbian, Gay, and Bisexual Persons' Experiences of Minority Stress, Psychological Distress, and...

Permanent Link: http://ufdc.ufl.edu/UFE0022386/00001

Material Information

Title: Roles of Spirituality in Lesbian, Gay, and Bisexual Persons' Experiences of Minority Stress, Psychological Distress, and Well-Being
Physical Description: 1 online resource (83 p.)
Language: english
Creator: Goodman, Melinda
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: bisexual, gay, homosexual, lesbian, minority, psychological, religion, spirituality, well
Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Grounded in the minority stress framework, the present study examined concomitantly the relations of (a) perceived experiences of prejudice, (b) expectations of stigma, (c) internalized homophobia, and (d) concealment of sexual orientation with LGB persons? psychological distress and well-being. Within this framework, three posited roles of spirituality and religiosity were tested: that they are (a) mental health promoters, (b) buffers of minority stress and mental health relations, or (c) they are mental health stressors. Results showed that perceived experiences of prejudice, internalized homophobia, and concealment of sexual orientation each were related uniquely and positively to psychological distress and that perceived experiences of prejudice, expectations of stigma, internalized homophobia, and concealment of sexual orientation were related uniquely and negatively to psychological well-being. Additionally, beyond the role of the four minority stressors, spirituality was related uniquely and positively with psychological well-being while religiosity was shown to be related uniquely and negatively. Future directions for research and implications for practice are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Melinda Goodman.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Moradi, Banafsheh.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022386:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022386/00001

Material Information

Title: Roles of Spirituality in Lesbian, Gay, and Bisexual Persons' Experiences of Minority Stress, Psychological Distress, and Well-Being
Physical Description: 1 online resource (83 p.)
Language: english
Creator: Goodman, Melinda
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: bisexual, gay, homosexual, lesbian, minority, psychological, religion, spirituality, well
Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Grounded in the minority stress framework, the present study examined concomitantly the relations of (a) perceived experiences of prejudice, (b) expectations of stigma, (c) internalized homophobia, and (d) concealment of sexual orientation with LGB persons? psychological distress and well-being. Within this framework, three posited roles of spirituality and religiosity were tested: that they are (a) mental health promoters, (b) buffers of minority stress and mental health relations, or (c) they are mental health stressors. Results showed that perceived experiences of prejudice, internalized homophobia, and concealment of sexual orientation each were related uniquely and positively to psychological distress and that perceived experiences of prejudice, expectations of stigma, internalized homophobia, and concealment of sexual orientation were related uniquely and negatively to psychological well-being. Additionally, beyond the role of the four minority stressors, spirituality was related uniquely and positively with psychological well-being while religiosity was shown to be related uniquely and negatively. Future directions for research and implications for practice are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Melinda Goodman.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Moradi, Banafsheh.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022386:00001


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cbff9893c9d30ad24f0beb48823de8c27b90d89f







ROLES OF SPIRITUALITY IN LESBIAN, GAY, AND BISEXUAL PERSONS'
EXPERIENCES OF MINORITY STRESS, PSYCHOLOGICAL DISTRESS,
AND WELL-BEING




















By

MELINDA B. GOODMAN


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2008

































2008 Melinda B. Goodman




























To the two men in my life: my cat Calvin and my partner Matt. Both have provided me with an
immense amount of love and support during this time, one through purring and belly rubs, and
the other one through long phone conversations and encouragement. The order listed here does
not necessarily equate to order of importance.









ACKNOWLEDGMENTS

First of all I would like to thank my advisor and committee chair, Dr. Bonnie Moradi, for

all of her guidance, support, and encouragement. I feel incredibly lucky to have worked with Dr.

Moradi. She taught me how to be a dedicated psychologist. I am thankful for the assistance given

to me by my committee members: Drs. Catherine Cottrell, Mary Fukuyama, and Kenneth Wald.

In addition, I would like to thank my parents for all of their support. I could never have reached

this point without their love, encouragement, and devotion. I am thankful to my partner Matt,

and all my friends and family who could always make me laugh and kept me grounded and sane

during this process. Furthermore, I want to especially thank Brian, Gizem, and Marisa who

provided much help and support at my dissertation defense. Lastly, I want to acknowledge the

participants in my survey for their honest and open participation. I hope that this project and others

like it can lead to a greater understanding of the experiences of lesbian, gay, and bisexual persons.









TABLE OF CONTENTS

page

A CK N O W LED G M EN T S ................................................................. ........... ............. .....

LIST OF TABLES ......... ......... ......... ....................................7

ABSTRAC T ..........................................................................................

CHAPTER

1 IN TR O D U C TIO N .............................................. .............. .................... .... ....

M minority Stress F ram ew ork ...................................................................... ........................10
Roles of Spirituality and Religiosity........................................................................ 15
S tu dy O v erv iew .................................................................................................. ........... 18

2 REVIEW OF THE LITERATURE ............................................... ............................. 20

The M minority Stress Fram ew ork ............................................................................. ............20
N eed to Exam ine Psychological W ell-Being .................. .......... ... ............................ .... 28
Spirituality and Religiosity as Potential Health Promoting Factors, Stress-Mental Health
B uffers, or M ental H health Stressors ........................................................................ .. .... 32
Potential M ental H health Prom others ........................................ ........................... 34
Potential Stress-M ental H eath Buffers ........................................ ........................ 36
P potential M mental H health Stressors ...................................................................................38
Attending to Distinctions Between Spirituality and Religiosity ...................................39
P u rp o se o f S tu d y ............................................................................................................... 4 1

3 M E T H O D S .......................................................................................................4 3

P articip an ts .........................................................................4 3
P ro c e d u re s .............................................................................................4 4
Instruments .........................................46
C riterion V ariables ................................................................46
P redictor V ariables ................................................................47

4 R E S U L T S .............................................................................................5 2

D descriptive Statistics ................................................................... 52
G ender C om prisons ................................................................... 53
Test for Order Effects ............................................................ ......54
M minority Stress Fram ew ork: H ypothesis 1 ....................................................... 55









The Roles of Spirituality and Religiosity: Hypothesis 2 ................... ...............................56
Spirituality and Religiosity as Mental Health Promoters (Hypothesis 2a) or
Stressors (H hypothesis 2c)............................ ..... .............................. ...............56
Spirituality and Religiosity as Buffers in the Stress-Mental Health Relation
(H y p o th e sis 2 b ) ...................................................................................................5 7

5 D ISC U S SIO N ............................................................................... 6 1

L im itatio n s ..............................................................................................................................6 6
Implications for Future Research and Practice....................................................................68
S u m m ary ................... ...................7...................2..........

L IST O F R E F E R E N C E S ...................................................................................... ...................73

B IO G R A PH IC A L SK E T C H .......................................................................... .. .......................83







































6









LIST OF TABLES


Table page

4-1 Summary statistics and correlations among the variables of interest .............................59

4-2 Simultaneous regression equations of minority stressors regressed on psychological
distress and w ell-being ........ .................................................................... ........ .. .... 59

4-3 Hierarchical regression equations examining unique links of spirituality and
religiosity with psychological distress and well-being .............. ...................................60









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

ROLES OF SPIRITUALITY IN LESBIAN, GAY, AND BISEXUAL PERSONS'
EXPERIENCES OF MINORITY STRESS, PSYCHOLOGICAL DISTRESS,
AND WELL-BEING

By

Melinda B. Goodman

August 2008

Chair: Bonnie Moradi
Major: Counseling Psychology

Grounded in the minority stress framework, the present study examined concomitantly

the relations of (a) perceived experiences of prejudice, (b) expectations of stigma,

(c) internalized homophobia, and (d) concealment of sexual orientation with LGB persons'

psychological distress and well-being. Within this framework, three posited roles of spirituality

and religiosity were tested: that they are (a) mental health promoters, (b) buffers of minority

stress and mental health relations, or (c) they are mental health stressors. Results showed that

perceived experiences of prejudice, internalized homophobia, and concealment of sexual

orientation each were related uniquely and positively to psychological distress and that perceived

experiences of prejudice, expectations of stigma, internalized homophobia, and concealment of

sexual orientation were related uniquely and negatively to psychological well-being.

Additionally, beyond the role of the four minority stressors, spirituality was related uniquely and

positively with psychological well-being while religiosity was shown to be related uniquely and

negatively. Future directions for research and implications for practice are discussed.









CHAPTER 1
INTRODUCTION

Rates of some mental health concerns may be greater among lesbian, gay, and bisexual

(LGB) persons than among heterosexual persons. For example, compared to heterosexual

persons, LGB persons may be at higher risk for mood, anxiety, and substance use disorders

(Cochran & Mays 2000a; Gilman et al., 2001; Sandfort, de Graaf, Bijl, & Schnabel, 2001) and

may engage in more suicidal ideation and attempts (Fergusson, Horwood & Beautrais, 1999;

Gilman et al., 2001; Herrell et al., 1999; Cochran & Mays, 2000b). Based on a meta-analysis of

studies comparing LGB persons to heterosexual persons, Meyer (2003) concluded that at any

point over their lifetime, LGB persons are about 2.5 times more likely to experience a mental

disorder. Such data, suggesting greater symptomatology among LGB persons than among

heterosexual persons, have been interpreted as evidence of the pathology of LGB orientations

and identities. LGB affirming conceptualizations, however, point to minority stress, resultant

from societal oppression against LGB persons, as an alternative explanation for observed

symptom disparities (Brooks, 1981; DiPlacido, 1998; Mays & Chochran, 2001; Meyer, 1995;

2003) and also highlight the importance of exploring mental health promoting factors, given that

many LGB persons do not suffer from psychological symptomatology (Basic Behavioral Science

Task Force of the National Advisory Mental Health Council [BBSTF], 1996; DiPlacido, 1998;

Meyer, 1995).

Religiosity and spirituality have been identified as potentially critical health promoting

factors in the general population (Brady, Peterman, Fitchett, Mo, & Cella, 1999; Ellison, Gay, &

Glass, 1989; Powell, Shahabi, & Thoresen, 2003), but conceptualizations of their link to the

psychological distress and well-being of LGB persons have varied. Specifically, religiosity and

spirituality have been conceptualized as health promoters, stress buffers, and stressors for LGB









persons (Lease, Horn, & Noffsinger-Frazier, 2005; Ritter & O'Neill, 1989; Siegel, Anderman, &

Schrimshaw, 2001; Woods, Antoni, Ironson, & Kling, 1999).

Based on prior literature, the present study will explore these three different roles of

religiosity and spirituality in the psychological distress and well-being of LGB persons while

also considering the roles of previously identified minority stressors for LGB persons. More

specifically, the minority stress framework (Meyer, 1995, 2003) posits that (a) perceived

experiences of prejudice and discrimination, (b) expectations of stigma, (c) internalized

homophobia1, and (d) concealment of sexual orientation are minority stressors that can

contribute to greater psychological distress for LGB persons. Within this framework, spirituality

and religiosity may have unique additional relations to lower distress and greater well-being (i.e.,

function as health promoters), moderate the relation of each minority stressor with distress and

well-being (i.e., function as stress buffers), or have unique additional relations with greater

distress and lower well-being (i.e., function as additional stressors). Importantly, the roles of

religiosity and spirituality may differ from one another and may differ in relation to distress and

well-being. These various possibilities will be examined in the present study.

Minority Stress Framework

Meyer (1995, 2003) outlined an integrative framework for understanding the deleterious

implications of societal oppression for LGB persons' mental health. Specifically, he outlined

four sources of minority stress relevant to LGB individuals. The first source of minority stress is

LGB persons' experiences of anti-LGB discrimination and prejudice. Chronic exposure to such

external, stressful events and conditions can promote the second source of minority stress,


1 The author is choosing to use the term "internalized homophobia" for the purposes of continuity and consistency
with prior, published work on this topic. However, the author recognizes the problems of this term because of the
emphasis on the fear component of prejudice over other important processes including individual anti-LGB
cognitions and institutional prejudice (Williamson, 2000).









vigilance and expectations of further prejudice and discrimination. The third source of minority

stress is internalized homophobia. Internalized homophobia is defined as the "set of negative

attitudes and affects toward homosexuality in other persons and toward homosexual features in

oneself' (p. 178), including same gender sexual and affectional feelings, sexual behavior,

intimate relationships, and self labeling as LGB (Shidlo, 1994). The final source of minority

stress is the concealment of sexual orientation. Such concealment may reflect internalized shame

about one's own LGB orientation or serve as an attempt to prevent further prejudice. Together,

this set of four minority stressors is posited to promote psychological distress and reduce

psychological well-being of LGB persons.

Extant research has examined the links of each of these minority stressors with

psychological distress. Indeed, empirical research has demonstrated that anti-LGB prejudice and

discrimination, including verbal insults, threats of violence, physical attacks, and victimization

due to sexual orientation are regrettably common (D'Augelli, 1989; Herek, 1993; Herek, Gillis,

& Cogan 1999). Furthermore, data with samples of LGB persons support Meyer's (1995; 2003)

proposition that experiences of prejudice, expectations of stigma, and internalized homophobia

are related to an array of negative mental and physical symptoms including suicidal ideation and

behaviors, anxiety, depression, demoralization, guilt, insomnia, somatic symptoms, substance

abuse, body image dissatisfaction, reduced relationship quality, and overall psychological

distress (Balsam & Syzmanski, 2005; Diaz, Ayala, Bein, Henne, & Marin, 2001; DiPlacido,

1998; Herek, Cogan, Gillis, and Glunt, 1997; Kimmel & Mahalik, 2005; Lewis, Derlega, Clarke,

& Kuang, 2006; Meyer, 1995; Szymanski & Chung, 2003).

On the other hand, support has been mixed for a link between sexual orientation

concealment and psychological distress indicators; with some studies finding that concealment is









related to some symptomatology (Ayala & Coleman, 2000; Cole, Kemeny, Taylor, & Visscher,

1996; Cole, Kemeny, Taylor, Visscher, & Fahey, 1996; Diplacido, 1998; Lewis, Derlega,

Derndt, Morris, & Rose, 2001; Nicholson & Long, 1990; Szymanski, Chung, & Balsam, 2001)

and other studies finding that it is not (D'Augelli, Grossman, Hersherger, & O'Connell, 2001;

Lewis, Derlega, Griffin & Krowinski, 2003; McGregor et al., 2001). One possible explanation

for these mixed findings regarding sexual orientation concealment is the observed restriction in

range of sexual orientation concealment in most prior studies, with sample averages typically

near the high end of the outness continuum. Thus, additional research with samples that include a

broader range of sexual orientation concealment/outness is needed.

In addition to studies that focus on the relation of each specific minority stressor with

psychological distress, a few studies provide a more complete examination of the minority stress

framework by examining two or more minority stressors together to identify their unique

relations with psychological symptomatology. For instance, when examined together, reported

experiences of prejudice events, expectation of stigma, and internalized homophobia each were

related positively and uniquely to demoralization, guilt, and suicidal ideation and behaviors for

gay and bisexual men (Meyer, 1995) and to body image dissatisfaction for gay men (Kimel and

Mahalik, 2005). Additionally with a sample of LGB persons, Lewis et al. (2003) examined

concomitantly the relations of depressive symptoms with expectations of stigma, internalized

homophobia, concealment of sexual orientation, and perceived stressfulness of a range of sexual

orientation-related issues (e.g., experiences of prejudice and discrimination, internalized

homophobia, expectations of stigma, concealment and disclosure of sexual orientation, rejection

from family, fear of HIV/AIDS). They found that the perceived stressfulness of sexual

orientation-related issues, expectations of stigma, internalized homophobia, and concealment of









sexual orientation each had significant zero-order correlations with depressive symptoms. When

all predictors were entered together into a multiple regression analysis, however, only perceived

sexual orientation-related stress and expectations of stigma emerged as related uniquely to

depressive symptoms. It is not clear, however, if internalized homophobia and concealment were

not related uniquely to depression because there was a restriction in range for these constructs,

with the sample scoring near the high end of both variables. Additionally, since experiences of

prejudice and discrimination were not assessed separately, the potential unique relations of these

experiences to depression remain unclear.

Overall the literature reviewed provides some support for aspects of minority stress theory.

Specifically, extant data are consistent with the posited relations of perceived experiences of

prejudice and discrimination, expectations of stigma, and internalized homophobia to

psychological distress when these minority stressors are examined separately; but support for the

posited role of concealment of sexual orientation is mixed. Compared to studies that focused on

individual minority stressors in isolation, fewer studies have examined two or more minority

stressors concomitantly. Nevertheless, in the studies that examined two or more minority

stressors, some support exists for the unique roles of experiences of prejudice, internalized

homophobia, and expectations of stigma in psychological symptomatology (Kimel & Mahalik,

2005; Meyer, 1995; Szymanski, 2005).

In contrast to accumulating data about the links of minority stressors with LGB persons'

psychological distress, limited data are available about the links of minority stressors with

indicators of psychological well-being (e.g., self-esteem, positive affect, life satisfaction), and

these limited data are mixed. For example, perceived experiences of prejudice have been found

to be related negatively to self-esteem for 15-21 year old LGB youth (Hershberger & D'Augelli,









1995), but not to positive affect for LGB adults (Herek et al, 1999). Similarly, most studies with

LGB persons link internalized homophobia with lower levels of self-esteem (Allen & Oleson,

1999; Herek et al., 1997; McGregor et al., 2001; Mohr & Fassinger 2000; Peterson & Gerrity,

2006; Shildo, 1994; Syzmanski & Chung, 2001), psychological well-being, and satisfaction with

life (Lease et al., 2005). In other studies, however, internalized homophobia was not related to

self-esteem for lesbian women (Herek et al., 1997; Mohr & Fassinger, 2000), and for HIV

positive gay men (Nicholson & Long, 1990). Mixed findings also have emerged with regard to

concealment of sexual orientation. Mohr and Fassinger (2000) found that, for gay men,

concealment of their sexual orientation to strangers, friends, and colleagues, but not to family

members or members of their religious organization, was related negatively to self-esteem; for

lesbian women, however, none of the concealment indicators were related to self-esteem.

Finally, the relation between expectations of stigma and psychological well-being has not been

examined with samples of LGB persons but it has been examined with other minority

populations. For example, for women, expectations of stigma were related negatively to aspects

of psychological well-being (Schmitt, Branscombe, Korbynowicz, & Owen, 2002), but the link

with well-being was not found for African American persons (Branscombe, Schmitt, & Harvey,

1999).

Thus, prior studies provide some support for the relations of the minority stressors with

self-esteem, but this support is mixed. Also, none of the studies reviewed examined the links of

self-esteem with the set of minority stress variables concomitantly. Thus, the unique relations of

each of the minority stressors with self-esteem remain unclear. Furthermore, aspects of well-

being other than self-esteem have been explored only minimally in minority stress research.

Therefore there is a need for additional research to assess psychological well-being more broadly









than the narrow focus on self-esteem in prior research, and to examine its relations with the set of

minority stressors concomitantly.

Roles of Spirituality and Religiosity

For counseling psychologists working with LGB persons it is important to understand the

mechanisms that can lead to psychological distress and impede psychological well-being, but it

is also important to understand factors that relate to positive functioning and promote well-being.

Indeed there have been repeated calls for further empirical research on mechanisms that might

alleviate distress and variables that might moderate or buffer the negative health consequences of

minority stress (BBSTF, 1996; DiPlacido, 1998; Meyer, 1995). Therefore an additional aim of

this study is to examine potential mental health promoting factors in the context of minority

stressors' links with psychological distress and well-being. This study focuses on spirituality and

religiosity because they have been identified as important health promoting factors in the general

population (Brady et al., 1989; Powell et al., 2003) and may be linked with psychological health

for LGB persons as well (Lease et al., 2005; Miller, 2005; Woods et al., 1999). Theory and

empirical research point to three possible roles of spirituality and religiosity in the mental health

of LGB persons; spirituality and religiosity may serve as (a) mental health promoters, (b) buffers

of the stress and mental health relation, or (c) mental health stressors. The current study will

examine these three competing hypotheses within the context of the minority stress framework.

The first perspective suggests that spirituality and religiosity are two factors that may

promote the mental health of LGB persons and so should be related to lower psychological

distress and greater psychological well-being. Conceptually, spiritual and religious beliefs are

hypothesized to add comfort, relieve pain and suffering, provide hope and meaning, and help

people cope with their problems (C. E. Ross, 1990). Consistent with this perspective, using a

variety of measures and across numerous samples of the general population, higher levels of









spirituality and religiosity have been linked to greater physical health and psychological well-

being (Brady et al., 1999; Ellison et al., 1989; Powell et al., 2003). Similarly, spirituality and

religiosity could be factors that promote mental health for LGB persons. Indeed theorists have

proposed that, through spirituality and religiosity, LGB people may gain benefits such as a sense

of wholeness, affirmation of the person's basic goodness, and greater self-acceptance and

psychological well-being (Davidson, 2000; Ritter & O'Neill, 1989; Wagner, Serafini, Rabkin,

Remien, & Williams, 1994). Findings from some qualitative and quantitative research are

consistent with the espoused benefits of spiritual and/or religious beliefs for LGB persons (Lease

et al., 2005; Miller, 2005; Tan, 2005; Varner, 2004; Woods et al., 1999; Yakushko, 2005).

In addition to suggesting direct links of spirituality and religiosity with positive physical

and mental health outcomes, theory and empirical research have also pointed to spirituality and

religiosity as buffers of the relation between stress and negative health outcomes. For instance,

spirituality and religiosity may buffer against stress by providing a framework for interpreting

stressful events, enhancing coping resources, and facilitating access to social support (Siegel et

al., 2001). Indeed, with various samples, there is empirical support for the notion that spirituality

and religiosity are moderators of the relation between stress and negative health conditions

(Fabricatore, Handal, & Fenzel, 2000; Forthus, Pidcock & Fischer, 2003; Mascaro & Rosen,

2006; Wills, Yaeger, & Sandy, 2003). Furthermore, spirituality specifically has been shown to

buffer the relation of minority stress with symptomatology for African American persons.

Specifically, Bowen-Reid and Harrell (2002) found that, for African American college students,

spirituality moderated the relation between racist stressful events and psychological distress. The

direction of moderation indicated that, for participants with high levels of spirituality, there was

no significant relation between perceived racist stressful events and psychological distress,









whereas, for participants with low levels of spirituality, there was a significant and positive

relation between perceived racist stressful events and psychological distress. As such, spirituality

and religiosity may moderate or buffer the relations of minority stressors with mental health for

LGB persons.

Despite the literature suggesting potential benefits of spirituality and religiosity for LGB

persons (i.e., mental health promoter or stress buffers), there is also theory and research that

points to potential spiritual wounding for LGB persons due to their participation in religions that

describe same-gender sexuality as sinful. Indeed Ritter and O'Neill (1989) explained that for

LGB persons', traditional Judeo-Christian religions can be psychologically damaging because

they "have heaped accusations of shame, contamination, and sinfulness, upon the heads of

lesbian and gay people" (p.68). Additionally, Barret and Brazan (1996) described that there is a

fundamental struggle for LGB persons to overcome the clash between homophobic religious

institutions and personal spiritual experiences that connect them to a higher power. Empirical

research also demonstrates the potential negative implications of religiosity for LGB persons.

Indeed, research has shown that many LGB persons feel that they must choose between being

LGB and being religious (Rodriguez & Ouellette, 2000), and that being religious in a non-gay

affirming church and holding conservative religious views are related to internalized

homophobia (Meyer & Dean, 1998; Wagner et al., 1994). Furthermore, religiously oriented

programs aimed at changing the sexual orientation of LGB persons have been shown to be

psychologically damaging (Beckstead & Morrow, 2004). Due to these negative experiences that

many LGB persons face within their religions, greater spirituality and religious participation may

be related to greater psychological symptomatology and lower well-being.









Thus, spirituality and religiosity have been conceptualized as potential mental health

promoters, stress buffers, and stressors for LGB persons. In examining these three positions, it is

important to be mindful of the potentially distinct roles that may be played by spirituality and

religiosity. Specifically, spirituality and religiosity are related (Hill et al., 2000; Hill &

Pargament, 2003), but theory and empirical research have highlighted that they are not identical

constructs (Miller & Thoresen, 2003). Spirituality is considered an individual experience that

includes a personal connection to a Scared or Higher Being, personal transcendence, and

meaningfulness (Zinnbauer et al., 1997). Religiosity, on the other hand, is defined more narrowly

to include participating in formally structured religious institutions, prescribed theology, and

rituals (Zinnbauer et al., 1997). This distinction between spirituality and religiosity may be

especially important for LGB persons because many religions condemn non-heterosexuality.

Such condemnation may lead some LGB persons to have a strained relationship with their

religious institutions, but not necessarily with their individual spirituality. Therefore, this study

will examine if spirituality and religiosity have distinct, rather than parallel roles in the

psychological distress and well-being of LGB persons.

Study Overview

Based on the literature reviewed here, and using the minority stress framework, the present

study advances understanding of LGB persons' psychological distress and well-being in a

number of ways. First, this study examines concomitantly the relations of the four minority stress

variables (i.e., perceived experiences of discrimination and prejudice, expectations of stigma,

internalized homophobia, and concealment of sexual orientation) to psychological distress and

psychological well-being of LGB persons. Second, this study examines the potential additional

roles of spirituality and religiosity in the psychological distress and well-being of LGB persons.

Specifically, based on theory and empirical research that suggest three possible roles of









spirituality and religiosity in the mental health of LGB persons, this study will test three rival

hypotheses that spirituality and religiosity are (a) mental health promoters, (b) buffers of the

stress and mental health relation, or (c) mental health stressors. Finally, the present study will

explore the potential distinct rather than parallel roles of spirituality and religiosity in LGB

persons' mental health.









CHAPTER 2
REVIEW OF THE LITERATURE

As discussed in the previous chapter, the present study uses the minority stress

framework to advance understanding of LGB persons' psychological distress and well-being and

examines the additional roles of spirituality and religiosity. As such, the present study fits well

with the aims of counseling psychology to understand and alleviate sources of distress and also

understand and promote sources of well-being within diverse populations. In order to provide the

groundwork for the present study, this chapter reviews relevant literatures on (a) minority stress

and psychological distress, (b) minority stressor and psychological well-being, (c) the relations

of spirituality and religiosity to psychological distress and well-being, (d) the moderating role of

spirituality and religiosity in the relations of stressors with psychological distress and well-being

for LGB persons, and (e) the potentially distinct roles of spirituality and religiosity in LGB

persons mental health.

The Minority Stress Framework

The minority stress framework is rooted in the work of pioneering scholars in the area of

psychological stress who theorized that disproportionate stress due to minority status may be

linked to higher rates of symptomatology among minority populations (Allport, 1954;

Dohrenwend, 1973; Kardiner & Ovesey, 1951). For instance, Allport (1954) stated that, "A

minority group member has to make many times as many adjustments to his status as does the

majority group member...the awareness, the strain, the accommodation all fall more heavily and

more frequently on the minority group members" (p. 145). More recently, the Basic Behavioral

Science Task Force (BBSTF) of the National Advisory Mental Health Council (1996) explained

that repeated experiences of discrimination and stigmatization are damaging to an individual's

sense of identity and that coping with this stigma, prejudice, and discrimination is stressful and









can result in increased levels of psychological distress. Many researchers and theorists who have

examined this position with respect to LGB persons concur that stigma and discrimination

against LGB persons may be a source of increased symptomatology for this population (Brooks,

1981; DiPlacido, 1998; Mays & Cochran, 2001; Meyer, 1995; 2003).

Based on an integration of prior theory and empirical research (Allison, 1998; Brooks,

1981, Crocker & Major, 1989; Lazarus & Folkman, 1984), Meyer (1995, 2003) argued that

stigma and prejudice against LGB persons create a stressful and hostile environment that can

promote mental health problems. He outlined four processes of minority stress relevant to LGB

individuals. The first source of minority stress is LGB persons' experiences of discrimination

and prejudice. Chronic exposure to such external, stressful events and conditions can promote

the second source of minority stress, vigilance and expectations of further prejudice and

discrimination. The third source of minority stress is internalized homophobia. Internalized

homophobia is defined as the "set of negative attitudes and affects toward homosexuality in other

persons and toward homosexual features in oneself" (p. 178), including same gender sexual and

affectional feelings, sexual behavior, intimate relationships, and self labeling as LGB (Shildo,

1994). The final source of minority stress is concealment of sexual orientation. Such

concealment may reflect internalized shame about one's own LGB orientation or serve as an

attempt to prevent further prejudice. Together, this set of four minority stressors is posited to

promote psychological distress and reduce psychological well-being of LGB persons. Extant

research has examined the links of each of these minority stressors with psychological distress.

First, research focusing on experiences of anti-LGB prejudice events, including antigay

violence and discrimination, suggests that such events are unfortunately common. For example,

D'Augelli (1989) found that 50% of the gay and lesbian college students surveyed reported









sexual orientation based victimization including having overheard disparaging comments, 26%

reported having experienced personal verbal insults, 26% reported having been threatened with

physical violence, and 23% reported having been victims of assault. In another study, over three

quarters of LGB college students reported that they had experienced verbal insults and 25%

reported that they had experienced threats of violence, which they attributed to their sexual

orientation (Herek, 1993). With a study of non-college student LGB persons, Herek, et al. (1999)

found that one-fifth of the women and one-forth of the men experienced victimization that they

attributed to their sexual orientation.

Data with samples of gay and bisexual men support Meyer's (1995; 2003) proposition

that experiences of anti-LGB prejudice, harassment, and victimization are related positively to an

array of mental and physical symptoms including suicidal ideation and behaviors, anxiety,

depression, demoralization, guilt, insomnia, somatic symptoms, and overall psychological

distress (Diaz et al., 2001; Meyer, 1995; M. W. Ross, 1990). Additionally, with a sample of

women and men recruited using a random digit-dial method (N= 73 LGB persons and 2,844

heterosexual persons), Mays and Cochran (2001) assessed discrimination experiences broadly

(e.g., being fired from a job, being threatened or harassed, being treated with less respect or

courtesy than other people) and found that, compared to heterosexual persons, LGB persons

were more likely to report having experienced discrimination. Furthermore, participants who

reported experiencing discrimination were more likely to meet diagnostic criteria for a

psychiatric disorder than were those who did not report any discrimination experiences.

The culture of prejudice and discrimination described above can promote LGB persons'

expectations of anti-LGB prejudice and stigmatization. Such expectations of prejudice are the

second source of minority stress identified by Meyer (1995, 2003). According to Meyer (2003),









in order to cope with prejudice and discrimination, LGB persons maintain a sense of vigilance,

by remaining mindful of the possibility that others will be hostile towards them. Meyer (2003)

suggested that this constant need for vigilance is stressful and can result in greater

symptomatology for LGB persons. Available data support the link between perceptions of

widespread stigma against one's minority group and psychological distress. For example,

perceiving negative events as prejudice was related negatively to self-esteem and positively to

negative emotions for African American persons (N= 139; Branscombe et al., 1999) and

positively to anxiety and depression and negatively to life satisfaction, self-esteem, and positive

affect for women (N= 220; Schmitt et al., 2002). Research also has shown that expectations of

stigma are related to negative health outcomes for LGB people. For instance, with a sample of

gay and bisexual men (N= 741), Meyer (1995) found that expectations of stigma were related

positively to demoralization, guilt, and suicidal ideation. Also, expectations of stigma were

related positively to somatic symptoms and intrusive thoughts for lesbian women (N = 105;

Lewis, et al., 2006) and to depression with a sample of LGB persons (N= 204; Lewis et al.,

2003).

In addition to promoting expectations of stigmatization, the culture of anti-LGB prejudice

and stigma can also promote LGB persons' internalization of that stigma. As such, internalized

homophobia is the third source of minority stress outlined by Meyer (1995; 2003). Internalized

homophobia has been an important focus within LGB studies and in gay-affirmative

psychotherapy approaches (Williamson, 2000). Consistent with Meyer's (1995; 2003)

conceptualization, for gay and bisexual men, internalized homophobia has been linked positively

to depression, anxiety, substance abuse, demoralization, guilt, body image dissatisfaction, shame,

and suicidal ideation and behaviors (Allen & Oleson, 1999; Herek et al., 1997; Kimmel &









Mahalik, 2005; Meyer, 1995; Meyer & Dean, 1998; Rowen & Malcom, 2002; Shidlo, 1994;

Williamson, 2000). For instance, in a longitudinal study with HIV positive gay and bisexual men

(N = 142), Wagner, Brondolo, and Rabkin (1996) found that baseline internalized homophobia

predicted both self-reported and clinician-rated distress two years later, even after controlling for

HIV-illness stage and psychological distress. Also, with samples of lesbian and bisexual women,

internalized homophobia has been linked positively to alcohol consumption, negative affect,

depression, low relationship quality, loneliness, and somatic symptoms (Balsam & Syzmanski,

2005; DiPlacido, 1998; Lewis et al., 2006; Szymanski & Chung, 2003; Szymanski, et al., 2001).

Additionally, Herek et al. (1997) found that lesbian and bisexual women (N=75) with high

internalized homophobia reported significantly greater symptoms of depression and

demoralization than did those with low internalized homophobia. Lastly, with a sample of LGB

persons (N = 204), Lewis et al. (2003) found that internalized homophobia was related positively

to depressive symptoms.

The fourth posited source of minority stress for LGB persons is sexual orientation

concealment. Unlike data relevant to the other minority stressors, however, support has been

mixed for a link between sexual orientation concealment and negative health consequences. With

respect to the physical health of gay and bisexual HIV-positive men, concealment of sexual

orientation was related positively to a more rapid advancement of HIV infection and higher rates

of other diseases including cancer, pneumonia, bronchitis, sinusitis, and tuberculosis, even after

controlling for demographic characteristics, health practices, and other significant variables

(Cole, Kemeny, Taylor, & Visscher, 1996; Cole, Kemeny, Taylor, Visscher, & Fahey, 1996).

With samples of lesbian and bisexual women, concealment of sexual orientation was related

positively to depression, alcohol consumption, and negative affect (Ayala & Coleman, 2000;









Diplacido, 1998; Szymanski et al., 2001), but not with somatic complaints (Szymanski et al.

2001). On the other hand, with samples of lesbian women (N= 167; Oetjen & Rothblum, 2000)

and lesbian women treated for early stage breast cancer (N= 57; McGregor et al., 2001),

concealment of sexual orientation was not related to depression and psychological distress. A

number of studies that examined LGB persons together also yielded some mixed findings. With

a sample of LGB persons (N= 979), concealment of sexual orientation was related positively to

symptoms of depression (Lewis et al., 2001). Also with a sample of LGB older adults (N= 416;

60 years and older), concealment of sexual orientation was related positively to drug abuse, but

not to alcohol abuse, current mental health, or suicidal ideation (D'Augelli et al., 2001). In

contrast to these findings, Lewis et al. (2003) found that concealment of sexual orientation was

not related to depression with a sample of LGB persons (N= 204). One possible explanation for

these mixed findings regarding sexual orientation concealment is the observed restriction in

range of sexual orientation concealment in most prior studies, with sample averages typically

near the high end of the outness continue. Indeed both Lewis et al. (2003) and McGregor et al.

(2001) claim that a majority of their samples were considerably open about their sexual

orientation. Thus, additional research with samples that include a broader range of sexual

orientation concealment/outness is needed.

Taken together, the studies reviewed thus far suggest that, when examined independently,

perceived prejudice events, expectations of stigma, internalized homophobia, and in some

studies, concealment of sexual orientation, are related to psychological distress. A few studies

provide a more complete examination of the minority stress framework by examining two or

more minority stressors together to identify their unique relations with psychological symptoms

and other negative outcomes. For instance, with a sample of LGB couples (N= 130), Otis,









Rostosky, Riggle, and Hamrin (2006) found that perceived experiences of prejudice and

internalized homophobia each were correlated significantly and negatively with relationship

quality. When examined together, however, only internalized homophobia was related uniquely

to relationship quality. Additionally, Balsam and Szymanski (2005) examined the relations of

minority stressors with domestic violence perpetration and victimization with a sample of lesbian

and bisexual women (N= 272). Reported experiences of prejudice and internalized homophobia

each were related positively and uniquely to respondents' reports of their own domestic violence

perpetration, but only reported experiences of prejudice and not internalized homophobia were

related uniquely to respondents' reports of domestic violence victimization. Lastly, Szymanski

(2005) found that both experiences of sexual orientation based victimization and internalized

homophobia were related uniquely to psychological distress for a sample of lesbian and bisexual

women (N 143).

Further evidence for the minority stress framework has been found from studies that

examined three of the minority stressors concomitantly. For example, Bos, van Balen, van den

Boom, and Sandfort (2004) found that for Dutch lesbian mothers (N = 100), reported experiences

of prejudice events, expectation of stigma, and internalized homophobia each were related

positively and uniquely to a self-reported need to justify the quality of their parenthood to others.

Additionally, in a study with gay men (N= 357), reported experiences of prejudice events,

expectations of stigma, and internalized homophobia each were related positively and uniquely

to body image dissatisfaction and distress about failing to meet the ideal muscular masculine

body (Kimel & Mahalik, 2005). Meyer (1995) also examined multiple minority stressors with a

sample of gay and bisexual men living in New York City (N= 741). He found that reports of

prejudice events, expectation of stigma, and internalized homophobia each accounted for unique









variance in demoralization, guilt, and suicidal ideation and behaviors. Furthermore, he included

concealment of sexual orientation as a covariate in separate regressions that examined links of

each minority stressor with psychological symptoms, and found that concealment was correlated

significantly and positively with psychological distress in these analyses. Unfortunately, he did

not include concealment of sexual orientation when he examined the other three minority

stressors concomitantly, leaving unclear the unique role of each minority stressor when the set of

four stressors are considered together.

Building on Meyer's (1995) work, Lewis et al. (2003) examined concomitantly the

relations of expectations of stigma, internalized homophobia, and concealment of sexual

orientation to depressive symptoms with a sample of LGB persons (N= 204). In addition to these

three minority stressors, they also examined the perceived stressfulness of sexual orientation-

related issues including prejudice and discrimination, internalized homophobia, expectations of

stigma, concealment and disclosure of sexual orientation, rejection from family, and fear of

HIV/AIDS. They found that the perceived stressfulness of sexual orientation-related issues, and

levels of expectations of stigma, internalized homophobia, and concealment of sexual orientation

each had significant zero-order correlations with depressive symptoms. However, when all of

these variables were entered together into a multiple regression analysis, only perceived

stressfulness of sexual orientation-related issues and level of expectations of stigma emerged as

related uniquely to depressive symptoms. It is important to note, however, that in this sample

there was a restriction in range for scores on internalized homophobia and concealment of sexual

orientation, with the sample scoring near the low end of both variables. Such range restriction

may have attenuated the observed relations of internalized homophobia and concealment of

sexual orientation with depression. Furthermore, the frequency of experiences of prejudice and









discrimination was not examined in this study, leaving unclear the potential unique relation of

such experiences with symptomatology.

Overall these studies provide some support for the minority stress theory. Specifically,

there is support for the relations of perceived experiences of prejudice and discrimination,

expectations of stigma, internalized homophobia, and concealment of sexual orientation to

psychological distress when these minority stressors are examined separately. Additionally, the

unique contributions of experiences of prejudice and discrimination, expectations of stigma, and

internalized homophobia to psychological distress are supported in some of the studies reviewed.

However, Lewis et al.'s study (2003) is the only study that examined concealment of sexual

orientation along with the other minority stressors, and found that it was not related uniquely to

symptomatology. Thus, additional research is needed to determine if concealment of sexual

orientation should be retained in the minority stress framework as a stressor. To provide a more

complete examination of the minority stress framework than that provided in much of the prior

literature, the present study will examine concomitantly the relations of the four minority

stressors with psychological distress. An important additional direction for research that is

addressed by the present study is to evaluate the relations of minority stressors with

psychological well-being. Literature relevant to this issue is discussed next.

Need to Examine Psychological Well-Being

The studies reviewed thus far attend mostly to the relations between minority stressors

and psychological distress. Understanding the correlates of LGB persons' psychological distress

is important for informing appropriate therapies and interventions to reduce distress within this

population. Based upon calls to attend to indicators of well-being as well as distress, however,

(Goodman, Liang, Helms, Latta, Sparks, & Weintraub, 2004; Sandage, Hill, & Vang, 2003;

Seligman, Steen, Park, & Peterson, 2005), it is also important to understand how experiences









associated with living in a society that condemns non-heterosexuality (i.e., minority stressors)

might relate to the psychological well-being of LGB persons

Unfortunately, there is limited research on the links of minority stressors with indicators

of psychological well-being (e.g., self-esteem, positive affect, life satisfaction) for LGB persons.

Also, the limited available research in this area has yielded mixed results. With regard to

experiences of prejudice and discrimination, Diaz et al. (2001) found that self-esteem was linked

negatively to experiences of social discrimination including homophobia, racism, and financial

discrimination in a study with gay and bisexual Latino men (N= 912). However, because

analyses were conducted only with an overall score of social discrimination, it is difficult to

determine the specific link between self-esteem and experiences of sexual orientation-based

prejudice. Additionally, perceived experiences of prejudice, as measured by sexual orientation

based victimization experiences ranging from verbal insults to physical assault, have been found

to be related negatively to self-esteem for 15-21 year old LGB youth (N= 194; Hershberger &

D'Augelli, 1995), but not to positive affect for LGB adults (N= 2259; Herek et al, 1999).

The relation between expectations of stigma and psychological well-being has not been

examined with samples of LGB persons, but it has been examined with other minority

populations. For example, with a sample of women, expectations of stigma were related

negatively to self-esteem, positive affect, and life satisfaction (Schmitt et al., 2002). However,

Branscombe et al. (1999) found that for a sample of African American persons, tendency to

perceive negative events as prejudice was not correlated with either self-esteem or the frequency

of experiencing negative emotions. Thus additional research is needed to examine the relation

between expectation of stigma and psychological well-being for LGB persons.









With respect to internalized homophobia, the majority of prior findings support its

expected link with self-esteem. Indeed, Herek et al. (1997; N= 1089), Mohr and Fassinger

(2000; N= 414), and Allen and Oleson (1999; N= 90) found that internalized homophobia was

related negatively to self-esteem for gay men. Additionally, Shildo (1994) reviewed four

unpublished studies with gay men, and concluded that internalized homophobia was linked

negatively to self-esteem across these studies. However, Nicholson and Long (1990) found that

for HIV positive gay men (N = 89), internalized homophobia and self-esteem were not correlated

significantly. There are also some mixed results with samples of lesbian and bisexual women.

For example, internalized homophobia was related negatively to self-esteem with a sample of

lesbian college women (N= 35; Peterson & Gerrity, 2006), a sample of non-college lesbian and

bisexual women (N= 303; Syzmanski & Chung, 2001), and a sample of lesbian women treated

for breast cancer (N = 57; McGregor et al., 2001). On the other hand, both Herek et al. (1997)

with a sample of lesbian and bisexual women recruited from an LGB street fair (N= 74), and

Mohr and Fassinger (2000) with a sample of lesbian women recruited from various community

sources (N= 590) found no significant relation between internalized homophobia and self-

esteem. One potential reason for these non-significant findings is that there were skewed

distributions and restricted ranges of scores for internalized homophobia, that may have

attenuated observed correlations between scores on internalized homophobia and self-esteem.

Indeed in both of these studies gay men had significantly higher levels of internalized

homophobia than lesbian women, and for gay men, internalized homophobia was related

significantly to self-esteem. Finally, with a sample of LGB persons (N = 583), Lease et al. (2006)

found that internalized homophobia was related negatively to overall psychological well-being

and life satisfaction.









Regarding the relation of concealment of sexual orientation with psychological well-

being, a study by Rosario, Rotheram-Borus, and Reid (1996) found that concealment of sexual

orientation was not linked to self-esteem for gay and bisexual, predominantly Hispanic and

Black youth (N= 134). However, they assessed concealment of sexual orientation with a

measure including frequency of disclosing one's sexual identity, having one's sexual identity

discovered by others, and having one's sexual identity ridiculed (Rosario et al, 1996). Thus, in

this study, concealment of sexual orientation was confounded with experiences related to anti-

LGB prejudice. In another study, Mohr and Fassinger (2000) found that for gay men (N= 590),

self-esteem was related negatively to concealing their sexual orientation to stranger, friends, and

work colleagues, but not to concealing their sexual orientation from their family members or

religious organization. Finally, for lesbian women (N = 414), concealment of sexual orientation

was not related to self-esteem (Mohr & Fassinger, 2000).

In general, the studies described above provide mixed support for the relations of the

minority stressors with self-esteem. However, none of the studies reviewed examined relations of

self-esteem with the set of minority stress variables concomitantly. Thus, the unique relations of

each of the minority stressors with self-esteem remain unclear. Also, aspects of well-being other

than self-esteem have been explored only minimally in the minority stress research. Although,

self-esteem is a component of psychological well-being, recent literature has conceptualized

psychological well-being as broader in scope (Ryff, 1989). Indeed Ryff (1989) defines

psychological well-being to include sense of autonomy, environmental mastery, personal growth,

positive relations with others, purpose in life, and self-acceptance. Self-esteem is conceptually

similar to and correlated significantly with scores on Ryff s (1989) measure of self-acceptance,

but self-esteem alone does not encapsulate the larger construct of well-being. Lease et al. (2005)









conducted the only study that examined the relation of a minority stressor (i.e., internalized

homophobia) with this broader measure of psychological well-being. Therefore, there is a need

for additional research to examine the relations of the set of minority stressors to psychological

well-being. As such, the present study will examine the relations of the set of minority stress

variables to psychological well-being using a measure based on Ryff s (1989) conceptualization

of psychological well-being. In addition to considering distress and well-being correlates of

minority stressors, the present study will examine the potential roles of spirituality and religiosity

in distress and well-being. Literature about the potential roles of spirituality and religiosity in the

distress and mental health of LGB persons is reviewed next.

Spirituality and Religiosity as Potential Health Promoting Factors, Stress-Mental Health
Buffers, or Mental Health Stressors

For counseling psychologists working with LGB clients, it is important to understand the

mechanisms that can lead to psychological distress and impede psychological well-being, and

minority stressors may be important variables to examine in this regard. It is also important,

however, to examine strengths and factors that could reduce distress, promote well-being and

protect clients from minority stress. Therefore, in addition to considering minority stressors, it is

necessary to examine factors that may play a role in positive functioning. Indeed, Meyer (1995)

stated "further work on minority coping needs to specify mechanisms that alleviate minority

stress" (p. 52). DiPlacido (1998) echoed this sentiment by highlighting that many LGB persons

successfully manage their minority stress so that they do not have any negative health outcomes.

Therefore she emphasized a need to investigate variables that might moderate or buffer the

negative health consequences of minority stress. Lastly, the BBSTF (1996) has called for

increased research on discovering how people successfully cope with disempowering situations.

Thus, there is a need for additional empirical research that examines potential mental health









promoting factors in the context of minority stressors' links with psychological distress and well-

being. As a step in addressing this need, the present study builds on prior literature to explore the

roles of spirituality and religiosity.

Davidson (2000) highlighted that counseling psychologists and therapists need to have a

greater understanding of the role of spirituality in the lives of LGB persons and that "because of

the oppression of heterosexist society, gay, bisexual, and lesbian persons are more in need of,

and more open to, spiritual nourishment than others" (p. 409). Unfortunately, attention to the

roles of spirituality and religiosity in the mental health of LGB persons has been limited.

Perhaps, since many mainstream religions condemn homosexuality (Boswell, 1980; Ellison,

1993), it is assumed that most LGB persons would have little to do with religious practices.

Anecdotal evidence, however, suggests that LGB persons are actively engaged in religious

practices. Indeed, Barret and Barzan (1996), two clinicians who identify as gay and have

expertise in working with LGB persons, stated "it has been our collective personal and

professional experiences that, in fact, the spiritual experiences of gay men and lesbians

frequently mirror those of nongay persons" (p. 5).

Beyond such testimonials, the limited empirical research on the religious participation of

LGB persons has yielded mixed findings. For example, Ellis and Wagemann (1993) found that

children who were not exclusively heterosexual were less religious and less likely to follow the

religion of their mother, as compared to exclusively heterosexual children. However, they

measured sexual orientation with a single item assessing percentage of time fantasizing about the

same sex. Thus, it is difficult to determine how these results apply to people who identify as

LGB. In contrast to these findings, Sherkat (2002) found that many LGB persons are active

religious participants. In a comparison of LGB persons and heterosexual persons, Sherkat (2002)









found that gay men have higher rates of religious participation than do heterosexual men, but that

lesbian and bisexual women and bisexual men have rates of religious participation that are lower

than heterosexual woman and men, respectively. Additionally, Sherkat (2002) found that

although LGB persons are more likely to abandon their religion than heterosexual women, they

were no more likely to abandon their religion than heterosexual men. Taken together, these

findings suggest that spirituality and religiosity are a part of some LGB persons' lives.

Additional theory and empirical research point to three possible roles of spirituality and

religiosity in the mental health of LGB persons: (a) spirituality and religiosity are mental health

promoting factors and so should be related negatively to psychological distress and positively to

psychological well-being, (b) spirituality and religiosity are moderators of the stress and mental

health relation, and (c) because many religions condemn non-heterosexuality, spirituality and

religiosity act as mental health stressors and will be related positively to psychological distress

and negatively to psychological well-being. The present study will examine these three

competing hypotheses within the context of the minority stress framework.

Potential Mental Health Promoters

The perspective that spirituality and religiosity are mental health promoting factors is

consistent with findings from studies using a variety of measures and with numerous samples of

the general population, that higher levels of spirituality and religiosity are linked to greater

physical and mental health (Brady et al., 1999; Ellison et al., 1989; Powell et al., 2003).

Conceptually, spiritual and religious beliefs are hypothesized to add comfort, relieve pain and

suffering, provide hope and meaning, and help people cope with their problems (C. E. Ross,

1990).

Numerous studies have examined the links of spirituality and religiosity with the physical

and psychological health of the general population. Indeed in a review of empirical research on









adults, older adults, and older patients, Powell et al. (2003) found some evidence that religious

service attendance was associated with lower rates of death and that religiosity (often measured

by frequency of service attendance) was associated with lower rates of cardiovascular disease. In

another review of empirical research on a variety of samples including adolescents, adults, and

older adults from the U.S. and abroad, Seeman, Dubin, and Seeman (2003) concluded that

Judeo-Christian practices of spirituality and religion were associated with lower blood pressure

and hypertension and better immune function. Additionally, they concluded that Zen, yoga, and

meditation practices were associated with better health outcomes in clinical patient populations

and with lower blood pressure, cholesterol, and stress hormone levels for a wide range of

samples including both U.S. and international samples, as well as for samples with a variety of

ages and health statuses. Lastly, C. E. Ross (1990) found that higher levels of religious beliefs

were associated with lower levels of psychological distress for a probability sample of Illinois

residents recruited through a random digit-dialing system (N = 401).

Based on such data, it may be that spirituality and religiosity could serve as mental health

promoting factors for LGB persons as well. Indeed there is theory and research that espouses the

benefits of spiritual and/or religious beliefs for LGB persons. For instance, Ritter and O'Neill

(1989) proposed that for many LGB persons, spirituality and religion may provide benefits such

as a sense of wholeness, a relationship to the Divine, and an affirmation of the person's basic

goodness. Additionally, Wagner et al. (1994) proposed that LGB persons who integrate their

religious faith with their sexuality might have greater self-acceptance and psychological well-

being. Miller (2005) described a case study of an African American gay man with AIDS who

used his spiritual and religious beliefs to cope with his disease. Additionally, in a qualitative

study of eight lesbian women suffering from cancer, Varner (2004) found that all of the women









found spirituality, and five of them found religion to be both supportive and health promoting.

Four quantitative studies on the topic also highlighted the potential benefits of spirituality and

religion. With a sample of HIV-infected gay men (N= 106), using religion as coping mechanism

(e.g., placing trust in God, seeking comfort in religion) was linked with fewer depressive

symptoms and religious behavior was linked with positive immunological status (Woods et al.,

1999). Additionally, spirituality and involvement in the social aspects of religion have been

found to be related significantly to greater self-esteem and acceptance of one's sexual

orientation, and to feeling less alienated (Tan, 2005; Yakushko, 2005). Lastly, Lease et al. (2005)

found that spirituality was related to greater psychological well-being and lower depressive

symptomatology for Caucasian LGB persons (N= 583). Overall, all of these studies are

consistent with conceptualizations of spirituality and religiosity as health promoters, such that

they are related negatively to psychological distress and positively to psychological well-being.

This study will test this position by examining concomitantly the unique relations of spirituality

and religiosity to the psychological distress and well-being of LGB persons, above and beyond

the roles of minority stress variables.

Potential Stress-Mental Heath Buffers

In addition to direct links of spirituality and religiosity with physical and mental health

outcomes, theory and empirical research has also pointed to spirituality and religiosity as

potential buffers of the relations between stress and negative health outcomes. For instance,

spirituality and religiosity may buffer against stress by providing a framework for interpreting

stressful events, enhancing coping resources, and facilitating access to social support (Siegel et

al., 2001). Indeed, with various samples, there is empirical support for the notion that spirituality

and religiosity are moderators of the relationship between stress and negative health conditions.

For instance, Mascaro and Rosen (2006) found that spirituality moderated the relation between









daily stress and depression for college students (N= 143) such that the relation between stress

and depression was positive for those with low levels of spirituality and non-significant for those

with high levels of spirituality. Additionally with college students (N= 120), Fabricatore et al.

(2000) found that spirituality moderated the relation of stress (e.g., daily hassles, significant life

events) with life satisfaction. The results indicated that for participants low in spirituality, there

was a significant and negative relation between stress and life satisfaction, whereas for those

high in spirituality, there was no significant relation between stress and life satisfaction.

Additionally, in a four-year longitudinal study of adolescents (N = 1,182), Wills et al. (2003)

found that religiosity buffered the relation of stressful life events with substance use.

Specifically, there was a significant reduction in the effect size of the relation between stressful

life events and substance use for those with high religiosity compared to those with low

religiosity. Also, religiosity moderated the relation of family dysfunction with disordered eating

for college women (N = 876), such that when participants had high levels of religiosity there was

no relationship between family risk and disordered eating, but when participants had low levels

of religiosity, there was a significant positive relation between family risk and disordered eating

(Forthus et al., 2003).

Finally, spirituality has been shown to serve as a buffer of minority stress. Specifically,

Bowen-Reid and Harrell (2002) found that, for African American college students (N= 155),

spirituality moderated the relation between racist stressful events and psychological distress. For

participants with high levels of spirituality, there was no significant relation between perceived

racist stressful events and psychological distress; but, for participants with low levels of

spirituality, there was a significant and positive relation between perceived racist stressful events

and psychological distress. Based upon this literature, this study will explore the possibility that









spirituality and religiosity moderate or buffer the relations of minority stressors with

psychological distress and well-being for LGB persons.

Potential Mental Health Stressors

Despite the literature suggesting potential benefits of spirituality and religiosity for LGB

persons, there is also theory and research that suggests possible spiritual wounding for LGB

persons due to their participation in religions that describe same-gender sexual orientation as

sinful. Indeed, James (1928) proposed that for a religion to be useful it must be philosophically

reasonable, morally helpful, and spiritually illuminating. However, Ritter and O'Neill (1989)

explained that for LGB persons', traditional Judeo-Christian religions do not provide these

necessary facets and instead "have heaped accusations of shame, contamination, and sinfulness,

upon the heads of lesbian and gay people" (p.68). Additionally, Barret and Brazan (1996)

described that there is a fundamental struggle for LGB persons to overcome the clash between

homophobic religious institutions and personal spiritual experiences that connect them to a

higher power.

Empirical research also demonstrates the potential negative implications of religiosity for

LGB persons. Qualitative research has shown that many LGB persons feel that they must choose

between being LGB and being religious (Rodriguez & Ouellette, 2000). Furthermore,

quantitative research indicates that being religious in a non-gay affirming church and holding

conservative religious views are correlated with internalized homophobia (Meyer & Dean, 1998;

Wagner et al., 1994). Lastly, religiously oriented programs aimed at changing the sexual

orientation of LGB persons have been shown to be psychologically damaging (Beckstead &

Morrow, 2004). Due to these negative experiences that many LGB persons could face within

their religions, spirituality and religious participation may be related to poor mental health for

LGB persons. Therefore, the perspective that spirituality and religiosity are mental health









stressors that are related positively to psychological distress and negatively to psychological

well-being will be examined in the present study.

Attending to Distinctions Between Spirituality and Religiosity

In addition to testing the three different perspectives about the roles of spirituality and

religiosity in LGB persons' mental health, the present study will attend to potentially distinct

roles played by spirituality and religiosity. More specifically, spirituality and religiosity are

related (Hill et al., 2000; Hill & Pargament, 2003), but theorists have highlighted that they are

not identical constructs (Miller & Thoresen, 2003). Spirituality is considered an individual

experience that includes a personal connection to a Sacred or Higher Being, personal

transcendence, and meaningfulness (Zinnbauer et al. 1997). Religiosity on the other hand is

defined more narrowly to include participating in formally structured religious institutions,

prescribed theology, and rituals (Zinnbauer et al. 1997).

Empirical data are consistent with the notion that spirituality and religiosity are related

but distinct constructs. For instance, Zinnbauer et al. (1997) asked participants (N= 346) from a

wide range of religious backgrounds to define the terms religiousness and spirituality in addition

to reporting the degree to which they considered themselves religious and spiritual. A content

analysis of these responses revealed that the definitions of spirituality and religiousness differed.

The definitions of spirituality most frequently included feelings of connectedness with and

personal beliefs about God or a Higher Power, feelings of transcendence, attaining a state of

inner peace, and obtaining actualization. On the other hand, the most frequent definitions of

religiousness included belief or faith in God or a Higher Power, organizational practices or

activities such as attendance at religious services, performance of rituals, and belief in

institutionally based dogma. Thus, although the definitions included some common features,

such as a belief in God, there are significant differences in that spirituality mainly focused on a









personal relationship or connection with a Higher Power and religiousness focused on

institutional beliefs and practices. Zinnbauer et al. (1997) also found that although the majority

of participants considered themselves to be spiritual and religious (74%), a number of

participants considered themselves to be spiritual but not religious (19%) or religious but not

spiritual (3%). Lastly, in this study, spirituality and religiosity had some different correlates. For

example spirituality, but not religiosity, was related positively to education, income, mystical

experiences, and being hurt by clergy in the past, while religiosity, but not spirituality, was

related positively to parent's church attendance during childhood, interdependence with others,

and a positive view of religion.

Despite the distinctiveness of spirituality and religiosity, however, a limitation in much

of the prior research is that these constructs are not assessed separately. The distinction between

spirituality and religiosity may be especially important for LGB persons because many religions

condemn non-heterosexuality. Such condemnation may lead some LGB persons to have a

strained relationship with their religious institutions, but not necessarily with their individual

spirituality. Indeed Schuck and Liddle (2001) found that for LGB persons (N= 66) nearly two-

thirds reported having conflicts between their religion and their sexual orientation and that fifty-

three percent of the respondents tried to resolve this conflict by considering themselves spiritual

rather than religious. Additionally, Lease and Shulman (2003) found that family members of

LGB persons made a distinction between their spiritual beliefs (e.g., personal connection to a

loving Higher Power) and organized religion. Lease and Shulman (2003) also found that spiritual

beliefs were more important in helping the participants understand and accept their family

member's sexual orientation than was participation in a particular religion. Indeed, family

members of LGB persons often have to struggle with integrating their religious beliefs, which









may condemn non-heterosexuality, and their love for their LGB family member. This struggle

that family members of LGB persons experience, may parallel the struggle that LGB persons

themselves grapple with. Additionally, Ritter and O'Neill (1989) explained that some LGB

persons cope with the homonegativity that they receive in their traditional religions by turning to

their spirituality, and enriching it, with ancient or non-Judeo-Christian expressions such as

Shamanism and Native American Spirituality. Thus, the distinction between spirituality and

religiosity may be particularly important to attend to in research with LGB persons and this study

will examine if spirituality and religiosity have distinct, rather than parallel roles in the

psychological distress and well-being of LGB persons.

Purpose of Study

Based on the literature reviewed here, and using the minority stress framework, the

present study advances understanding of LGB persons' psychological distress and well-being in

a number of ways. First, this study examines concomitantly the relations of the four minority

stress variables (i.e., perceived experiences of prejudice and discrimination, expectations of

stigma, internalized homophobia, and concealment of sexual orientation) to psychological

distress and psychological well-being of LGB persons. Second, this study examines the potential

additional roles of spirituality and religiosity in the psychological distress and well-being of LGB

persons. Specifically, based on prior theory and empirical research about the roles of spirituality

and religiosity in the mental health of LGB persons, this study will test three rival hypotheses

that spirituality and religiosity are (a) mental health promoters, (b) buffers of the stress and

mental health relation, or (c) mental health stressors. Finally, the present study will explore the

potentially distinct roles of spirituality and religiosity in LGB persons' psychological distress and

well-being. To address these aims, the present study tests the following hypotheses:









1. Based on the minority stress framework it is expected that perceived experiences of prejudice

and discrimination, expectations of stigma, and internalized homophobia will be linked

uniquely and positively with psychological distress and uniquely and negatively with

psychological well-being. Given the mixed prior findings about the role of concealment of

sexual orientation, its unique relation will be examined, but no specific hypothesis is made.

2. Three competing hypotheses will be explored separately for spirituality and religiosity:

a. Spirituality and religiosity are mental health promoters and will be related negatively

to psychological distress and positively to psychological well-being.

b. Spirituality and religiosity are buffers in the stress-mental health relation and

moderate the relations of perceived prejudice events, expectations of stigma,

internalized homophobia, and concealment of sexual orientation to psychological

distress and well-being.

c. Spirituality and religiosity are mental health stressors and will be related positively to

psychological distress and negatively to psychological well-being.

To allow for the examination of distinct roles played by spirituality and religiosity, these

variables will be assessed and examined as separate variables in the tests of the hypotheses.









CHAPTER 3
METHODS

Participants

Analyses were based on data from 398 participants. With regard to gender, 48% (n = 190)

of participants identified as female, 49% (n = 195) as male, 1% (n = 3) as transgender male-to-

female, and 1% (n = 4) as transgender female-to-male. Participants ranged in age from 18 to 70

years (M= 38.3, SD = 12.9, Mdn = 38). In terms of sexual orientation, 62% (n = 246) of

participants self identified as exclusively lesbian/gay, 21% (n = 83) as mostly lesbian/gay, and

15% (n = 61) as bisexual. With regard to race/ethnicity, 68% (n = 271) identified as Caucasian,

followed by 8% (n = 31) African-American/Black, 4% (n = 17) Native American, 4% (n = 16)

Hispanic, 4% (n = 16) Asian American, 5% (n = 18) multiracial, and 6% (n = 23) other. In terms

of social class, 7% (n = 28) of the sample identified as lower class, 24% (n = 95) as working

class, 46% (n = 184) as middle class, 18% (n = 72) as upper middle class, and 2% (n = 9) as

upper class.

Approximately 25% (n = 100) of the sample reported that they had no current religious

affiliation and 12% (n = 49) reported that they were agnostic. Other participants identified as

current adherents of Catholicism (7%, n = 29), Buddhism (6%, n = 24), Judaism (5%, n = 21),

the Baptist denomination (5%, n = 20), Universal Unitarianism (4%, n = 15), Native American

Spiritualities (3%, n = 13), Paganism (3%, n = 11), the Methodist denomination (3%, n = 10), the

Universal Fellowship of Metropolitan Community Churches (3%, n = 10), Presbyterianism (2%,

n = 8), Episcopalianism (2%, n = 8), Hinduism (2%, n = 6), and Quakerism (1%, n = 5). An

additional 8% (n = 31) identified as other Christian denominations. With respect to current

attendance to religious services, 5% (n = 21) reported attending more than once a week, 11% (n

= 42) attending once a week, 6% (n = 23) attending twice a month, 5% (n = 20) attending once a









month, 22% (n = 86) attending less than once a month, and 49% (n = 194) never attending.

Approximately 91% of participants (n = 360) reported currently living in the United States,

whereas 8% (n = 31) were living in other countries. With regard to the 31 participants who

reported living in countries other than the United States, 23% reported residing in Canada (n =

7), 16% in the United Kingdom (n = 5), 13% in Mexico (n = 4), 10% in Turkey (n = 3), 6% in

Australia (n =2), and 32% (n = 10) living in a variety of other countries (e.g., Argentina,

Portugal, South Africa) with 1 participant residing in each of these countries. These international

participants correctly responded to the validity check items (described next), indicating that they

were able to read and understand the instructions and survey questions.

Procedures

Participants were recruited through advertising in LGB Internet listserves and groups and

through networking with personal contacts. Advertisements were sent to a variety of listserves

specifically including those that focused on LGB, spiritual, and religious issues and those that

had a combined focus on LGB issues and spirituality or religiosity. The study was also

advertised through various Yahoo, Google, Facebook, and My Space groups. In addition,

listerserves, Internet groups, and organizations serving racial/ethnic and religious minority LGB

persons were targeted in an attempt to obtain a racially, ethnically, and religiously diverse

sample.

Data were collected using an online survey. Research has shown some potential benefits

of online data collection. Specifically, Internet samples have been shown to be relatively diverse

with respect to age, gender, geographic regions, and socioeconomic status (Gosling, Vazire,

Srivastava, & John, 2004). Also, findings from online data collection have been found to be

consistent with findings from traditional data collection methods (Gosling et al., 2004).

Furthermore, large numbers of LGB participants may be easily recruited via the Internet (Epstein









& Klinkenberg, 2002). Online data collection also may result in better representation of

individuals who are less "out" about their sexual orientation than do data collection strategies

that require lesbian and gay persons to "come out" to researchers in person (Epstein &

Klinkenberg, 2002). Lastly, with online surveys, LGB participants may feel that they have a

greater sense of privacy and anonymity, which may encourage them to be more open and honest

with their responses (Riggle, Rostosky, & Reedy, 2005).

The study advertisements directed participants to an online survey. Upon connecting to

the survey website, the informed consent was displayed which described the purpose of the

study, confidentiality of responses, and contact information of the researcher. Participants then

clicked a link that served as an indication that they were voluntarily agreeing to participate, and

they were then taken to the survey. The survey instruments were counterbalanced to reduce order

effects. Embedded into each of the measures in the survey was a validity item. These items

directed participants to respond in a particular manner. For example, an item asked participants

to select the option for "strongly agree." The purpose of these items was to identify random

responding, and to ensure that participants were reading and understanding the questions.

Following the completion of the survey, all participants received a thank you note, debriefing

message, and the researcher's contact information so that any additional questions or concerns

could be addressed. A total of 803 surveys were submitted and screened to eliminate (a) 7

participants who were ineligible because they identified as either exclusively or mostly

heterosexual, (b) 25 instances of potential random responding (i.e., more than one inaccurate

validity item response), and (c) 373 surveys missing substantial amounts of data. Of the 373

surveys with substantial missing data, 113 only had the informed consent completed and









completed no survey items. The resulting final sample size used for the present analyses is 398

LGB persons.

Instruments

Criterion Variables

Psychological distress was measured with the Hopkins Symptom Checklist-21 (HSCL-

21). The HSCL-21 (Green, Walkey, McCormick, & Taylor, 1988) is a 21-item version of the

longer 58-item Hopkins Symptom Checklist (Derogatis, Lipman, Rickels, Uhlenhuth & Covi,

1974). It assesses psychological distress along the dimensions of general distress, somatic

distress, and performance difficulty. The HSCL-21 items are rated on a 4-point continuum (1 =

not at all to 4 = extremely). Sample items include, "Feeling inferior to others," and "Blaming

yourself for things." Item ratings were averaged to yield an overall score, with higher scores

indicating higher levels of psychological distress. HSCL-21 items had a Cronbach's alpha of .90

in prior research (Green et al., 1988). Validity of HSCL-21 scores was supported by significant

correlations with maladaptive perfectionism, perceived stress, and hopelessness (Kawamura &

Frost, 2004; Moller, Fouladi, McCarthy, & Hatch, 2003). Additionally, the HSCL-21 has been

used with diverse samples including substance abuse users (Downey, Rosengren, & Donovan,

2003), East Asian immigrants in the United States (Declan & Mizrahi, 2005), and international

students (Komiya & Eells, 2001). With the current sample, HSCL-21 items yielded a Cronbach's

alpha of .92.

Psychological well-being was assessed with the Psychological Well-Being Scale (PWB).

The PWB (Ryff, 1989) is a theoretically based measure, assessing psychological well-being

conceptualized to reflect autonomy, environmental mastery, personal growth, positive relations

with others, purpose in life, and self-acceptance. The PWB is an 84-item, 6-point Likert-type

scale (1 = strongly disagree to 6 = strongly agree). Sample questions include, "I feel like I get a









lot out of my friendships," and "In general, I feel confident and positive about myself." Item

ratings were averaged to yield an overall score, with higher scores indicating higher levels of

psychological well-being. With a sample of LGB persons, PWB items had a Cronbach's alpha of

.96 (Lease et al., 2005). Validity of PWB scores was demonstrated with significant correlations

with theoretically related constructs such as self-esteem and life satisfaction (Ryff, 1989).

Similar to Lease et al. (2005), in the present study, the Purpose in Life subscale items were not

assessed because of high conceptual overlap with the measure of spirituality, and an overall

PWB average score was computed without the Purpose of Life subscale items. Cronbach's alpha

for PWB items with the current sample was .97.

Predictor Variables

Perceived Experiences of prejudice were assessed with the Schedule of Heterosexist

Events (SHE). Selvidge (2000) developed the 18-item SHE to measure the frequency of

perceived prejudice events that lesbian and bisexual women encountered. Selvidge (2000)

developed this measure by adapting the Schedule of Sexist Events (Klonoff & Landrine, 1995),

and parallel versions of this measure have been used to asses perceived racist events with

African American and Arab American persons as well (Landrine & Klonoff, 1996; Moradi &

Hasan, 2004). In the current study, items were modified to be inclusive of gay and bisexual men

in addition to lesbian and bisexual women. Sample items include, "How many times have you

been treated unfairly by your family because you are lesbian, gay, or bisexual?" and "How many

times have you been really angry about something heterosexist or homophobic that was done to

you?" Items were rated on a 6-point continuum (1 = never to 6 = almost all of the time); item

ratings are averaged, and higher scores indicate more frequent experiences of prejudice. In two

samples of lesbian and bisexual women, Selvidge (2000) found Cronbach's alphas of .91 and .92

for SHE items. Supporting validity of SHE scores, Selvidge found a positive correlation between









SHE scores and self-concealment and a negligible correlation between SHE scores and self-

monitoring. In the current sample, Cronbach's alpha for SHE items was .93.

Expectations of stigma were assessed with the Stigma Consciousness Questionnaire for

Gay Men and Lesbians (SCQ). The LG version of the SCQ (Pinel, 1999) was designed to

measure the extent to which LG persons expect to be stigmatized by others. The version of the

measure used by Pinel was modified slightly to apply to bisexual persons as well. The SCQ is a

10-item, 7-point Likert-type scale (1 = strongly disagree to 7 = strongly agree). Sample items

include, "Most heterosexuals have a lot more homophobic thoughts than they actually express,"

and "Stereotypes about gay, lesbian, or bisexual persons have not affected me personally

(reverse scored)." Item ratings were average with higher scores indicating greater expectations of

stigma. SCQ items had adequate internal consistency with Cronbach's alpha of .81 and items

load on a single factor (Pinel, 1999). Pinel reported that, as expected, SCQ scores were

significantly and positively correlated with scores on measures of perceived discrimination and

past experiences of discrimination. Additionally, discriminant validity was demonstrated in that

SCQ scores were not related to social anxiety (Pinel, 1999). In the current sample, Cronbach's

alpha for SCQ items was .79.

Internalized Homophobia was assessed with the InternalizedHomophobia (IHP) scale.

Martin and Dean (1987; as cited in Herek et al., 1997) originally created the IHP as interview

questions with gay men. The current study used the self-report version used by Herek et al.

(1997) that is applicable to LGB persons. The IHP is a 9-item, 5-point Likert-type scale (1 =

disagree strongly to 7 = agree strongly). Sample items include "I feel that being gay, lesbian, or

bisexual is a personal shortcoming for me," and "I wish I weren't gay, lesbian, or bisexual."

Items ratings were averaged, with higher scores indicating greater levels of internalized









homophobia. In terms of reliability, IHP items had Cronbach's alphas of .71 and .83 for women

and men, respectively. As expected, Herek et al. (1997) found that compared to those with low

IHP scores, men and women with high IHP scores reported significantly higher levels of

depression and demoralization and lower levels of self-esteem. With the current sample,

Cronbach's alpha for IHP items was .90.

Disclosure versus Concealment of sexual orientation was assessed with the Outness

Inventory (01). The OI (Mohr & Fassinger, 2000) measures the degree to which respondents'

sexual orientation is disclosed versus concealed with people in different areas of their lives. The

10 OI items are rated on a 7-point continuum (1 = person definitely does not know about your

sexual orientation status to 7 = person definitely knows about your sexual orientation status, and

it is openly talked about). The OI has three subscales that assess concealment of sexual

orientation with different sets of people including "Out to the World" (e.g., my new straight

friends), "Out to Family" (e.g., mother, siblings), and "Out to Religion" (e.g., leaders of my

religious community). For ease of interpretation, item ratings were reverse coded and averaged

so that higher scores indicated greater concealment of sexual orientation and lower scores

indicated greater disclosure of sexual orientation. Based on the results of a factor analysis of OI

items, Mohr and Fassinger concluded that either the full scale or individual subscales could be

used when analyzing OI data. Since the focus of this study is on overall level of concealment of

sexual orientation, results will be analyzed using the overall score. Validity for OI scores has

been demonstrated by positive correlations of outness with level of self-acceptance about same-

sex desires and identification with LG communities. Lastly, OI items had a Cronbach's alpha of

.85 with a sample of LGB persons (Moradi et al., 2006) and Cronbach's alpha for OI items with

the current sample was .91.









Spirituality was assessed with the Spiritual Involvement and Beliefs Scale (SIBS). The

SIBS (Hatch, Burg, Naberhaus, & Hellmich, 1998) was designed to assess spiritual beliefs,

involvement, and activities including a relationship with a higher power, fulfillment from

nonmaterial things, faith, and trust. The SIBS is a 26-item, 5-point Likert-type scale (1 = strongly

agree to 5 = strongly disagree). Sample items include, "Some experiences can be understood

only through one's spiritual beliefs," and "My spiritual life fulfills me in ways that material

possessions do not." Item ratings were averaged and higher scores indicate a greater level of

spirituality. Validity for SIBS scores has been demonstrated by expected correlations between

these scores and other indicators of spirituality including scores on the Spiritual Well-Being

Scale, The Santa Clara Strength of Religious Faith Questionnaire, and the Intrinsic subscale of

the Religious Orientation scale (Hatch et al., 1998; Lease et al., 2006). Reliability for SIBS

scores has been indicated by strong test-retest reliability (r = .92), and high internal consistency

with Cronbach's alpha of .92 (Hatch et al., 1998). The SIBS also was used with a sample of LGB

persons and yielded a Cronbach's alpha of .75 (Lease et al., 2006). With the current sample,

Cronbach's alpha for SIBS items was .92.

Religiosity was assessed with the Religious Commitment Inventory-10 (RCI-10) scale.

The RCI-10 (Worthington et al., 2003) was designed to assess the degree to which respondents

adhere to their religious beliefs, practices, and values and use them in daily living. The RCI-10

was created to be a shorter and more psychometrically sound version of the previous 62, 20, and

17-item Religious Commitment Inventories. The 10 items of the RCI-10 are rated on a 5-point

continuum (1 = not at all true of me to 5 = totally true of me). Sample items include, "I enjoy

working in the activities of my religious organization," and "My religious beliefs lie behind my

whole approach to life." Item ratings were averaged and higher scores indicate a greater level of









religiosity. Validity of RCI-10 scores has been demonstrated by their correlations with other

related constructs such as frequency of religious service attendance and measures of religiosity

(Worthington et al., 2003). Additionally, RCI-10 items have strong internal consistency

(Cronbach's alpha ranging from .88 .96) and test-retest reliability with estimates of .87 for three

weeks and .84 for five months (Worthington et al., 2003). RCI-10 items yielded a Cronbach's

alpha of .95 with the current sample.









CHAPTER 4
RESULTS

Preliminary analyses were conducted to examine descriptive information, and to explore

potential gender and order effects in the data. Tests of hypotheses were conducted following

these preliminary analyses.

Descriptive Statistics

The present sample's means and standard deviations on the variables of interest (see

Table 1) were generally comparable to those obtained in previous samples of LGB persons.

More specifically, relatively low levels of psychological distress were reported by the current

sample (M= 1.70, SD= .53). These low scores are comparable to HSCL-58 scores reported by

Szymanski (2005) with a sample of lesbian women (M= 1.44, SD = .32). Scores for

psychological well-being (M= 4.53, SD = .79) were similar to scores reported by Lease et al.

(2005) with a sample of LGB persons (M= 4.81, SD= .64). The present sample's scores for

experiences of prejudice (M= 2.22, SD = .75) were similar to scores reported by Goodman et al.

(2005) with a sample of LGB persons (M = 2.23, SD = .76). The current sample's scores for

expectations of stigma (M= 4.31, SD = 1.03) were similar to those reported by Lewis et al.

(2003) with a sample of LGB persons (M= 4.32, SD= .64). The current sample's scores for

internalized homophobia (M= 1.54, SD = .78) were also similar to those reported by Lewis et al.

(2003) with a sample of LGB persons (M= 1.52, SD= .64). The sample's scores for

concealment of sexual orientation were (M= 3.58, SD = 1.56). However, when sample's score

for the Outness Inventory were not reversed scores they were (M = 4.42, SD = 1.56), which fell

between those reported by Moradi et al. (2006) for a Caucasian sample (M = 4.70, SD = 1.36)

and racial/ethnic minority sample (M= 3.78, SD = 1.35) of LGB persons. Likewise, scores for

spirituality for the current sample (M= 4.69, SD = 1.16) were similar to those reported by Lease









et al. (2005) with a sample of LGB persons (M= 4.03, SD = .35). Lastly, with respect to

religiosity, scores for the current sample were (M= 2.16, SD = 1.14). No study was found that

used the Religious Commitment Inventory-10 with a sample of LGB persons. However, the

present sample's scores were similar to scores reported by Worthington et al. (2003) with

samples of university students (M= 2.31, SD = 1.02) and clients in a secular counseling center

(M= 2.14, SD = 1.17). Skewness and kurtosis values for all variables of interest met

recommended cut-offs for normality (Weston and Gore, 2006).

Gender Comparisons

To explore potential gender differences in the data, a MANOVA was conducted with

gender as the independent variable and the variables of interest (i.e., psychological distress,

psychological well-being, experiences of prejudice, expectations of stigma, internalized

homophobia, concealment of sexual orientation, spirituality, and religiosity) as dependent

variables. To be inclusive of transgender persons, male-to-female transgender persons were

categorized as women and female-to-male transgender persons were categorized as men. Box's

test of equality of covariance matrices and Levene's test of equality of error variances were not

significant indicating that data met assumptions of homogeneity of covariance matrices and

variance. The overall model was significant (F [1, 378] = 3.35,p < .01, r = .07), indicating a

significant but small gender difference in the set of dependent variables. Follow-up univariate

analyses, with alpha adjusted to .01 (given that there were 8 comparisons), indicated no

significant gender differences on the individual dependent variables. With alpha of .05, there

were small but significant gender differences on psychological well-being (F [1, 378] = 4.77, p

< .05, rp = .01), with women (M= 4.63, SD = .73) reporting slightly greater well-being than

men (M= 4.46, SD = .82); and on religiosity (F [1, 378] = 5.30,p < .05, rP = .01), with men









(M= 2.30, SD = 1.17) reporting slightly greater religiosity than women (M= 2.03, SD = 1.10).

Gender accounted for approximately 1% of variability in these data. Parallel results were found

when gender comparisons were made with transgender persons excluded from the analyses;

again, the overall model was significant, but no gender effects were significant with alpha

adjusted to .01, and only psychological well-being yielded a significant gender effect with alpha

at .05, again with women scoring higher than men. Thus, overall, gender differences on the

dependent variables were non-significant or negligible. As such, hypotheses were tested with the

entire sample, and without gender as a covariate.

Test for Order Effects

To test for order effects across the two orders of the survey, a MANOVA was conducted

with survey order as the independent variable and the variables of interest (i.e., psychological

distress, psychological well-being, experiences of prejudice, expectations of stigma, internalized

homophobia, concealment of sexual orientation, spirituality, and religiosity) as dependent

variables. Box's test of equality of covariance matrices and Levene's test of equality of error

variances were not significant indicating that the data met assumptions of homogeneity of

covariance matrices and variance. The overall model was significant (F [1, 384] = 2.25,p <.05,

r2 = .05) suggesting a significant but small order difference in the set of dependent variables.

Again given the number of comparisons being conducted, a more conservative alpha of .01 was

used for follow-up univariate analyses. These analyses indicated that there were no significant

order effects at thep = .01 level. At the less conservative = .05 level, only religiosity yielded a

significant order effect (F [1, 384] = 5.42, p < .05, r/p = .01), with the order effect accounting for

approximately 1% of variance in the data. Thus, overall, order effects on the dependent variables

were non-significant or negligible.









Minority Stress Framework: Hypothesis 1

Hypothesis 1 was that experiences of prejudice and discrimination, expectations of

stigma, and internalized homophobia are linked uniquely and positively with psychological

distress and uniquely and negatively with psychological well-being. Given the mixed prior

findings about the role of concealment of sexual orientation, no specific hypothesis was made

about its relation to psychological distress and well-being.

Zero-order correlations were computed to test hypothesized relations among variables of

interest (see Table 1). Psychological distress was correlated positively with reported experiences

of prejudice (r = .33, p < .001), expectations of stigma (r = .30, p < .001), internalized

homophobia (r = .38, p < .001), and concealment of sexual orientation (r = .21, p < .001).

Additionally, psychological well-being was correlated negatively with reported experiences of

prejudice (r = -. 17, p < .001), expectations of stigma (r = -.30, p < .001), internalized

homophobia (r = -.51, p < .001), and concealment of sexual orientation (r = -.38, p < .001).

To examine the unique relation of each minority stressor with each mental health

indicator, simultaneous multiple regression analyses were conducted. In the first equation,

experiences of prejudice, expectations of stigma, internalized homophobia, and concealment of

sexual orientation were regressed on psychological distress. These predictors were associated

significantly with psychological distress, R = .49, F(4, 389) = 31.19, p < .001, accounting for

24% of the variance in distress (see Table 2). Inspection of individual variables indicated that

reported experiences of prejudice (B = .30, t = 5.62, p < .001), internalized homophobia (B = .28,

t = 5.38,p < .001), and concealment of sexual orientation (B = .12, t = 2.37, p < .05), but not

expectations of stigma, each accounted for unique variance in psychological distress. In the

second equation, experiences of prejudice, expectations of stigma, internalized homophobia, and

concealment of sexual orientation were regressed on psychological well-being. These predictors









were significantly associated with psychological well-being, R = .57, F(4, 389) = 45.59, p < .001,

accounting for 32% of the variance (see Table 2). Inspection of individual variables indicated

that reported experiences of prejudice (B = -.11, t = -2.22, p < .05), expectations of stigma (B = -

.12, t = -2.50, p < .05), internalized homophobia (B = -.37, t = -7.50, p < .001), and concealment

of sexual orientation (B = -.21, t = -4.36, p < .001) each accounted for unique variance in

psychological well-being.

Thus, Hypothesis 1 was mostly supported. Participants who reported greater experiences

of prejudice, internalized homophobia, and concealment of sexual orientation, but not

expectation of stigma also reported more psychological distress. Additionally participants who

reported greater experiences of prejudice, expectations of stigma, internalized homophobia, and

concealment of sexual orientation also reported less psychological well-being.

The Roles of Spirituality and Religiosity: Hypothesis 2

Three competing hypotheses were presented for the potential roles of spirituality and

religiosity in relation to psychological distress and well-being: (a) that they are mental health

promoters (i.e., related to lower distress and greater well-being), (b) buffers (i.e., moderators) in

the stress-mental health relation, (c) or mental health stressors (i.e., related to greater distress and

lower well-being).

Spirituality and Religiosity as Mental Health Promoters (Hypothesis 2a) or Stressors
(Hypothesis 2c)

Zero-order correlations revealed that spirituality and religiosity were not correlated

significantly with psychological distress. Furthermore, spirituality (r = .25, p < .001), but not

religiosity, was correlated positively with psychological well-being (see Table 1). Additional

exploratory analyses indicated that neither current nor childhood attendance at religious services

was related to psychological distress or well-being. Lastly, there was no mean difference in









psychological distress or well-being between participants who indicated that religion and

spirituality are important parts of their lives and participants who indicated that religion and

spirituality are not important parts of their lives.

Additionally, Hypothesis 2a and 2c were tested by conducting two hierarchical multiple

regression analyses with the set of four minority stressors entered as step one and spirituality and

religiosity entered as step 2 to determine their unique relations with psychological distress and

well-being, above and beyond the set of minority stressors. In the first equation, with

psychological distress as the criterion variable, spirituality and religiosity did not account for

unique variance, beyond that accounted for by the set of minority stress variables (see Table 3).

In the second equation, with psychological well-being as the criterion variable, spirituality and

religiosity accounted for an additional 7% of variance beyond that accounted for by minority

stressors (see Table 3). Specifically, both spirituality (8 = .37, t = 6.33,p < .001) and religiosity

(8 = -.18, t = -3.03, p < .01) accounted for unique variance in psychological well-being, with

spirituality related uniquely and positively and religiosity related uniquely and negatively with

psychological well-being. Thus, Hypotheses 2a and 2c were partially supported in that the data

were consistent with the view of spirituality as a well-being promoter and religiosity as a well-

being stressor.

Spirituality and Religiosity as Buffers in the Stress-Mental Health Relation (Hypothesis 2b)

To test Hypothesis 2b, regarding the potential moderating roles of spirituality and

religiosity in the relations of perceived experiences of prejudice and discrimination, expectations

of stigma, internalized homophobia, and concealment of sexual orientation with psychological

distress and well-being, the recommendations of Barron and Kenny (1989) to use moderator

regression analyses were followed. Following recommendations by Aiken and West (1991),

predictor and moderator variables were centered (i.e., mean deviation scores were computed) to









reduce multicollinearity between the interaction term and the main effects when testing for

moderator effects. In order to test for moderation, a series of hierarchical multiple regression

analyses were conducted; eight to test spirituality as a moderator of the relation of each of the

four minority stressors with (a) psychological distress and (b) psychological well-being and

another eight to test religiosity as a moderator in these relations. For each analysis, the centered

minority stressor was entered in Step 1 predicting psychological distress or well-being. In Step 2

of each regression, centered scores for either spirituality or religiosity were entered. Lastly, in

Step 3, scores reflecting the interaction between the respective centered minority stressor and

centered spirituality or religiosity scores (e.g., experiences of prejudice scores multiplied by

spirituality scores) were entered. Significant moderation is indicated if adding the interaction

term results in a significant change in R2, and the beta weight for the interaction term is

significant. Given the difficulty in detecting interaction effects with correlational research, use of

liberal alphas (e.g., .10) has been recommended (McClelland & Judd, 1993). But, due to the

number of regression equations conducted to test for moderation in the present study, alpha was

set at .05. None of the interaction terms emerged as significant in the regressions for

psychological distress or well-being. Thus Hypothesis 2b that spirituality and religiosity were

buffers in the stress-mental health relation was not supported.










Table 4-1. Summary statistics and correlations among the variables of interest
Variables 1 2 3 4 5 6 7 8
1. Psychological distress ---
2. Psychological well-being -.68** ---
3. Perceived experiences of prejudice .33** -.17** ---
4. Expectations of stigma .30** -.30** .49** ---
5. Internalized homophobia .38** -.51** .12* .25** ---
6. Concealment of sexual orientation .21** -.38** -.17** .09 .47** ---
7. Spirituality -.07 .25** .11* .02 -.01 -.06 ---
8. Religiosity .02 .02 .11* .09 .14** -.03 .72** ---
M 1.70 4.53 2.22 4.31 1.54 3.58 4.69 2.16
SD .53 .79 .75 1.03 .78 1.56 1.16 1.14
ac .92 .97 .93 .79 .90 .91 .92 .95
Possible Range 1-4 1-6 1-6 1-7 1-5 1-7 1-7 1-5
Higher scores indicate higher levels of the construct assessed. *p <.05, **p <.01.


Table 4-2. Simultaneous regression equations of minority stressors regressed on psychological distress and well-being
Total Adjusted
Variable B SEB B t R R2 R2 F df

Psychological distress
Perceived experiences of prejudice .20 .04 .30 5.62** .49 .24 .24 31.19** 4,389
Expectations of stigma .03 .03 .05 1.02
Internalized homophobia .19 .04 .28 5.38**
Concealment of sexual orientation .04 .02 .12 2.37*

Psychological well-being
Perceived experiences of prejudice -.11 .05 -.11 -2.22* .57 .32 .31 45.59** 4,389


Expectations of stigma
Internalized homophobia
Concealment of sexual orientation
*p <.05. **p <.01.


-.09
-.37
-.11


.04 -.12 -2.50*
.05 -.37 -7.50**
.02 -.21 -4.36**










Table 4-3. Hierarchical regression equations examining unique links of spirituality and religiosity with psychological distress and
well-being
Total Adjusted
Step Predictor B 3f t R2 R2 A R2 AF df
Psychological distress
1.26 .25 .26 32.56** 4, 380
Perceived experiences of prejudice .21 .31 5.95**
Expectations of stigma .03 .06 1.22
Internalized homophobia .18 .27 5.13**
Concealment of sexual orientation .04 .12 2.30*
2 .27 .25 .01 2.42 6, 378
Spirituality -.05 -.11 -1.76
Religiosity .01 .02 .36
Psychological well-being
1 .33 .32 .33 46.20** 4, 380
Perceived experiences of prejudice -.14 -.14 -2.91**
Expectations of stigma -.09 -.12 -2.55*
Internalized homophobia -.33 -.33 -7.01**
Concealment of sexual orientation -.11 -.22 -4.66**
2 .40 .39 .07 22.59** 6, 378
Spirituality .25 .37 6.33**
Religiosity -.12 -.18 -3.03**
Note. *p < .05. **p <.01. B, 1, and t reflect values from the final regression equation.









CHAPTER 5
DISCUSSION

Spirituality and religiosity may be important in the lives of many LGB persons (Barret &

Barza, 1996; Sherkat, 2002), but there is limited attention to these variables in the LGB literature

(Phillips, Ingram, Smiths, & Mindes, 2003). The present study addresses this gap and contributes

to the understanding of LGB persons' experiences and mental health by examining the roles of

spirituality and religiosity in the psychological distress and well-being of this population.

Specifically, this study advances the literature in three important ways. First, this study provides

a test of the minority stress model by examining concomitantly the relations of (a) perceived

experiences of prejudice, (b) expectations of stigma, (c) internalized homophobia, and (d)

concealment of sexual orientation with psychological distress. Second, this study advances the

current literature on minority stress by examining the relations of the set of minority stressors

with psychological well-being, in addition to psychological distress. Third, this study examines

three conceptualizations regarding the roles of spirituality and religiosity in the mental health of

LGB persons: (a) that they are mental health promoters (i.e., related to lower distress and greater

well-being), (b) buffers (i.e., moderators) in stress-mental health relations, or (c) mental health

stressors (i.e., related to greater distress and lower well-being). Finally, by assessing spirituality

and religiosity separately, this study explores the possibility that spirituality and religiosity have

distinct, rather than parallel roles in the psychological distress and well-being of LGB persons.

The results of this study provide further evidence for the minority stress framework that

Meyer (1995, 2003) outlined. Indeed, when examined separately with zero-order correlations,

perceived experiences of prejudice and discrimination, expectations of stigma, internalized

homophobia, and concealment of sexual orientation each were correlated positively with

psychological distress and negatively with psychological well-being. Additionally, when









examined concomitantly, perceived experiences of prejudice and discrimination, internalized

homophobia, and concealment of sexual orientation each were related uniquely to greater

psychological distress and all four minority stressors were related uniquely to lower

psychological well-being. This study demonstrated that minority stressors are not only linked

with greater psychological distress, but also are linked with lower psychological well-being. In

fact the minority stressors accounted for 24% of the variance in psychological distress and 32%

of variance in psychological well-being. Thus, the posited stressors of living as a sexual minority

person seem relevant to consider in understanding psychological distress as well as

psychological well-being of LGB persons. As such, researchers and clinicians should attend to

the relations of minority stressors with psychological well-being in addition to their relations

with psychological distress of LGB persons.

Interestingly, when considered in the context of other minority stressors, expectations of

stigma did not account for unique variance in psychological distress. This finding is inconsistent

with the minority stress framework and prior studies that did find a unique relationship between

expectations of stigma and some negative outcomes. For instance, prior studies found that when

expectations of stigma were examined concomitantly with reported experiences of prejudice

events and internalized homophobia, expectations of stigma were related uniquely to (a) self-

reported need to justify the quality of one's parenthood to others for Dutch lesbian mothers (Bos

et al., 2004), (b) body image dissatisfaction and distress about failing to meet the ideal muscular

masculine body for gay men (Kimel & Mahalik, 2005), and (c) demoralization, guilt, and

suicidal ideation and behaviors for gay and bisexual men (Meyer, 1995). There are two major

differences between these studies and the current study that could account for the different

findings. First, the current study examined the relationship of minority stressors to overall









psychological distress while the previous studies examined more specific negative outcomes.

Second, the current study examined concealment of sexual orientation concomitantly with

perceived experiences of prejudice, expectations of stigma, and internalized homophobia,

whereas the prior studies did not examine concealment of sexual orientation.

In one prior study, Lewis et al. (2003) examined concomitantly the relations of

expectations of stigma, internalized homophobia, and concealment of sexual orientation to

depressive symptoms with a sample of LGB persons. Although Lewis et al. (2003) did not

examine perceived experiences of prejudice directly, they did examine perceived stressfulness of

a range of sexual orientation-related issues including prejudice and discrimination, internalized

homophobia, expectations of stigma, concealment and disclosure of sexual orientation, rejection

from family, and fear of HIV/AIDS. In contrast to the findings of the current study, Lewis et al.

(2003) found that expectations of stigma and perceived stressfulness of sexual orientation-related

issues were related uniquely to depressive symptoms, but that internalized homophobia and

concealment of sexual orientation were not related uniquely to depressive symptoms. Perhaps

these mixed findings are due to the fact that Lewis et al.'s (2003) sample reflected restricted

ranges of internalized homophobia and concealment of sexual orientation, with the sample

scoring near the low end of both variables. This restriction in range many also have restricted the

observed covariation of internalized homophobia and concealment of sexual orientation with

depressive symptoms, allowing greater variance to be accounted for by expectations of stigma.

Furthermore, perceived frequency of experiences of prejudice and discrimination was not

examined in Lewis et al.'s (2003) study, and this difference also may have accounted for the

different results found in that study and the present study. Although the current study does not

support the unique role of expectations of stigma to psychological distress, researchers and









clinicians should continue to pay attention to expectations of stigma in LGB persons given its

unique relationship to psychological well-being.

It is important to note that prior research has yielded mixed findings regarding the link

between sexual orientation concealment and psychological distress, with some studies finding a

positive relationship (Ayala & Coleman, 2000; Cole, Kemeny, Taylor, & Visscher, 1996; Cole,

Kemeny, Taylor, Visscher, & Fahey, 1996; Diplacido, 1998; Lewis et al., 2001; Szymanski et

al., 2001) and other studies finding no significant link (D'Augelli et al., 2001; Lewis et al., 2003;

McGregor et al., 2001). The current study supports the hypothesis that sexual orientation

concealment is related uniquely to greater psychological distress and lower psychological well-

being. One possible explanation for mixed findings across studies regarding sexual orientation

concealment is the observed restriction in range of sexual orientation concealment in many prior

studies, with sample averages typically near the high end of the outness continuum (Lewis et al.,

2003; McGregor et al., 2001). Another consideration is that some researchers assess sexual

orientation concealment with a single item (D'Augelli et al., 2001), which may not adequately

capture participants' levels of outness across contexts. In the current study, disclosure -

concealment of sexual orientation scores were near the mid-point of possible scores,

demonstrating a greater range of reported concealment versus outness than has been typically

represented in prior studies. Thus, attention to sample characteristics and range restriction in

level of outness is important in interpreting prior and future findings regarding the link of sexual

orientation concealment with mental health indicators. Findings of the current study support the

posited role of concealment of sexual orientation as a minority stressor.

In addition to testing and generally providing support for the tenets of the minority stress

model, the present study also examined several competing hypotheses regarding the roles of









spirituality and religiosity in the mental health of LGB persons. First, the hypothesis that

spirituality and religiosity would be buffers of the stress and psychological distress and well-

being relationship was not supported. Therefore minority stress is related to positively to

psychological distress and negatively to psychological well-being regardless of level of

spirituality and religiosity. By contrast, Bowen-Reid & Harrell (2002) found that for African

American college students, spirituality moderated the relationship between racist stressful events

and psychological distress. For participants with high levels of spirituality, there was no

significant relation between perceived racist stressful events and psychological distress, whereas,

for participants with low levels of spirituality, there was a significant and positive relation

between perceived racist stressful events and psychological distress. Perhaps spirituality serves

as a buffer of minority stress for African American persons because in the African American

community, spirituality and religiosity are also connected with a sense of family, community,

and history of strength. However, spirituality and religiosity may not have the same meaning in

the LGB community as they do in the African American community because many religions are

condemning of homosexuality. Additionally, many LGB persons struggle with their spirituality

and religion and many LGB persons may have split from the spirituality or religion that they

were raised in (Ritter & O'Neill, 1998). For instance, in the current sample, 69% of participants

reported that their current religion is not the religion that they were raised in.

Despite lack of support for a buffering or moderating effect, results of this study were

consistent with the view of spirituality as a mental health promoter. Specifically, spirituality was

not related significantly to psychological distress, but it was correlated positively with

psychological well-being. Additionally, spirituality accounted for unique variance in well-being

above and beyond that accounted for by the minority stressors and religiosity. On the other hand,









results were consistent with the view of religiosity as a mental health stressor. Specifically,

religiosity was not correlated significantly with either psychological distress or well-being, but

religiosity accounted for unique negative variance in psychological well-being when entered into

a regression analysis with the minority stressors and spirituality. This pattern of findings suggests

that religiosity is not related to psychological distress, but that it is related to lower well-being

for LGB persons when the positive effects of spirituality are accounted for. The different patterns

of findings for spirituality and religiosity also support the perspective that spirituality and

religiosity have distinct, rather than parallel roles in the psychological distress and well-being of

LGB persons.

Limitations

The present findings must be interpreted in light of a number of limitations. For example,

overall, the sample reported fairly low levels of distress and high levels of well-being. Also, this

study did not assess whether participants are currently or have ever sought therapy. Therefore

these results may not generalize to LGB persons who have greater levels of distress, diagnosable

mental illnesses, or are seeking therapy. Future research should examine if minority stress is

significantly related to mental illnesses such as depression, anxiety, and substance abuse with

clinical populations of LGB persons.

An additional potential limitation is use of the Internet to collect data. Thus, persons who

did not have access to a computer and the Internet were excluded from this study. This limitation

should be considered in light of the fact that over two-thirds of Americans have access to the

Internet at home, school, work, or in other venues, and that LGB persons spent more time on the

Internet than their heterosexual counterparts (Riggle et al., 2005). Another concern about using

an online study is the potential vulnerability to random responding. In the current study validity

check items were utilized to ensure that participants were not randomly responding and that they









were reading and understanding the questions. Despite concerns about sample restriction and

random responding, use of the Internet to collect data in the present study was deemed

appropriate given some of the benefits of Internet data collection, specifically for LGB research.

Specifically, online recruitment does not require that participants "come out" in person to

researchers, and this may result in greater representation of participants who are less "out" about

their sexual orientation (Epstein & Klinkenberg, 2002). Additionally, online recruitment has

been shown to be geographically diverse (Gosling et al., 2004) which circumvents the challenge

of oversampling LGB participants from a few large metropolitan areas. Instead with online data

collection, researchers are able to recruit participants from a broader geographic area. For

instance, the current study had participants that came from over 40 states and from 15 countries.

Despite these benefits of online recruitment, it is important to highlight that about half of

the participants who attempted the study did not complete the study. Although it is impossible to

know the reasons that participants did not completed the study, one potential explanation is the

length of time it took to complete the study. The on-line survey took approximately 25 minutes

to complete which may have created study fatigue and increased the drop out rate. Future on-line

studies should aim to reduce the length of the research survey. But such decisions need to be

balanced against the loss of potentially important information. It is also possible that some of the

participants who did not complete the study initially, may have come back to complete it at a

later time. For instance, some participants may have wanted to see what the study was about

first, and then completed the survey at a time that was more convenient for them. Lastly, it is

impossible to know if there are any important differences between the group of persons who

completed the study and the group that did not.









Another limitation of this study is that while participants were diverse in terms of age,

religion, and social class, the sample was largely White/Caucasian and most participants reported

having at least a college degree. Additionally, this study recruited participants who identified as

lesbian, gay, or bisexual. This study did not recruit participants who engage in same-gender

sexual behaviors but do not identify as LGB. There may be different levels of minority stress for

persons who identify as LGB and are open about their sexual orientation than for persons who

identify as heterosexual but engage in same-gender sexual behaviors. The relations among

minority stressors, psychological distress and well-being, spirituality, and religiosity may also be

different for these different groups. For instance, for persons who identify as heterosexual,

internalized homophobia may play a larger role in accounting for psychological distress and

well-being, and experiences of prejudice, expectations of stigma, and concealment of sexual

orientation may play smaller roles given that these individuals do not have public sexual

minority identities. These issues limit the generalizeability of the present findings to individuals

of the racial/ethnic backgrounds and sexual orientation identifications reflected in the present

sample. Future studies are needed to assess the roles of spirituality, religiosity, minority stress,

and psychology distress and well-being with racial/ethnic minority samples of LGB persons and

with persons who do not identify as LGB but engage in same-gender sexual activity.

Implications for Future Research and Practice

The current study found that spirituality was related to lower psychological distress and

greater psychological well-being. Future research should explore what specific aspects of

spirituality (e.g. a belief in a higher power, a daily meditative practice, or a relationship with a

spiritual leader) are protective features for LGB persons. This information would not only

increase our scientific understanding of spirituality, but could also be used to inform

development of interventions for the LGB community and society at large. Additionally, future









investigations could explore ways that LGB persons can increase their spirituality without being

exposed to potentially harmful aspects of some religions that condemn homosexuality as a sin.

Furthermore, a critical direction for future research is to continue to explore variables that may

act as protective factors for LGB persons. Although research has suggested that LGB people are

at increased risk for some mental health concerns (Cochran & Mays 2000a; Gilman et al., 2001;

Meyer, 2003; Sandfort et al., 2001), the majority of LGB persons do not have a mental illness. In

fact, the current sample reported relatively low levels of psychological distress and high levels of

psychological well-being. Thus, many LGB persons appear to cope adaptively with minority

stress. This study identified spirituality as one potential mental health promoter. Future research

is needed to explore additional mental health promoters and buffers of minority stress for LGB

persons. This line of research will be essential in creating prevention and mental health

promotion programs for the LGB community.

By advancing scientific understanding of the roles of minority stressors, as well as

spirituality and religiosity in the mental health of LGB persons, the present study can inform

theoretically and empirically based therapies and interventions that aim to improve the mental

health of LGB persons. More specifically, the present data suggest that the roles of minority

stressors in the psychological distress and well-being of LGB persons are important to address in

therapy. When working with LGB clients, therapists should assess clients' perceived experiences

of prejudice and discrimination, expectations of stigma, internalized homophobia, and

concealment of sexual orientation. Therapists can inform clients of the relationship between

these minority stressors and psychology distresses and work to reduce their clients' exposure to

such stress. To this end, social justice promotion efforts aiming to increase protection of LGB

persons' rights and reduce societal prejudice against LGB persons continue to be needed.









However, clinicians should be aware that expecting stigma from others and concealing sexual

orientation might be an effective way for LGB persons to cope with societal stigma. Thus,

reducing stigma vigilance and sexual orientation concealment may not necessarily be adaptive

for clients in a cultural context of anti-LGB prejudice and stimgatization. But, helping clients to

make informed decisions about when and how to disclose their sexual orientation and how to

protect themselves from potential stigma might foster some sense of perceived control in the

context of societal stigma. Indeed, perceived control has been found to mediate the link of

perceived prejudice with psychological distress in racial/ethnic minority samples (Moradi &

Hasan, 2004; Moradi & Risco, 2006).

In addition to social justice efforts to reduce societal stigma against LGB individuals, it is

also important for therapists to work with their clients to develop tools for mitigating the

potentially negative effects of current minority stressors in their clients' lives. The present

findings regarding the role of spirituality provide one potentially useful tool for therapists and

clients to consider. Specifically, spirituality was found to be linked uniquely and positively with

psychological well-being. Therefore aspects of spirituality may be used in therapy as a tool to

help clients cope with minority stress or can be incorporated into prevention programs that might

promote health for LGB persons. Specifically, with clients who are open to considering

spirituality as a resource, clinicians can explore the role of spirituality in the clients' lives and

psychological well-being, encourage clients to set aside time for meditation or prayer, and help

clients identify resources for spiritual guidance. Additionally, since religiosity was found to be

related uniquely and negatively with psychological well-being, clinicians should assess for and

work to reduce the impact of religious wounding for LGB persons. Specifically, clinicians may

educate clients about the distinction between spirituality and religiosity. Additionally, they may









assess for maladaptive religious beliefs, such as inappropriate deferral to or feeling punished by

God or a Higher Power (Pragament et al., 1998) and offer alternative messages. For instance,

therapists can inform clients about religious organizations and recourses that take an affirming

stance toward LGB individuals (e.g. Metropolitan Community Churches, The World Congress of

Gay, Lesbian, Bisexual, and Transgendered Jews).

An important consideration is that research has shown that therapists are less religious

than the general population (Begin & Jensen, 1990), although therapists do view religiosity and

spirituality as important areas of functioning (Hathaway, Scott, & Garver, 2004). Despite the

value that therapists may place on spirituality, most do not routinely assess the domain or address

it in treatment planning (Hathaway, Scott, & Garver, 2004). Indeed, Lindgren and Coursey

(1995) found that for a sample of adults with mental illness, two thirds wanted to discuss

spiritual concerns with their therapists, but only half of the sample was doing so. The limited

attention given to spirituality in therapy may be because therapists receive little training in

spirituality or religiosity (Brawer, Hangal, Fabricatore, Roberts, & Wajda-Johnston, 2002). Thus

it seems important for training programs to incorporate education about spirituality into their

curricula and for current therapists to receive training on how to address spirituality with both

LGB and heterosexual clients. To this end, Fukuyama (2007) made a number of training

recommendations for the inclusion of spirituality into multicultural therapy that include

clinicians (1) becoming self aware of their own issues or biases, (2) learning about diverse

religious and spiritual traditions, (3) discussing spiritual topics with colleagues or supervisors,

(4) having a personal spiritual practice, and (5) having spiritual/religious referrals or consultants.

Lastly, clinicians should base their integration of spiritually into therapy in the burgeoning body

of theory and research on spirituality (Pargament, Murray-Swank, & Tarakeshwar, 2005). For









instance, clinicians could examine a client's level of spiritual development based on the

Experience Based Stages of Spiritual Development (Sandhu, 2007), a developmental stage

model of spirituality that is comparable to other identity stage models used in counseling

psychology (e.g. Model of Homosexual Identity Formation; Cass, 1979). Also, when appropriate

clinicians could utilize a manualized spiritually integrated treatment (Avants, Beitel, & Margolin,

2005; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992).

Summary

The findings of the current study are largely supportive of the minority stress theory and

the posited relations of minority stressors with greater psychological distress and lower

psychological well-being. The findings also suggest different roles for spirituality and religiosity,

such that spirituality is linked with greater psychological well-being whereas religiosity is linked

with lower psychological well-being of LGB individuals. Future studies should expand on the

current findings by exploring what aspects of spirituality promote mental health and by

identifying additional mental health promoters for LGB populations.









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BIOGRAPHICAL SKETCH

Melinda B. Goodman was born and raised in Silver Spring, Maryland. She graduated

magna cum laude with a Bachelor of Science in psychology from the University of Maryland in

2002. After graduating she spent a year working with autistic children and traveling overseas. In

August 2003 she moved to Gainesville to enter into University of Florida's Counseling

Psychology program. She is currently completing her Predoctoral Internship at the Virginia

Commonwealth University Counseling Services.





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1 ROLES OF SPIRITUALITY IN LESBI AN, GAY, AND BISEXUAL PERSONS EXPERIENCES OF MINORITY STRESS, PSYCHOLOGICAL DISTRESS, AND WELL-BEING By MELINDA B. GOODMAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008

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2 2008 Melinda B. Goodman

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3 To the two men in my life: my cat Calvin and my partner Matt. Both have provided me with an immense amount of love and support during this time, one through purring and belly rubs, and the other one through long phone c onversations and encouragement. The order listed here does not necessarily equate to order of importance.

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4 ACKNOWLEDGMENTS First of all I would like to thank m y advisor and committee chair, Dr. Bonnie Moradi, for all of her guidance, support, and encouragement. I feel incredibly lucky to have worked with Dr. Moradi. She taught me how to be a dedicated psyc hologist. I am thankful for the assistance given to me by my committee members: Drs. Catherine Cottrell, Mary Fukuyama, and Kenneth Wald. In addition, I would like to thank my parents for all of their support. I could never have reached this point without their love, encouragement, a nd devotion. I am thankful to my partner Matt, and all my friends and family who could always make me laugh and ke pt me grounded and sane during this process. Furthermore, I want to especially thank Brian, Gizem, and Marisa who provided much help and support at my disserta tion defense. Lastly, I want to acknowledge the participants in my survey for their honest and open participation. I hope that this project and others like it can lead to a greater understanding of the experiences of lesbian, gay, and bisexual persons.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ............................................................................................................... 4 LIST OF TABLES ...........................................................................................................................7 ABSTRACT ...................................................................................................................... ...............8 CHAP TER 1 INTRODUCTION .................................................................................................................. ..9 Minority Stress Framework .................................................................................................... 10 Roles of Spiritualit y and Religiosity ....................................................................................... 15 Study Overview ...................................................................................................................... 18 2 REVIEW OF THE LITERATURE ........................................................................................20 The Minority Stress Framework .............................................................................................20 Need to Examine Psychological Well-Being .........................................................................28 Spirituality and Religiosity as Potential Hea lth Pr omoting Factors, Stress-Mental Health Buffers, or Mental Health Stressors .................................................................................... 32 Potential Mental Health Promoters .................................................................................34 Potential Stress-Mental Heath Buffers ............................................................................ 36 Potential Mental Health Stressors ................................................................................... 38 Attending to Distincti ons Between Spirituality and Religiosity .....................................39 Purpose of Study .....................................................................................................................41 3 METHODS ....................................................................................................................... ......43 Participants .................................................................................................................. ...........43 Procedures .................................................................................................................... ...........44 Instruments ................................................................................................................... ..........46 Criterion Variables ..........................................................................................................46 Predictor Variables ..........................................................................................................47 4 RESULTS ....................................................................................................................... ........52 Descriptive Statistics ........................................................................................................ ......52 Gender Comparisons ..............................................................................................................53 Test for Order Effects ........................................................................................................ .....54 Minority Stress Framework: Hypothesis 1 ............................................................................. 55

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6 The Roles of Spirituality and Religio sity: Hypothesis 2 ........................................................ 56 Spirituality and Religiosity as Mental Health Promoters (Hypothesis 2a) or Stressors (H ypothesis 2c) ............................................................................................. 56 Spirituality and Religiosity as Buffers in the Stress-Mental Health Relation (Hypothesis 2b) ............................................................................................................ 57 5 DISCUSSION .................................................................................................................... .....61 Limitations ................................................................................................................... ...........66 Implications for Future Research and Practice ....................................................................... 68 Summary ....................................................................................................................... ..........72 LIST OF REFERENCES ...............................................................................................................73 BIOGRAPHICAL SKETCH .........................................................................................................83

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7 LIST OF TABLES Table page 4-1 Summary statistics and correlations am ong the variables of interest ................................59 4-2 Simultaneous regression equations of mi nority stressors regressed on psychological distress and well-being ....................................................................................................... 59 4-3 Hierarchical regression equations exam ining unique li nks of spirituality and religiosity with psychological distress and well-being ...................................................... 60

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8 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy ROLES OF SPIRITUALITY IN LESBI AN, GAY, AND BISEXUAL PERSONS EXPERIENCES OF MINORITY STRESS, PSYCHOLOGICAL DISTRESS, AND WELL-BEING By Melinda B. Goodman August 2008 Chair: Bonnie Moradi Major: Counseling Psychology Grounded in the minority stress framework, the present study examined concomitantly the relations of (a) perceived experiences of prejudice, (b) exp ectations of stigma, (c) internalized homophobia, and (d) concealme nt of sexual orientation with LGB persons psychological distress and well-bein g. Within this framework, three posited roles of spirituality and religiosity were tested: that they are (a) mental health pr omoters, (b) buffers of minority stress and mental health relations or (c) they are mental health stressors. Results showed that perceived experiences of prejudice, internalized homophobia, and concealment of sexual orientation each were related uniquely and positively to psychologica l distress and that perceived experiences of prejudice, expect ations of stigma, internalized homophobia, and concealment of sexual orientation were related uniquely and negatively to psychological well-being. Additionally, beyond the role of the four minority stressors, spirituality was related uniquely and positively with psychological well-being while relig iosity was shown to be related uniquely and negatively. Future directions for research and implications for practice are discussed.

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9 CHAPTER 1 INTRODUCTION Rates of som e mental health concerns may be greater among lesbian, gay, and bisexual (LGB) persons than among heterosexual persons. For example, compared to heterosexual persons, LGB persons may be at higher risk for mood, anxiety, and substance use disorders (Cochran & Mays 2000a; Gilman et al., 2001; Sandf ort, de Graaf, Bijl, & Schnabel, 2001) and may engage in more suicidal ideation and at tempts (Fergusson, Horwood & Beautrais, 1999; Gilman et al., 2001; Herrell et al., 1999; Coch ran & Mays, 2000b). Based on a meta-analysis of studies comparing LGB persons to heterosexual persons, Meyer (2003) c oncluded that at any point over their lifetime, LGB pe rsons are about 2.5 times more likely to experience a mental disorder. Such data, suggesting greater symptomatology among LGB persons than among heterosexual persons, have been interpreted as evidence of the pathology of LGB orientations and identities. LGB affirming conceptualizations however, point to minority stress, resultant from societal oppression against LGB persons, as an alternative e xplanation for observed symptom disparities (Brooks, 1981; DiPlacido, 1998; Mays & Chochran, 2001; Meyer, 1995; 2003) and also highlight the importance of exploring ment al health promoting factors, given that many LGB persons do not suffer from psychological symptomatology (Basic Behavioral Science Task Force of the National Advisory Mental Health Council [BBSTF], 1996; DiPlacido, 1998; Meyer, 1995). Religiosity and spirituality have been identifi ed as potentially cri tical health promoting factors in the general population (Brady, Peterman, Fitchett, Mo, & Cella, 1999; Ellison, Gay, & Glass, 1989; Powell, Shahabi, & Thoresen, 2003), but conceptualizations of their link to the psychological distress and well-bein g of LGB persons have varied. Specifically, religiosity and spirituality have been conceptualized as health promoters, stress buffers, and stressors for LGB

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10 persons (Lease, Horn, & Noffsinger-Frazier, 2005; Ritter & ONeill, 1989; Siegel, Anderman, & Schrimshaw, 2001; Woods, Antoni, Ironson, & Kling, 1999). Based on prior literature, the present study w ill explore these three different roles of religiosity and spirituality in the psychological distress and we ll-being of LGB persons while also considering the roles of previously iden tified minority stressors for LGB persons. More specifically, the minority stress framework (Meyer, 1995, 2003) posits that (a) perceived experiences of prejudice and discrimination, (b) expectations of stigma, (c) internalized homophobia1, and (d) concealment of sexual orientation are minority stressors that can contribute to greater psychological distress for LGB persons. Within this framework, spirituality and religiosity may have unique a dditional relations to lower dist ress and greater well-being (i.e., function as health promoters), moderate the rela tion of each minority stressor with distress and well-being (i.e., function as stress buffers), or have unique additional relations with greater distress and lower well-being (i.e., function as ad ditional stressors). Importantly, the roles of religiosity and spirituality may differ from one another and may differ in relation to distress and well-being. These various possibilities w ill be examined in the present study. Minority Stress Framework Meyer (1995, 2003) outlined an integrative fr amework for understanding the deleterious im plications of societal oppression for LGB pe rsons mental health. Specifically, he outlined four sources of minority stress relevant to LGB individuals. The first source of minority stress is LGB persons experiences of anti-LGB discrimina tion and prejudice. Chronic exposure to such external, stressful events and conditions can promote the second source of minority stress, 1 The author is choosing to use the term internalized homophobia for the purposes of continuity and consistency with prior, published work on this topic. However, the author recognizes the problems of this term because of the emphasis on the fear component of prejudice over other important processes including individual anti-LGB cognitions and institutional prejudice (Williamson, 2000).

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11 vigilance and expectations of further prejudice and discrimina tion. The third source of minority stress is internalized homophobi a. Internalized homophobia is de fined as the set of negative attitudes and affects toward homosexuality in ot her persons and toward homosexual features in oneself (p. 178), including same gender sexual and affectional feelings, sexual behavior, intimate relationships, and self labeling as LGB (Shidlo, 1994). The final source of minority stress is the concealment of sexual orientation. Such concealment may reflect internalized shame about ones own LGB orientation or serve as an attempt to preven t further prejudice. Together, this set of four minority stressors is posite d to promote psychological distress and reduce psychological well-being of LGB persons. Extant research has examined the links of each of these minority stressors with psychological distress. Indeed, em pirical research has demonstrat ed that anti-LGB prejudice and discrimination, including verbal in sults, threats of violence, physic al attacks, and victimization due to sexual orientation are regrettably co mmon (DAugelli, 1989; Herek, 1993; Herek, Gillis, & Cogan 1999). Furthermore, data with sample s of LGB persons support Meyers (1995; 2003) proposition that experiences of prejudice, expe ctations of stigma, and internalized homophobia are related to an array of negative mental and physical symptoms includi ng suicidal ideation and behaviors, anxiety, depression, demoralization, guilt, insomnia, somatic symptoms, substance abuse, body image dissatisfaction, reduced re lationship quality, and overall psychological distress (Balsam & Syzmanski, 2005; Diaz, Ayala, Bein, Henne, & Marin, 2001; DiPlacido, 1998; Herek, Cogan, Gillis, and Glunt, 1997; Kimmel & Mahalik, 2005; Lewis, Derlega, Clarke, & Kuang, 2006; Meyer, 1995; Szymanski & Chung, 2003). On the other hand, support has been mixe d for a link between sexual orientation concealment and psychological distress indicators; w ith some studies finding that concealment is

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12 related to some symptomatology (Ayala & Co leman, 2000; Cole, Kemeny, Taylor, & Visscher, 1996; Cole, Kemeny, Taylor, Visscher, & Fahe y, 1996; Diplacido, 1998; Lewis, Derlega, Derndt, Morris, & Rose, 2001; Nicholson & L ong, 1990; Szymanski, Chung, & Balsam, 2001) and other studies finding that it is not (DA ugelli, Grossman, Hersherger, & OConnell, 2001; Lewis, Derlega, Griffin & Krowinski, 2003; Mc Gregor et al., 2001). On e possible explanation for these mixed findings regarding sexual orienta tion concealment is the observed restriction in range of sexual orientation concealment in most prior studies, with sample averages typically near the high end of the outness continuum. Thus, additional research with samples that include a broader range of sexual orientation concealment/outness is needed. In addition to studies that focus on the relation of each specific minority stressor with psychological distress, a few studi es provide a more complete examination of the minority stress framework by examining two or more minority st ressors together to identify their unique relations with psychological symptomatology. Fo r instance, when examined together, reported experiences of prejudice events, expectation of stigma, and internalized homophobia each were related positively and uniquely to demoralization, guilt, and suicidal ideation and behaviors for gay and bisexual men (Meyer, 1995) and to body image dissatisfaction for gay men (Kimel and Mahalik, 2005). Additionally with a sample of LGB persons, Lewis et al. (2003) examined concomitantly the relations of de pressive symptoms with expectations of stigma, internalized homophobia, concealment of sexual orientation, and perceived stress fulness of a range of sexual orientation-related issues (e.g., experiences of prejudice and discrimination, internalized homophobia, expectations of stigma, concealment a nd disclosure of sexual orientation, rejection from family, fear of HIV/AIDS). They found that the perceived stressfulness of sexual orientation-related issues, expect ations of stigma, internalized homophobia, and concealment of

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13 sexual orientation each had significant zero-order co rrelations with depressive symptoms. When all predictors were entered together into a mu ltiple regression analysis, however, only perceived sexual orientation-related stress and expectations of stigma em erged as related uniquely to depressive symptoms. It is not clear, however, if internalized homophobia and concealment were not related uniquely to depressi on because there was a restriction in range for these constructs, with the sample scoring near the high end of both variables. Additionally since experiences of prejudice and discrimination were not assessed sepa rately, the potential unique relations of these experiences to depression remain unclear. Overall the literature reviewed provides some support for as pects of minority stress theory. Specifically, extant data are consistent with th e posited relations of perceived experiences of prejudice and discrimination, expectations of stigma, and intern alized homophobia to psychological distress when these minority stressor s are examined separately; but support for the posited role of concealment of sexual orientation is mixed. Compared to studies that focused on individual minority stressors in isolation, fewer studies have examined two or more minority stressors concomitantly. Nevertheless, in the st udies that examined two or more minority stressors, some support exists for the unique ro les of experiences of prejudice, internalized homophobia, and expectations of stigma in psychological symptomatology (Kimel & Mahalik, 2005; Meyer, 1995; Szymanski, 2005). In contrast to accumulating data about the li nks of minority stressors with LGB persons psychological distress, limited data are availabl e about the links of mi nority stressors with indicators of psychological well-being (e.g., self-esteem, positive affect, life satisfaction), and these limited data are mixed. For example, per ceived experiences of prejudice have been found to be related negatively to self-esteem for 1521 year old LGB youth (Hershberger & DAugelli,

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14 1995), but not to positive affect for LGB adults (H erek et al, 1999). Similarly, most studies with LGB persons link internalized homophobia with lower levels of self-esteem (Allen & Oleson, 1999; Herek et al., 1997; McGre gor et al., 2001; Mohr & Fass inger 2000; Peterson & Gerrity, 2006; Shildo, 1994; Syzmanski & Chung, 2001), psychol ogical well-being, and satisfaction with life (Lease et al., 2005). In othe r studies, however, in ternalized homophobia was not related to self-esteem for lesbian women (Herek et al ., 1997; Mohr & Fassinger, 2000), and for HIV positive gay men (Nicholson & Long, 1990). Mixed findings also have emerged with regard to concealment of sexual orientation. Mohr a nd Fassinger (2000) found that, for gay men, concealment of their sexual orientation to strang ers, friends, and colleague s, but not to family members or members of their re ligious organization, was related negatively to self-esteem; for lesbian women, however, none of the concealment indicators were related to self-esteem. Finally, the relation between exp ectations of stigma and psychol ogical well-being has not been examined with samples of LGB persons but it has been examined with other minority populations. For example, for women, expectations of stigma were related negatively to aspects of psychological well-being (Schmitt, Bransc ombe, Korbynowicz, & Owen, 2002), but the link with well-being was not found for African Ameri can persons (Branscombe, Schmitt, & Harvey, 1999). Thus, prior studies provide some support for the relations of the minority stressors with self-esteem, but this support is mixed. Also, none of the studies reviewed examined the links of self-esteem with the set of minor ity stress variables concomitantl y. Thus, the unique relations of each of the minority stressors with self-esteem remain unclear. Furtherm ore, aspects of wellbeing other than self-esteem have been explored only minimally in minority stress research. Therefore there is a need for additional research to assess psychological well-being more broadly

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15 than the narrow focus on self-est eem in prior research, and to exam ine its relations with the set of minority stressors concomitantly. Roles of Spirituality and Religiosity For counseling psychologists working with LG B persons it is im portant to understand the mechanisms that can lead to psychological dist ress and impede psychological well-being, but it is also important to understand fa ctors that relate to positive functioning and promote well-being. Indeed there have been repeated calls for furt her empirical research on mechanisms that might alleviate distress and variables that might moderate or buffer the negative health consequences of minority stress (BBSTF, 1996; DiPl acido, 1998; Meyer, 1995). Ther efore an additional aim of this study is to examine potential mental health promoting factors in the context of minority stressors links with psychological distress and well-being. This study focuses on spirituality and religiosity because they have been identified as important health promoting factors in the general population (Brady et al., 1989; Powell et al., 2003) and may be linked with psychological health for LGB persons as well (Lease et al., 2005; Miller, 2005; Woods et al., 1999). Theory and empirical research point to three possible roles of spirituality and religiosity in the mental health of LGB persons; spirituality and religiosity may serv e as (a) mental health promoters, (b) buffers of the stress and mental health relation, or (c) mental health stressors. The current study will examine these three competing hypo theses within the c ontext of the minority stress framework. The first perspective suggests that spiritual ity and religiosity are two factors that may promote the mental health of LGB persons and so should be related to lower psychological distress and greater psychological well-being. Con ceptually, spiritual and religious beliefs are hypothesized to add comfort, relieve pain a nd suffering, provide hope and meaning, and help people cope with their problems (C. E. Ross, 1990) Consistent with this perspective, using a variety of measures and across numerous sample s of the general population, higher levels of

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16 spirituality and religiosity have been linked to greater physical health and psychological wellbeing (Brady et al., 1999; Elli son et al., 1989; Powell et al., 2 003). Similarly, spirituality and religiosity could be factors that promote mental health for LGB persons. Indeed theorists have proposed that, through spirituality and religiosity, LGB people may gain benefits such as a sense of wholeness, affirmation of the persons ba sic goodness, and greater self-acceptance and psychological well-being (Davidson, 2000; Ritt er & ONeill, 1989; Wagner, Serafini, Rabkin, Remien, & Williams, 1994). Findings from some qualitative and quantitative research are consistent with the espoused benefits of spiritual and/or religio us beliefs for LGB persons (Lease et al., 2005; Miller, 2005; Ta n, 2005; Varner, 2004; Woods et al., 1999; Yakushko, 2005). In addition to suggesting direct links of sp irituality and religiosity with positive physical and mental health outcomes, theory and empirical research have also poin ted to spirituality and religiosity as buffers of the relation between stress and negative health outcomes. For instance, spirituality and religiosity may buffer against stress by providing a framework for interpreting stressful events, enhancing coping resources, and facilitating access to social support (Siegel et al., 2001). Indeed, with various samples, there is empirical support for the notion that spirituality and religiosity are moderators of the relati on between stress and negative health conditions (Fabricatore, Handal, & Fenzel 2000; Forthus, Pidcock & Fischer, 2003; Mascaro & Rosen, 2006; Wills, Yaeger, & Sandy, 2003). Furthermore, spirituality specifically has been shown to buffer the relation of minority stress with symptomatology for African American persons. Specifically, Bowen-Reid and Harre ll (2002) found that, for African American college students, spirituality moderated the relation between racist stressful events and psychological distress. The direction of moderation indicated that, for participants with high levels of spirituality, there was no significant relation between pe rceived racist stressful events and psychological distress,

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17 whereas, for participants with low levels of spirituality, there was a significant and positive relation between perceived racist stressful events and psychological distress. As such, spirituality and religiosity may moderate or buffer the relations of minority stressors with mental health for LGB persons. Despite the literature suggesting potential bene fits of spirituality and religiosity for LGB persons (i.e., mental health prom oter or stress buffers), there is also theory and research that points to potential spiritual wounding for LGB persons due to their pa rticipation in religions that describe same-gender sexuality as sinful. Indeed Ritter and ONeill (1989) explained that for LGB persons, traditional Judeo-Christian religions can be psychologically damaging because they have heaped accusations of shame, contamination, and sinfulness, upon the heads of lesbian and gay people (p.68). Addi tionally, Barret and Brazan (1996) described that there is a fundamental struggle for LGB persons to overcome the clash between homophobic religious institutions and personal spirit ual experiences that connect th em to a higher power. Empirical research also demonstrates the potential negative implications of religiosity for LGB persons. Indeed, research has shown that many LGB persons feel that they must choose between being LGB and being religious (Rodri guez & Ouellette, 2000), and that being religious in a non-gay affirming church and holding conservative reli gious views are relate d to internalized homophobia (Meyer & Dean, 1998; Wagner et al., 1994). Furthermore, religiously oriented programs aimed at changing the sexual orientat ion of LGB persons have been shown to be psychologically damaging (Beckstead & Morrow, 2004). Due to these negative experiences that many LGB persons face within their religions, greater spirituality and religious participation may be related to greater psychological symptomatology and lower well-being.

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18 Thus, spirituality and religiosity have been conceptualized as potential mental health promoters, stress buffers, and stressors for LGB persons. In examining these three positions, it is important to be mindful of the pot entially distinct roles that ma y be played by spirituality and religiosity. Specifically, spirituality and re ligiosity are related (Hill et al., 2000; Hill & Pargament, 2003), but theory and empirical research have highlighted that they are not identical constructs (Miller & Thoresen, 2003). Spirituality is considered an individual experience that includes a personal connection to a Scared or Higher Being, personal transcendence, and meaningfulness (Zinnbauer et al., 1997). Religiosity, on th e other hand, is defined more narrowly to include participating in formally structured religious institutions, pr escribed theology, and rituals (Zinnbauer et al., 1997). This distinction between spirit uality and religiosity may be especially important for LGB persons because many religions condemn non-heterosexuality. Such condemnation may lead some LGB persons to have a strained re lationship with their religious institutions, but not necessarily with th eir individual spirituality. Therefore, this study will examine if spirituality and religiosity have distinct, rather than parallel roles in the psychological distress and we ll-being of LGB persons. Study Overview Based on the literature reviewed here, and us ing the m inority stress framework, the present study advances understanding of LGB persons psychological distress and well-being in a number of ways. First, this study examines concom itantly the relations of the four minority stress variables (i.e., perceived experi ences of discrimination and prej udice, expectations of stigma, internalized homophobia, and con cealment of sexual orientation) to psychological distress and psychological well-being of LGB persons. Secon d, this study examines the potential additional roles of spirituality and religiosity in the psyc hological distress and well-being of LGB persons. Specifically, based on theory and empirical rese arch that suggest three possible roles of

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19 spirituality and religiosity in th e mental health of LGB persons, this study will test three rival hypotheses that spirituality and relig iosity are (a) mental health promoters, (b) buffers of the stress and mental health relation, or (c) mental health stressors. Finally, the present study will explore the potential distinct rather than paralle l roles of spirituality and religiosity in LGB persons mental health.

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20 CHAPTER 2 REVIEW OF THE LITERATURE As discussed in the previous chapter, the present study uses the m inority stress framework to advance understanding of LGB pe rsons psychological distress and well-being and examines the additional roles of spirituality a nd religiosity. As such, th e present study fits well with the aims of counseling psychology to understa nd and alleviate sources of distress and also understand and promote sources of well-being within diverse populations. In order to provide the groundwork for the present study, this chapter reviews re levant literatures on (a) minority stress and psychological distress, (b) minority stressor and psychological well-be ing, (c) the relations of spirituality and religiosity to psychological distress and well-being, (d) the moderating role of spirituality and religiosity in the relations of stressors with psychological distress and well-being for LGB persons, and (e) the poten tially distinct roles of spirit uality and religiosity in LGB persons mental health. The Minority Stress Framework The m inority stress framework is rooted in the work of pioneering scho lars in the area of psychological stress who theorized that disproportionate stress due to minority status may be linked to higher rates of symptomatology among minority populations (Allport, 1954; Dohrenwend, 1973; Kardiner & Ovesey, 1951). For in stance, Allport (1954) stated that, A minority group member has to make many times as many adjustments to his status as does the majority group memberthe awareness, the stra in, the accommodation all fall more heavily and more frequently on the minority group members (p. 145). More recently, the Basic Behavioral Science Task Force (BBSTF) of the National Ad visory Mental Health Council (1996) explained that repeated experiences of discrimination a nd stigmatization are damaging to an individuals sense of identity and that coping with this stigma prejudice, and discrimination is stressful and

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21 can result in increased levels of psychological distress. Many rese archers and theorists who have examined this position with respect to LGB persons concur that stigma and discrimination against LGB persons may be a source of incr eased symptomatology for this population (Brooks, 1981; DiPlacido, 1998; Mays & Co chran, 2001; Meyer, 1995; 2003). Based on an integration of prior theory and empirical research (Allison, 1998; Brooks, 1981, Crocker & Major, 1989; Lazarus & Folkman, 1984), Meyer (1995, 2003) argued that stigma and prejudice against LGB persons creat e a stressful and hostile environment that can promote mental health problems. He outlined four processes of minority stress relevant to LGB individuals. The first source of minority stress is LGB persons experiences of discrimination and prejudice. Chronic exposure to such extern al, stressful events and conditions can promote the second source of minority stress, vigilan ce and expectations of further prejudice and discrimination. The third source of minority stre ss is internalized hom ophobia. Internalized homophobia is defined as the set of negative atti tudes and affects toward homosexuality in other persons and toward homosexual features in one self (p. 178), including same gender sexual and affectional feelings, sexual behavior, intimate relationships, and self labeling as LGB (Shildo, 1994). The final source of minority stress is concealment of sexual orientation. Such concealment may reflect internalized shame about ones own LGB orientation or serve as an attempt to prevent further prejud ice. Together, this set of four minority stressors is posited to promote psychological distress a nd reduce psychological well-b eing of LGB persons. Extant research has examined the links of each of thes e minority stressors with psychological distress. First, research focusing on experiences of anti-LGB prejudice ev ents, including antigay violence and discrimination, suggests that such events are unfortunately common. For example, DAugelli (1989) found that 50% of the gay and lesbian college students surveyed reported

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22 sexual orientation based victimization includ ing having overheard disp araging comments, 26% reported having experienced personal verbal insults, 26% reported having been threatened with physical violence, and 23% reported having been vi ctims of assault. In another study, over three quarters of LGB college students reported that they had experi enced verbal insults and 25% reported that they had experienced threats of violence, which th ey attributed to their sexual orientation (Herek, 1993). With a study of non-colle ge student LGB persons Herek, et al. (1999) found that one-fifth of the women and one-forth of the men experi enced victimization that they attributed to their sexual orientation. Data with samples of gay and bisexual men support Meyers (1995; 2003) proposition that experiences of anti-LGB prejudice, harassment, and victimization are related positively to an array of mental and physical symptoms includi ng suicidal ideation a nd behaviors, anxiety, depression, demoralization, guilt, insomnia, somatic symptoms, and overall psychological distress (Diaz et al., 2001; Meyer, 1995; M. W. Ross, 1990). Additionall y, with a sample of women and men recruited using a random digit-dial method ( N = 73 LGB persons and 2,844 heterosexual persons), Mays and Cochran (2001) assessed discriminati on experiences broadly (e.g., being fired from a job, being threatened or harassed, being treated with less respect or courtesy than other people) and found that, compared to heterosexual persons, LGB persons were more likely to report having experienced discrimination. Furthermore, participants who reported experiencing discrimination were more likely to meet diagnostic criteria for a psychiatric disorder than were those who di d not report any discrimination experiences. The culture of prejudice and discrimination described above can promote LGB persons expectations of anti-LGB prejudice and stigmati zation. Such expectations of prejudice are the second source of minority stress identified by Meyer (1995, 2003). According to Meyer (2003),

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23 in order to cope with prejudice and discrimination, LGB persons maintain a sense of vigilance, by remaining mindful of the possibility that ot hers will be hostile towards them. Meyer (2003) suggested that this constant need for vigilance is stress ful and can result in greater symptomatology for LGB persons. Available da ta support the link betw een perceptions of widespread stigma against ones minority gr oup and psychological distress. For example, perceiving negative events as prejudice was related negatively to self-esteem and positively to negative emotions for Afri can American persons ( N = 139; Branscombe et al., 1999) and positively to anxiety and depression and negatively to life satisfaction, self-esteem, and positive affect for women (N = 220; Schmitt et al., 2002). Research also has shown that expectations of stigma are related to negative health outcomes fo r LGB people. For instance, with a sample of gay and bisexual men ( N = 741), Meyer (1995) found that expectations of stigma were related positively to demoralization, guilt, and suicidal ideation. Also, expectations of stigma were related positively to somatic symptoms and intrusive t houghts for lesbian women ( N = 105; Lewis, et al., 2006) and to depressi on with a sample of LGB persons ( N = 204; Lewis et al., 2003). In addition to promoting expectations of stig matization, the culture of anti-LGB prejudice and stigma can also promote LGB persons interna lization of that stigma. As such, internalized homophobia is the third source of minority stre ss outlined by Meyer (1995; 2003). Internalized homophobia has been an important focus with in LGB studies and in gay-affirmative psychotherapy approaches (Williamson, 2000). Consistent with Meyers (1995; 2003) conceptualization, for gay and bisexual men, internalized homophobia has been linked positively to depression, anxiety, substance abuse, demoralization, guilt, body image dissatisfaction, shame, and suicidal ideation and behaviors (Allen & Oleson, 1999; Herek et al., 1997; Kimmel &

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24 Mahalik, 2005; Meyer, 1995; Meyer & Dean, 1998; Rowen & Malcom, 2002; Shidlo, 1994; Williamson, 2000). For instance, in a longitudina l study with HIV positive gay and bisexual men ( N = 142), Wagner, Brondolo, and Ra bkin (1996) found that base line internalized homophobia predicted both self-reported and c linician-rated distress two years later, even after controlling for HIV-illness stage and psychological distress. Also, with samples of lesbian and bisexual women, internalized homophobia has been linked positiv ely to alcohol consumption, negative affect, depression, low relationship quality, loneliness, and somatic symptoms (Balsam & Syzmanski, 2005; DiPlacido, 1998; Lewis et al., 2006; Szymanski & Chung, 2003; Szymanski, et al., 2001). Additionally, Herek et al. (1997) found that lesbian and bisexual women ( N =75) with high internalized homophobia reported significantly greater symptoms of depression and demoralization than did those with low internalized homophobia. Lastly, with a sample of LGB persons ( N = 204), Lewis et al. (2003) found that inte rnalized homophobia was related positively to depressive symptoms. The fourth posited source of minority stre ss for LGB persons is sexual orientation concealment. Unlike data relevant to the othe r minority stressors, however, support has been mixed for a link between sexual or ientation concealment and negativ e health consequences. With respect to the physical health of gay and bisexual HIV-positive men, concealment of sexual orientation was related positively to a more rapi d advancement of HIV infection and higher rates of other diseases including cancer, pneumonia, br onchitis, sinusitis, and t uberculosis, even after controlling for demographic characteristics, hea lth practices, and other significant variables (Cole, Kemeny, Taylor, & Visscher, 1996; Cole, Kemeny, Taylor, Visscher, & Fahey, 1996). With samples of lesbian and bisexual women, co ncealment of sexual orientation was related positively to depression, alcohol consumption, an d negative affect (Ayala & Coleman, 2000;

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25 Diplacido, 1998; Szymanski et al., 2001), but not with somatic complaints (Szymanski et al. 2001). On the other hand, with samples of lesbian women ( N = 167; Oetjen & Rothblum, 2000) and lesbian women treated fo r early stage breast cancer ( N = 57; McGregor et al., 2001), concealment of sexual orientation was not related to depression and psychological distress. A number of studies that examined LGB persons to gether also yielded some mixed findings. With a sample of LGB persons ( N = 979), concealment of sexual orie ntation was related positively to symptoms of depression (Lewis et al., 2001). Also with a sa mple of LGB older adults ( N = 416; 60 years and older), concealment of sexual orient ation was related positively to drug abuse, but not to alcohol abuse, current mental health, or suicidal ideation (DAugelli et al., 2001). In contrast to these findings, Lewi s et al. (2003) found that conceal ment of sexual orientation was not related to depression with a sample of LGB persons ( N = 204). One possible explanation for these mixed findings regarding sexual orientati on concealment is the observed restriction in range of sexual orientation concealment in most prior studies, with sample averages typically near the high end of the outness continua. Indeed both Lewis et al. (2003) and McGregor et al. (2001) claim that a majority of their sample s were considerably open about their sexual orientation. Thus, additional res earch with samples that incl ude a broader range of sexual orientation concealment/outness is needed. Taken together, the studies reviewed thus far suggest that, when examined independently, perceived prejudice events, expectations of stigma, internalized homophobia, and in some studies, concealment of sexual orientation, are re lated to psychological distress. A few studies provide a more complete examination of the minority stress framework by examining two or more minority stressors together to identify th eir unique relations with psychological symptoms and other negative outcomes. For instance, with a sample of LGB couples ( N = 130), Otis,

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26 Rostosky, Riggle, and Hamrin (2006) found that perceived experiences of prejudice and internalized homophobia each were correlated sign ificantly and negatively with relationship quality. When examined together, however, onl y internalized homophobia was related uniquely to relationship quality. Additionally, Balsam and Szymanski (2005) examined the relations of minority stressors with domestic violence perpetra tion and victimization with a sample of lesbian and bisexual women ( N = 272). Reported experiences of prejudice and intern alized homophobia each were related positively and uniquely to resp ondents reports of their own domestic violence perpetration, but only reported experiences of prejudice and not internalized homophobia were related uniquely to respondents reports of domestic violence vi ctimization. Lastly, Szymanski (2005) found that both experiences of sexual orie ntation based victimizat ion and internalized homophobia were related uniquely to psychological distress for a sa mple of lesbian and bisexual women ( N = 143). Further evidence for the minority stress framework has been found from studies that examined three of the minority stressors concom itantly. For example, Bos, van Balen, van den Boom, and Sandfort (2004) found that for Dutch lesbian mothers (N = 100), reported experiences of prejudice events, expectation of stigma, and internalized homophobia each were related positively and uniquely to a self-reported need to justify the quality of their parenthood to others. Additionally, in a study with gay men (N = 357), reported experiences of prejudice events, expectations of stigma, and internalized hom ophobia each were related positively and uniquely to body image dissatisfaction and distress about fa iling to meet the idea l muscular masculine body (Kimel & Mahalik, 2005). Meyer (1995) also ex amined multiple minority stressors with a sample of gay and bisexual men living in New York City ( N = 741). He found that reports of prejudice events, expectation of stigma, and internalized homophobia each accounted for unique

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27 variance in demoralization, guilt, and suicidal idea tion and behaviors. Furthermore, he included concealment of sexual orientation as a covariate in separate regr essions that examined links of each minority stressor with psychological symp toms, and found that concealment was correlated significantly and positively with psychological distress in these analyses. Un fortunately, he did not include concealment of sexual orientation when he examined the other three minority stressors concomitantly, leaving un clear the unique role of each mi nority stressor when the set of four stressors are considered together. Building on Meyers (1995) work, Lewis et al. (2003) examined concomitantly the relations of expectati ons of stigma, internalized hom ophobia, and concealment of sexual orientation to depressive symptoms with a sample of LGB persons ( N = 204). In addition to these three minority stressors, they also examined th e perceived stressfulness of sexual orientationrelated issues including prejud ice and discrimination, internalized homophobia, expectations of stigma, concealment and disclosure of sexual or ientation, rejection from family, and fear of HIV/AIDS. They found that the pe rceived stressfulness of sexual orientation-related issues, and levels of expectations of stig ma, internalized homophobia, and c oncealment of sexual orientation each had significant zero-order co rrelations with depressive sy mptoms. However, when all of these variables were entered together into a multiple regression analysis, only perceived stressfulness of sexual orientation-related issues and level of exp ectations of stigma emerged as related uniquely to depressive symptoms. It is im portant to note, however, that in this sample there was a restriction in range for scores on internalized homophobia and concealment of sexual orientation, with the sample scor ing near the low end of both vari ables. Such range restriction may have attenuated the observed relations of internalized homophobi a and concealment of sexual orientation with depression. Furthermore, the frequency of experiences of prejudice and

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28 discrimination was not examined in this study, le aving unclear the potential unique relation of such experiences with symptomatology. Overall these studies provide some support for the minority stress theory. Specifically, there is support for the relati ons of perceived experiences of prejudice and discrimination, expectations of stigma, intern alized homophobia, and concealmen t of sexual orientation to psychological distress when these minority stressor s are examined separately. Additionally, the unique contributions of experiences of prejudice and discrimination, expectations of stigma, and internalized homophobia to psyc hological distress are supported in some of the studies reviewed. However, Lewis et al.s study (2003) is the on ly study that examined concealment of sexual orientation along with the other minority stressors, and found that it was no t related uniquely to symptomatology. Thus, additional re search is needed to determine if concealment of sexual orientation should be retained in the minority stress framework as a stressor. To provide a more complete examination of the minority stress framew ork than that provided in much of the prior literature, the present study will examine conc omitantly the relations of the four minority stressors with psychological distress. An important additional direction for research that is addressed by the present study is to evaluate the relations of minority stressors with psychological well-being. Literature releva nt to this issue is discussed next. Need to Examine Psyc hological W ell-Being The studies reviewed thus far attend mostly to the relations between minority stressors and psychological distress. Understanding the co rrelates of LGB persons psychological distress is important for informing appropriate therapies and interventions to reduc e distress within this population. Based upon calls to attend to indicators of well-being as well as distress, however, (Goodman, Liang, Helms, Latta, Sparks, & Weintraub, 2004; Sandage, Hill, & Vang, 2003; Seligman, Steen, Park, & Peterson, 2005), it is also important to understand how experiences

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29 associated with living in a so ciety that condemns non-heterosexua lity (i.e., minority stressors) might relate to the psychologi cal well-being of LGB persons Unfortunately, there is limited research on the links of minority stressors with indicators of psychological well-being (e.g., self-esteem, pos itive affect, life satisfaction) for LGB persons. Also, the limited available research in this area has yielded mixed results. With regard to experiences of prejudice and disc rimination, Diaz et al. (2001) found that self-esteem was linked negatively to experiences of social discrimina tion including homophobia, racism, and financial discrimination in a study with gay and bisexual Latino men ( N = 912). However, because analyses were conducted only with an overall score of social di scrimination, it is difficult to determine the specific link between self-esteem and experiences of sexual orientation-based prejudice. Additionally, perceived experiences of prejudice, as measured by sexual orientation based victimization experiences ranging from verb al insults to physical as sault, have been found to be related negatively to self-e steem for 15-21 year old LGB youth ( N = 194; Hershberger & DAugelli, 1995), but not to positive affect for LGB adults ( N = 2259; Herek et al, 1999). The relation between expectati ons of stigma and psychologi cal well-being has not been examined with samples of LGB persons, but it has been examined with other minority populations. For example, with a sample of wo men, expectations of stigma were related negatively to self-esteem, positive affect, and li fe satisfaction (Schmitt et al., 2002). However, Branscombe et al. (1999) found that for a samp le of African American persons, tendency to perceive negative events as prej udice was not correlated with e ither self-esteem or the frequency of experiencing negative emotions. Thus addition al research is needed to examine the relation between expectation of stigma and ps ychological well-being for LGB persons.

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30 With respect to internalized homophobia, the majority of prior findings support its expected link with self-esteem Indeed, Herek et al. (1997; N = 1089), Mohr and Fassinger (2000; N = 414), and Allen and Oleson (1999; N = 90) found that internalized homophobia was related negatively to self-esteem for gay me n. Additionally, Shildo (1994) reviewed four unpublished studies with gay men, and conclude d that internalized homophobia was linked negatively to self-esteem across these studies. However, Nicholson and Long (1990) found that for HIV positive gay men ( N = 89), internalized homophobia and self-esteem were not correlated significantly. There are also some mixed result s with samples of lesbian and bisexual women. For example, internalized homophobia was related negatively to self-esteem with a sample of lesbian college women (N = 35; Peterson & Gerrity, 2006), a samp le of non-college lesbian and bisexual women ( N = 303; Syzmanski & Chung, 2001), and a sample of lesbian women treated for breast cancer ( N = 57; McGregor et al., 2001). On th e other hand, both Herek et al. (1997) with a sample of lesbian and bisexual wome n recruited from an LGB street fair ( N = 74), and Mohr and Fassinger (2000) with a sample of lesbian women recruited from various community sources ( N = 590) found no significant relation betw een internalized homophobia and selfesteem. One potential reason for these non-signif icant findings is that there were skewed distributions and restricted ranges of scores for internalized homophobia, that may have attenuated observed correlati ons between scores on internalized homophobia and self-esteem. Indeed in both of these studies gay men had significantly higher levels of internalized homophobia than lesbian women, and for gay men, internalized homophobia was related significantly to self-esteem. Finall y, with a sample of LGB persons ( N = 583), Lease et al. (2006) found that internalized homophobia was related negatively to ove rall psychological well-being and life satisfaction.

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31 Regarding the relation of concealment of se xual orientation with psychological wellbeing, a study by Rosario, Rotheram-Borus, and Reid (1996) found that concealment of sexual orientation was not linked to self-esteem for gay and bisexual, predominantly Hispanic and Black youth ( N = 134). However, they assessed conceal ment of sexual orientation with a measure including frequency of disclosing ones sexual identity, having ones sexual identity discovered by others, and having ones sexual identi ty ridiculed (Rosario et al, 1996). Thus, in this study, concealment of sexual orientation wa s confounded with experiences related to antiLGB prejudice. In another study, Mohr and Fassinger (2000) found that for gay men ( N = 590), self-esteem was related negatively to concealing their sexual orientation to stranger, friends, and work colleagues, but not to concealing their sexu al orientation from their family members or religious organization. Finally, for lesbian women ( N = 414), concealment of sexual orientation was not related to self-esteem (Mohr & Fassinger, 2000). In general, the studies described above provi de mixed support for the relations of the minority stressors with self-esteem. However, none of the studies reviewed examined relations of self-esteem with the set of minor ity stress variables concomitantl y. Thus, the unique relations of each of the minority stressors with self-esteem remain unclear. Also, aspects of well-being other than self-esteem have been explored only mi nimally in the minority stress research. Although, self-esteem is a component of psychological well-being, recent literature has conceptualized psychological well-being as broader in scope (Ryff, 1989). Indeed Ryff (1989) defines psychological well-being to include sense of au tonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Self-esteem is conceptually similar to and correlated significan tly with scores on Ryffs (1989) measure of self-acceptance, but self-esteem alone does not enca psulate the larger construct of well-being. Lease et al. (2005)

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32 conducted the only study that examined the relati on of a minority stresso r (i.e., internalized homophobia) with this broader measure of psychol ogical well-being. Therefore, there is a need for additional research to examine the relations of the set of minority stressors to psychological well-being. As such, the present study will examin e the relations of the set of minority stress variables to psychological well-b eing using a measure based on Ry ffs (1989) conceptualization of psychological well-being. In ad dition to considering distress and well-being correlates of minority stressors, the present study will examine the potential roles of spirit uality and religiosity in distress and well-being. Literature about the potential roles of spirituality and religiosity in the distress and mental health of LGB persons is reviewed next. Spirituality and Religiosity as Potential Heal th Promoting Factors, Stress-Men tal Health Buffers, or Mental Health Stressors For counseling psychologists working with LGB clients, it is impor tant to understand the mechanisms that can lead to psychological di stress and impede psychological well-being, and minority stressors may be important variables to examine in this regard. It is also important, however, to examine strengths and factors that could reduce distress, promote well-being and protect clients from minority stre ss. Therefore, in addition to c onsidering minority stressors, it is necessary to examine factors that may play a role in positive functioning. Indeed, Meyer (1995) stated further work on minority coping needs to specify mechanisms that alleviate minority stress (p. 52). DiPlacido (1998) echoed this sentiment by highlighting that many LGB persons successfully manage their minority stress so that they do not have any negative health outcomes. Therefore she emphasized a need to investigate variables that might moderate or buffer the negative health consequences of minority stress. Lastly, th e BBSTF (1996) has called for increased research on discovering how people succe ssfully cope with dise mpowering situations. Thus, there is a need for additional empirical re search that examines potential mental health

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33 promoting factors in the context of minority stressors links with psychological distress and wellbeing. As a step in addressing this need, the present study builds on prior literature to explore the roles of spirituality and religiosity. Davidson (2000) highlighted that counseling ps ychologists and therapists need to have a greater understanding of the role of spirituality in the lives of LGB persons and that because of the oppression of heterosexist so ciety, gay, bisexual, and lesbian persons are more in need of, and more open to, spiritual nourishment than ot hers (p. 409). Unfortunately, attention to the roles of spirituality and religiosity in the me ntal health of LGB persons has been limited. Perhaps, since many mainstream religions condemn homosexuality (Boswell, 1980; Ellison, 1993), it is assumed that most LGB persons would have little to do with religious practices. Anecdotal evidence, however, suggests that LGB persons are actively engaged in religious practices. Indeed, Barret and Ba rzan (1996), two clinicians w ho identify as gay and have expertise in working with LGB persons, stat ed it has been our collective personal and professional experiences that, in fact, the sp iritual experiences of gay men and lesbians frequently mirror those of nongay persons (p. 5). Beyond such testimonials, the limited empirical research on the religious participation of LGB persons has yielded mixed findings. For ex ample, Ellis and Wagemann (1993) found that children who were not exclusively heterosexual were less religious and less likely to follow the religion of their mother, as compared to excl usively heterosexual children. However, they measured sexual orientation with a single item a ssessing percentage of time fantasizing about the same sex. Thus, it is difficult to determine how these results apply to pe ople who identify as LGB. In contrast to these findings, Sherka t (2002) found that many LGB persons are active religious participants. In a co mparison of LGB persons and heterosexual persons, Sherkat (2002)

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34 found that gay men have higher rates of religious participation than do heterosexual men, but that lesbian and bisexual women and bisexual men have ra tes of religious partic ipation that are lower than heterosexual woman and men, respectiv ely. Additionally, Sherkat (2002) found that although LGB persons are more likely to abandon their religion than he terosexual women, they were no more likely to abandon their religion th an heterosexual men. Taken together, these findings suggest that spirituality and religiosi ty are a part of some LGB persons lives. Additional theory and empirical research point to three possible roles of spirituality and religiosity in the mental health of LGB persons: (a) spirituality and religiosity are mental health promoting factors and so should be related nega tively to psychological distress and positively to psychological well-being, (b) spirit uality and religiosity are modera tors of the stress and mental health relation, and (c) because many religions condemn non-heterosexuality, spirituality and religiosity act as mental health stressors and wi ll be related positively to psychological distress and negatively to psychological well-bei ng. The present study will examine these three competing hypotheses within the context of the minority stress framework. Potential Mental Health Promoters The perspec tive that spirituality and religiosi ty are mental health promoting factors is consistent with findings from st udies using a variety of measures and with numerous samples of the general population, that higher levels of spirituality and re ligiosity are linked to greater physical and mental health (Brady et al., 1999; Ellison et al., 1989; Powell et al., 2003). Conceptually, spiritual and religious beliefs are hypothesized to add comfort, relieve pain and suffering, provide hope and meaning, and help peopl e cope with their problems (C. E. Ross, 1990). Numerous studies have examined the links of spirituality and religiosi ty with the physical and psychological health of the general population. Indeed in a review of empirical research on

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35 adults, older adults, and older patients, Powell et al. (2003) found some ev idence that religious service attendance was associated with lower rates of death and th at religiosity (often measured by frequency of service attendance) was associated with lower rates of cardiovascular disease. In another review of empirical research on a variety of samples including adolescents, adults, and older adults from the U.S. and abroad, Seem an, Dubin, and Seeman (2003) concluded that Judeo-Christian practices of spirituality and religion were associated with lower blood pressure and hypertension and better immune function. Additionally, they concluded that Zen, yoga, and meditation practices were associated with better health outcomes in clinical patient populations and with lower blood pressure, cholesterol, and stress hormone levels for a wide range of samples including both U.S. and international sample s, as well as for samples with a variety of ages and health statuses. Lastl y, C. E. Ross (1990) found that highe r levels of religious beliefs were associated with lower leve ls of psychological distress for a probability sample of Illinois residents recruited through a random digit-dialing system ( N = 401). Based on such data, it may be that spirituality and religiosity could se rve as mental health promoting factors for LGB persons as well. Indeed there is theory and research that espouses the benefits of spiritual and/or religious beliefs for LGB persons. For instance, Ritter and ONeill (1989) proposed that for many LGB persons, spiritu ality and religion may provide benefits such as a sense of wholeness, a relationship to the Di vine, and an affirmation of the persons basic goodness. Additionally, Wagner et al. (1994) propos ed that LGB persons who integrate their religious faith with their sexuality might have greater self-acceptance and psychological wellbeing. Miller (2005) described a case study of an African Ameri can gay man with AIDS who used his spiritual and religious beliefs to cope with his disease. Additionally, in a qualitative study of eight lesbian women suffering from cancer Varner (2004) found that all of the women

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36 found spirituality, and five of them found religi on to be both supportive and health promoting. Four quantitative studies on the topic also highlight ed the potential benefits of spirituality and religion. With a sample of HIV-infected gay men ( N = 106), using religion as coping mechanism (e.g., placing trust in God, seeking comfort in religion) was linked with fewer depressive symptoms and religious behavior was linked with positive immunological status (Woods et al., 1999). Additionally, spirituality a nd involvement in the social as pects of religion have been found to be related significantly to greater self-esteem and acceptance of ones sexual orientation, and to feeling less alienated (Tan, 2005; Yakushko, 2005) Lastly, Lease et al. (2005) found that spirituality was related to greater psychological well-being and lower depressive symptomatology for Caucasian LGB persons ( N = 583). Overall, all of these studies are consistent with conceptualizations of spirituality and religiosity as health promoters, such that they are related negatively to psychological distress and positive ly to psychological well-being. This study will test this position by examining conc omitantly the unique rela tions of spirituality and religiosity to the psychological distress and well-being of LGB persons, above and beyond the roles of minority stress variables. Potential Stress-Mental Heath Buffers In addition to direct links of spiritu ality and religiosity with physical and mental health outcomes, theory and empirical research has also pointed to spiritual ity and religiosity as potential buffers of the relations between stre ss and negative health outcomes. For instance, spirituality and religiosity may buffer against stress by providing a framework for interpreting stressful events, enhancing coping resources, and facilitating access to social support (Siegel et al., 2001). Indeed, with various samples, there is empirical support for the notion that spirituality and religiosity are moderators of the relationshi p between stress and negative health conditions. For instance, Mascaro and Rosen (2006) found that spirituality moderated the relation between

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37 daily stress and depression for college students ( N = 143) such that the relation between stress and depression was positive for those with low levels of spirituality and n on-significant for those with high levels of spirituality. A dditionally with college students ( N = 120), Fabricatore et al. (2000) found that spirituality moderated the relation of stress (e .g., daily hassles, significant life events) with life satisfaction. The results indicated that for partic ipants low in spirituality, there was a significant and negative relation between stress and life satisfaction, whereas for those high in spirituality, there was no significant re lation between stress and life satisfaction. Additionally, in a fou r-year longitudinal st udy of adolescents ( N = 1,182), Wills et al. (2003) found that religiosity buffered the relation of stressful life events with substance use. Specifically, there was a significant reduction in the effect size of the relation between stressful life events and substance use for those with hi gh religiosity compared to those with low religiosity. Also, religiosity moderated the relation of family dysfunction with disordered eating for college women ( N = 876), such that when participants ha d high levels of religiosity there was no relationship between family risk and disordered eating, but when participants had low levels of religiosity, there was a significant positive relation between family risk and disordered eating (Forthus et al., 2003). Finally, spirituality has been shown to serv e as a buffer of minority stress. Specifically, Bowen-Reid and Harrell (2002) found that, fo r African American college students ( N = 155), spirituality moderated the relation between racist stressful events and psychological distress. For participants with high levels of spirituality, there was no signifi cant relation between perceived racist stressful events and psychological distre ss; but, for participants with low levels of spirituality, there was a significant and positive relation between perceived racist stressful events and psychological distress. Based upon this literatu re, this study will explore the possibility that

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38 spirituality and religiosity moderate or buffe r the relations of minority stressors with psychological distress and we ll-being for LGB persons. Potential Mental Health Stressors Despite the lite rature suggesting potential bene fits of spirituality and religiosity for LGB persons, there is also theory and research th at suggests possible spiritual wounding for LGB persons due to their participati on in religions that describe sa me-gender sexual orientation as sinful. Indeed, James (1928) proposed that for a re ligion to be useful it must be philosophically reasonable, morally helpful, and spiritually illuminating. However, Ri tter and ONeill (1989) explained that for LGB persons, traditional Ju deo-Christian religions do not provide these necessary facets and instead have heaped accusati ons of shame, contamination, and sinfulness, upon the heads of lesbian and gay people (p.68 ). Additionally, Barret and Brazan (1996) described that there is a funda mental struggle for LGB persons to overcome the clash between homophobic religious institutions and personal spir itual experiences that connect them to a higher power. Empirical research also demonstrates the poten tial negative implications of religiosity for LGB persons. Qualitative research has shown that many LGB persons feel that they must choose between being LGB and being religious (Rodriguez & Oue llette, 2000). Furthermore, quantitative research indicates that being relig ious in a non-gay affirming church and holding conservative religious views are correlated with internalized homophobia (Meyer & Dean, 1998; Wagner et al., 1994). Lastly, religiously oriented programs aimed at changing the sexual orientation of LGB persons have been shown to be psychologically damaging (Beckstead & Morrow, 2004). Due to these negative experien ces that many LGB persons could face within their religions, spirituality and re ligious participation may be rela ted to poor mental health for LGB persons. Therefore, the perspective that sp irituality and religiosity are mental health

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39 stressors that are related positively to psychol ogical distress and negatively to psychological well-being will be examined in the present study. Attending to Distinctions Betw een Spirituality and Religiosity In addition to testing the three different pers pectives about the role s of spirituality and religiosity in LGB persons mental health, the present study will attend to potentially distinct roles played by spirituality and religiosity. More specifically, spirituality and religiosity are related (Hill et al., 2000 ; Hill & Pargament, 2003), but theorists have highlighted that they are not identical constructs (Miller & Thoresen, 2003). Spirituality is considered an individual experience that includes a personal connecti on to a Sacred or Higher Being, personal transcendence, and meaningfulness (Zinnbauer et al. 1997). Re ligiosity on the other hand is defined more narrowly to include participating in formally stru ctured religious institutions, prescribed theology, and ritu als (Zinnbauer et al. 1997). Empirical data are consistent with the notion that spirituality and religiosity are related but distinct constructs. For instance, Zi nnbauer et al. (1997) asked participants ( N = 346) from a wide range of religious bac kgrounds to define the terms religiousness and spirituality in addition to reporting the degree to which th ey considered themselves reli gious and spiritual. A content analysis of these responses revealed that the definitions of spirituality and religiousness differed. The definitions of spirituality most frequently included feelings of connectedness with and personal beliefs about God or a Higher Power, f eelings of transcendence, attaining a state of inner peace, and obtaining actualization. On the other hand, the most frequent definitions of religiousness included belief or faith in God or a Higher Powe r, organizational practices or activities such as attendance at religious serv ices, performance of rituals, and belief in institutionally based dogma. Thus, although the definitions included some common features, such as a belief in God, there are significant di fferences in that spirituality mainly focused on a

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40 personal relationship or connection with a Higher Power and religiousness focused on institutional beliefs and practi ces. Zinnbauer et al. (1997) also found that although the majority of participants considered themselves to be spiritual and religious (74%), a number of participants considered themselves to be spiritu al but not religious (19 %) or religious but not spiritual (3%). Lastly, in this study, spirituality and religiosity had some different correlates. For example spirituality, but not relig iosity, was related positively to education, income, mystical experiences, and being hurt by clergy in the pa st, while religiosity, but not spirituality, was related positively to parents church attendance during child hood, interdependence with others, and a positive view of religion. Despite the distinctiveness of spirituality and religiosity, however, a limitation in much of the prior research is that these constructs ar e not assessed separatel y. The distinction between spirituality and religiosity may be especially important for LGB persons because many religions condemn non-heterosexuality. Such condemnation may lead some LGB persons to have a strained relationship with their religious institu tions, but not necessarily with their individual spirituality. Indeed Schuck and Liddl e (2001) found that for LGB persons ( N = 66) nearly twothirds reported having conflicts be tween their religion and their se xual orientation and that fiftythree percent of the respondents tr ied to resolve this conflict by considering themselves spiritual rather than religious. Additionally, Lease and Shulman (2003) found that family members of LGB persons made a distinction between their spiritual beliefs (e.g., personal connection to a loving Higher Power) and organize d religion. Lease and Shulman ( 2003) also found that spiritual beliefs were more important in helping the pa rticipants understand and accept their family members sexual orientation than was participa tion in a particular religion. Indeed, family members of LGB persons often have to struggle with integrating their religious beliefs, which

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41 may condemn non-heterosexuality, and their love for their LGB family member. This struggle that family members of LGB persons experience may parallel the struggle that LGB persons themselves grapple with. Additionally, Ritter and ONeill (1989) explained that some LGB persons cope with the homonegativity that they receive in their traditional religions by turning to their spirituality, and enriching it, with ancient or non-Judeo-Ch ristian expressions such as Shamanism and Native American Spirituality. T hus, the distinction between spirituality and religiosity may be particularly im portant to attend to in research with LGB persons and this study will examine if spirituality and religiosity have distinct, rather than parallel roles in the psychological distress and we ll-being of LGB persons. Purpose of Study Based on the literature reviewed here, and using the m inority stress framework, the present study advances understand ing of LGB persons psychologica l distress and well-being in a number of ways. First, this study examines c oncomitantly the relations of the four minority stress variables (i.e., perceived experiences of prejudice and discrimina tion, expectations of stigma, internalized homophobia, and concealment of sexual orientation) to psychological distress and psychological well-bei ng of LGB persons. Second, this study examines the potential additional roles of spiritu ality and religiosity in the psycholog ical distress and well-being of LGB persons. Specifically, based on prior theory and em pirical research about the roles of spirituality and religiosity in the mental health of LGB pe rsons, this study will test three rival hypotheses that spirituality and religiosity are (a) mental health promoters, (b) buffers of the stress and mental health relation, or (c) mental health st ressors. Finally, the present study will explore the potentially distinct roles of spirituality and re ligiosity in LGB persons psychological distress and well-being. To address these aims, the pr esent study tests the following hypotheses:

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42 1. Based on the minority stress framew ork it is expected that perceived experiences of prejudice and discrimination, expectations of stigma, and internalized ho mophobia will be linked uniquely and positively with psychological distress and uniquely and negatively with psychological well-being. Given the mixed prior findings about the role of concealment of sexual orientation, its unique relation will be examined, but no specific hypothesis is made. 2. Three competing hypotheses will be explored separately for sp irituality and religiosity: a. Spirituality and religiosity are mental health promoters and will be related negatively to psychological distress and posit ively to psychological well-being. b. Spirituality and religiosity are buffers in the stress-mental health relation and moderate the relations of perceived prej udice events, expectations of stigma, internalized homophobia, and concealment of sexual orientation to psychological distress and well-being. c. Spirituality and religiosity are mental health stressors and will be related positively to psychological distress and negatively to psychological well-being. To allow for the examination of distinct role s played by spirituality and religiosity, these variables will be assessed and examined as sepa rate variables in the tests of the hypotheses.

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43 CHAPTER 3 METHODS Participants Analyses were based on data from 398 part icipants. With regard to gender, 48% ( n = 190) of participants identified as female, 49% ( n = 195) as male, 1% (n = 3) as transgender male-tofemale, and 1% ( n = 4) as transgender female-to-male. Pa rticipants ranged in age from 18 to 70 years ( M = 38.3, SD = 12.9, Mdn = 38). In terms of se xual orientation, 62% ( n = 246) of participants self identified as exclusively lesbian/gay, 21% ( n = 83) as mostly lesbian/gay, and 15% ( n = 61) as bisexual. With rega rd to race/ethnicity, 68% ( n = 271) identified as Caucasian, followed by 8% ( n = 31) African-American/Black, 4% ( n = 17) Native American, 4% ( n = 16) Hispanic, 4% ( n = 16) Asian American, 5% ( n = 18) multiracial, and 6% ( n = 23) other. In terms of social class, 7% ( n = 28) of the sample identi fied as lower class, 24% ( n = 95) as working class, 46% ( n = 184) as middle class, 18% ( n = 72) as upper middle class, and 2% ( n = 9) as upper class. Approximately 25% ( n = 100) of the sample reported th at they had no cu rrent religious affiliation and 12% ( n = 49) reported that they were agnos tic. Other participants identified as current adherents of Catholicism (7%, n = 29), Buddhism (6%, n = 24), Judaism (5%, n = 21), the Baptist denomination (5%, n = 20), Universal Unitarianism (4%, n = 15), Native American Spiritualities (3%, n = 13), Paganism (3%, n = 11), the Methodist denomination (3%, n = 10), the Universal Fellowship of Metropoli tan Community Churches (3%, n = 10), Presbyterianism (2%, n = 8), Episcopalianism (2%, n = 8), Hinduism (2%, n = 6), and Quakerism (1%, n = 5). An additional 8% ( n = 31) identified as other Christian de nom inations. With respect to current attendance to religious services, 5% ( n = 21) reported attending more than once a week, 11% ( n = 42) attending once a week, 6% (n = 23) attending twice a month, 5% ( n = 20) attending once a

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44 month, 22% ( n = 86) attending less than once a month, and 49% ( n = 194) never attending. Approximately 91% of participants ( n = 360) reported currently living in the United States, whereas 8% ( n = 31) were living in other countries. W ith regard to the 31 participants who reported living in countries other than the Un ited States, 23% reported residing in Canada (n = 7), 16% in the United Kingdom ( n = 5), 13% in Mexico ( n = 4), 10% in Turkey ( n = 3), 6% in Australia ( n =2), and 32% ( n = 10) living in a variety of other countries (e.g., Argentina, Portugal, South Africa) with 1 par ticipant residing in each of thes e countries. These international participants correctly re sponded to the validity check items (described next), indicating that they were able to read and understand th e instructions and survey questions. Procedures Participants were recruited through advertising in LGB Internet list serves and groups and through networking with personal cont acts. Advertisem ents were sent to a variety of listserves specifically including those that focused on LGB, spiritual, and re ligious issues and those that had a combined focus on LGB issues and spirituality or religiosity. The study was also advertised through various Yahoo, Google, Facebook, and My Space groups. In addition, listerserves, Internet groups, a nd organizations serving racial/ethnic and religious minority LGB persons were targeted in an attempt to obtain a racially, ethnically, and religiously diverse sample. Data were collected using an online survey. Research has shown some potential benefits of online data collection. Specifically, Internet sa mples have been shown to be relatively diverse with respect to age, gender, geographic regi ons, and socioeconomic status (Gosling, Vazire, Srivastava, & John, 2004). Also, findings from on line data collection have been found to be consistent with findings from traditional da ta collection methods (Gosling et al., 2004). Furthermore, large numbers of LG B participants may be easily recruited via the Internet (Epstein

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45 & Klinkenberg, 2002). Online data collection also may result in better representation of individuals who are less out a bout their sexual orientation than do data collection strategies that require lesbian and gay persons to come out to researchers in person (Epstein & Klinkenberg, 2002). Lastly, with online surveys, LG B participants may feel that they have a greater sense of privacy and anonymity, which ma y encourage them to be more open and honest with their responses (Riggle, Rostosky, & Reedy, 2005). The study advertisements directed participan ts to an online survey. Upon connecting to the survey website, the informed consent wa s displayed which described the purpose of the study, confidentiality of responses, and contact information of the researcher. Participants then clicked a link that served as an indication that they were voluntarily agreeing to participate, and they were then taken to the survey. The survey instruments were counterb alanced to reduce order effects. Embedded into each of the measures in the survey wa s a validity item. These items directed participants to respond in a particular manner. For exam ple, an item asked participants to select the option for strongl y agree. The purpose of these items was to identify random responding, and to ensure that participants we re reading and unders tanding the questions. Following the completion of the survey, all par ticipants received a thank you note, debriefing message, and the researchers contact information so that any additional questions or concerns could be addressed. A total of 803 surveys were submitted and screened to eliminate (a) 7 participants who were ineligible because they identified as either exclusively or mostly heterosexual, (b) 25 instances of potential random responding (i.e., more than one inaccurate validity item response), and (c) 373 surveys missing substantial amounts of data. Of the 373 surveys with substantial mi ssing data, 113 only had the informed consent completed and

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46 completed no survey items. The resulting final sample size used for the present analyses is 398 LGB persons. Instruments Criterion Variables Psychological distress was m easured with the Hopkins Symptom Checklist-21 (HSCL21). The HSCL-21 (Green, Walkey, McCormick, & Ta ylor, 1988) is a 21-item version of the longer 58-item Hopkins Symptom Checklist (Derogatis, Lipma n, Rickels, Uhlenhuth & Covi, 1974). It assesses psychological distress along th e dimensions of general distress, somatic distress, and performance difficulty. The HSCL21 items are rated on a 4point continuum (1 = not at all to 4 = extremely). Sample items incl ude, Feeling inferior to others, and Blaming yourself for things. Item ratings were averaged to yield an overall scor e, with higher scores indicating higher levels of psychological distre ss. HSCL-21 items had a Cronbachs alpha of .90 in prior research (Green et al., 1988). Validity of HSCL-21 sc ores was supported by significant correlations with maladaptive perfectionism, perceived stress, and hopelessness (Kawamura & Frost, 2004; Moller, Fouladi, McCarthy, & Hatch, 2003). Additionally, the HSCL-21 has been used with diverse samples including substa nce abuse users (Downey, Rosengren, & Donovan, 2003), East Asian immigrants in the United States (Declan & Mi zrahi, 2005), and international students (Komiya & Eells, 2001). With the current sample, HSCL-21 items yielded a Cronbachs alpha of .92. Psychological well-being was assessed with the Psychological Well-Being Scale (PWB) The PWB (Ryff, 1989) is a theoretically base d measure, assessing psychological well-being conceptualized to reflect autonomy, environmen tal mastery, personal growth, positive relations with others, purpose in life, a nd self-acceptance. The PWB is an 84-item, 6-point Likert-type scale (1 = strongly disagree to 6 = strongly agree). Sample questions include, I feel like I get a

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47 lot out of my friendships, and In general, I feel confident and positiv e about myself. Item ratings were averaged to yield an overall score, with higher scores indi cating higher levels of psychological well-being. With a sample of LGB persons, PWB ite ms had a Cronbachs alpha of .96 (Lease et al., 2005). Validity of PWB scores was demonstrated with significant correlations with theoretically related constructs such as self-esteem and life satisfaction (Ryff, 1989). Similar to Lease et al. (2005), in the present study, the Purpose in Life subscale items were not assessed because of high conceptual overlap with the measure of spirituality, and an overall PWB average score was computed without the Pu rpose of Life subscale items. Cronbachs alpha for PWB items with the current sample was .97. Predictor Variables Perceived E xperiences of prejudice were assessed with the Schedule of Heterosexist Events (SHE). Selvidge (2000) developed th e 18-item SHE to meas ure the frequency of perceived prejudice events that lesbian and bisexual women encounter ed. Selvidge (2000) developed this measure by adapting the Schedule of Sexist Events (Klonoff & Landrine, 1995), and parallel versions of this measure have been used to asses perceive d racist events with African American and Arab American persons as well (Landrine & Klonoff, 1996; Moradi & Hasan, 2004). In the current study, it ems were modified to be incl usive of gay and bisexual men in addition to lesbian and bisexual women. Sa mple items include, How many times have you been treated unfairly by your family because you are lesbian, gay, or bisexual? and How many times have you been really angry about somethi ng heterosexist or homophobic that was done to you? Items were rated on a 6-point continuum (1 = never to 6 = almost all of the time); item ratings are averaged, and higher scores indicate mo re frequent experiences of prejudice. In two samples of lesbian and bisexual women, Selvi dge (2000) found Cronbachs alphas of .91 and .92 for SHE items. Supporting validity of SHE scores, Selvidge found a positive correlation between

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48 SHE scores and self-concealment and a negligib le correlation between SHE scores and selfmonitoring. In the current sample, Cr onbachs alpha for SHE items was .93. Expectations of stigma were assessed with the Stigma Consciousness Questionnaire for Gay Men and Lesbians (SCQ). The LG version of the SCQ (Pinel, 1999) was designed to measure the extent to which LG persons expect to be stigmatized by others. The version of the measure used by Pinel was modified slightly to apply to bisexual persons as well. The SCQ is a 10-item, 7-point Likert-type scale (1 = strongly disagree to 7 = strongly agree). Sample items include, Most heterosexuals have a lot more homophobic thoughts than they actually express, and Stereotypes about gay, lesbian, or bisexua l persons have not affected me personally (reverse scored). Item ratings were average with higher scores indicating gr eater expectations of stigma. SCQ items had adequate internal cons istency with Cronbachs alpha of .81 and items load on a single factor (Pinel, 1999). Pinel reported that, as expected, SCQ scores were significantly and positively correl ated with scores on measures of perceived discrimination and past experiences of discrimination. Additionally, di scriminant validity was demonstrated in that SCQ scores were not related to social anxiety (Pinel, 1999). In the current sample, Cronbachs alpha for SCQ items was .79. Internalized Homophobia was assessed with the Internalized Homophobia (IHP) scale. Martin and Dean (1987; as cited in Herek et al ., 1997) originally created the IHP as interview questions with gay men. The current study used the self-report version used by Herek et al. (1997) that is applicable to LGB persons. The IH P is a 9-item, 5-point Likert-type scale (1 = disagree strongly to 7 = agree strongly). Sample ite ms include I feel that being gay, lesbian, or bisexual is a personal shortcoming for me, and I wish I werent gay, lesbian, or bisexual. Items ratings were averaged, with higher scores indicating greater leve ls of internalized

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49 homophobia. In terms of reliability, IHP items had Cronbachs alphas of .71 and .83 for women and men, respectively. As expected, Herek et al. (1997) found that compared to those with low IHP scores, men and women with high IHP scor es reported significantly higher levels of depression and demoralization and lower levels of self-esteem. With the current sample, Cronbachs alpha for IHP items was .90. Disclosure versus Concealmen t of sexual orientation was assessed with the Outness Inventory (OI). The OI (Mohr & Fassinger, 2000) meas ures the degree to which respondents sexual orientation is disclosed versus concealed w ith people in different areas of their lives. The 10 OI items are rated on a 7-point continuum (1 = person definitely does not know about your sexual orientation status to 7 = person definite ly knows about your sexual orientation status, and it is openly talked about). The OI has three subscales that assess concealment of sexual orientation with different sets of people including Out to th e World (e.g., my new straight friends), Out to Family (e.g., mother, siblings ), and Out to Religi on (e.g., leaders of my religious community). For ease of interpretation, item ratings were reverse coded and averaged so that higher scores indicated greater concea lment of sexual orientation and lower scores indicated greater disclosure of se xual orientation. Based on the results of a factor analysis of OI items, Mohr and Fassinger concluded that either the full scale or individual subscales could be used when analyzing OI data. Since the focus of this study is on overall level of concealment of sexual orientation, results will be analyzed usi ng the overall score. Validity for OI scores has been demonstrated by positive correlations of outness with level of se lf-acceptance about samesex desires and identification with LG communitie s. Lastly, OI items had a Cronbachs alpha of .85 with a sample of LGB persons (Moradi et al ., 2006) and Cronbachs alpha for OI items with the current sample was .91.

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50 Spirituality was assessed with the Spiritual Involvement and Beliefs Scale (SIBS). The SIBS (Hatch, Burg, Naberhaus, & Hellmich, 1998) was designed to assess spiritual beliefs, involvement, and activities including a relations hip with a higher power, fulfillment from nonmaterial things, faith, and trust. The SIBS is a 26-item, 5-point Likert-type scale (1 = strongly agree to 5 = strongly disagree ). Sample items include, Some experiences can be understood only through ones spiritual beliefs, and My spiritual life fulfills me in ways that material possessions do not. Item ratings were averaged and higher scores indica te a greater level of spirituality. Validity for SIBS scores has been demonstrated by expected correlations between these scores and other indicator s of spirituality including scores on the Spiritual Well-Being Scale, The Santa Clara Strength of Religious Fa ith Questionnaire, and th e Intrinsic subscale of the Religious Orientation scale (Hatch et al., 1998; Lease et al., 2006). Reliability for SIBS scores has been indicated by st rong test-retest reliability ( r = .92), and high internal consistency with Cronbachs alpha of .92 (Hatch et al., 1998). The SIBS also was used with a sample of LGB persons and yielded a Cronbachs alpha of .75 (L ease et al., 2006). With the current sample, Cronbachs alpha for SIBS items was .92. Religiosity was assessed with the Religious Commitment Inventory (RCI-10) scale. The RCI-10 (Worthington et al., 2003) was designed to assess the degree to which respondents adhere to their religious beliefs practices, and values and use them in daily living. The RCI-10 was created to be a shorter and more psychomet rically sound version of the previous 62, 20, and 17-item Religious Commitment Inventories. The 10 items of the RCI-10 are rated on a 5-point continuum (1 = not at all true of me to 5 = totally true of me). Sample items include, I enjoy working in the activities of my religious organization, and My religious beliefs lie behind my whole approach to life. Item ra tings were averaged and higher sc ores indicate a greater level of

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51 religiosity. Validity of RCI-10 scores has been demonstrated by their correlations with other related constructs such as frequency of religious service attendance and measures of religiosity (Worthington et al., 2003). Additionally, RCI-10 items have strong internal consistency (Cronbachs alpha ranging from .88 .96) and test-retest reliability with estimates of .87 for three weeks and .84 for five months (Worthington et al., 2003). RCI-10 items yielded a Cronbachs alpha of .95 with the current sample.

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52 CHAPTER 4 RESULTS Prelim inary analyses were conducted to exam ine descriptive information, and to explore potential gender and order effects in the data Tests of hypotheses were conducted following these preliminary analyses. Descriptive Statistics The present sam ples means and standard devi ations on the variables of interest (see Table 1) were generally comparable to those obtained in previous samples of LGB persons. More specifically, relatively low levels of ps ychological distress were reported by the current sample ( M = 1.70, SD = .53). These low scores are comparable to HSCL-58 scores reported by Szymanski (2005) with a sample of lesbian women ( M = 1.44, SD = .32). Scores for psychological well-being ( M = 4.53, SD = .79) were similar to scor es reported by Lease et al. (2005) with a sample of LGB persons ( M = 4.81, SD = .64). The present samples scores for experiences of prejudice ( M = 2.22, SD = .75) were similar to scor es reported by Goodman et al. (2005) with a sample of LGB persons ( M = 2.23, SD = .76). The current samples scores for expectations of stigma ( M = 4.31, SD = 1.03) were similar to those reported by Lewis et al. (2003) with a sample of LGB persons ( M = 4.32, SD = .64). The current samples scores for internalized homophobia ( M = 1.54, SD = .78) were also similar to those reported by Lewis et al. (2003) with a sample of LGB persons ( M = 1.52, SD = .64). The samples scores for concealment of sexual orientation were ( M = 3.58, SD = 1.56). However, when samples score for the Outness Inventory were not reversed scores they were ( M = 4.42, SD = 1.56), which fell between those reported by Moradi et al. (2006) for a Caucasian sample ( M = 4.70, SD = 1.36) and racial/ethnic minority sample (M = 3.78, SD = 1.35) of LGB persons. Likewise, scores for spirituality for the current sample ( M = 4.69, SD = 1.16) were similar to those reported by Lease

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53 et al. (2005) with a sample of LGB persons ( M = 4.03, SD = .35). Lastly, with respect to religiosity, scores for th e current sample were ( M = 2.16, SD = 1.14). No study was found that used the Religious Commitment Inventory-10 with a sample of LGB persons. However, the present samples scores were similar to scor es reported by Worthingt on et al. (2003) with samples of university students ( M = 2.31, SD = 1.02) and clients in a secular counseling center ( M = 2.14, SD = 1.17). Skewness and kurtosis values for all variables of interest met recommended cut-offs for normality (Weston and Gore, 2006). Gender Comparisons To explore potential gender differences in the data, a MANOVA was con ducted with gender as the independent variab le and the variables of interest (i.e., psychological distress, psychological well-being, experiences of prejudi ce, expectations of stigma, internalized homophobia, concealment of sexual orientation, spirituality, and religiosity) as dependent variables. To be inclusive of transgender pers ons, male-to-female transgender persons were categorized as women and female-to-male transg ender persons were categorized as men. Boxs test of equality of covariance matrices and Levene s test of equality of error variances were not significant indicating that data met assumptions of homogeneity of covariance matrices and variance. The overall mo del was significant ( F [1, 378] = 3.35, p < .01, p 2 = .07), indicating a significant but small gender difference in the set of dependent variables. Follow-up univariate analyses, with alpha adjusted to .01 (given that there were 8 comparisons), indicated no significant gender differences on th e individual dependent variab les. With alpha of .05, there were small but significant gender diffe rences on psychological well-being ( F [1, 378] = 4.77, p < .05, p 2 = .01), with women ( M = 4.63, SD = .73) reporting slightly greater well-being than men ( M = 4.46, SD = .82); and on religiosity ( F [1, 378] = 5.30, p < .05, p 2 = .01), with men

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54 ( M = 2.30, SD = 1.17) reporting slightly great er religiosity than women ( M = 2.03, SD = 1.10). Gender accounted for approximately 1% of variabili ty in these data. Para llel results were found when gender comparisons were made with tran sgender persons excluded from the analyses; again, the overall model was significant, but no gender effects were si gnificant with alpha adjusted to .01, and only psychological well-being yielded a significant ge nder effect with alpha at .05, again with women scoring higher than men. Thus, overall, gender differences on the dependent variables were non-signif icant or negligible. As such, hypotheses were tested with the entire sample, and without gender as a covariate. Test for Order Effects To test for order effects across the two or ders of the survey, a MANOVA was conducted with survey order as the indepe ndent variable and the variables of interest (i.e., psychological distress, psychological well-being, e xperiences of prejudice, expecta tions of stigm a, internalized homophobia, concealment of sexual orientation, spirituality, and religiosity) as dependent variables. Boxs test of equality of covariance matrices and Levene s test of equality of error variances were not significant indicating that the data met assumptions of homogeneity of covariance matrices and variance. The overall model was significant ( F [1, 384] = 2.25, p < .05, p 2 = .05) suggesting a significant but small order difference in the set of dependent variables. Again given the number of comparisons being conducted, a more conser vative alpha of .01 was used for follow-up univariate analyses. These anal yses indicated that there were no significant order effects at the p = .01 level. At th e less conservative p = .05 level, only re ligiosity yielded a significant order effect ( F [1, 384] = 5.42, p < .05, p 2 = .01), with the order effect accounting for approximately 1% of variance in the data. Thus, overall, order effects on the dependent variables were non-significant or negligible.

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55 Minority Stress Framework: Hypothesis 1 Hypothesis 1 was that experiences of prejudice and discrim ination, expectations of stigma, and internalized homophobia are linked uniquely and positively with psychological distress and uniquely and negatively with psyc hological well-being. Given the mixed prior findings about the role of concealment of se xual orientation, no specific hypothesis was made about its relation to psychological distress and well-being. Zero-order correlations were computed to test hypothesized relati ons among variables of interest (see Table 1). Psychological distress was correlated positively with reported experiences of prejudice ( r = .33, p < .001), expectations of stigma (r = .30, p < .001), internalized homophobia (r = .38, p < .001), and concealment of sexual orientation (r = .21, p < .001). Additionally, psychological well-b eing was correlated negatively w ith reported experiences of prejudice ( r = -.17, p < .001), expectations of stigma (r = -.30, p < .001), internalized homophobia (r = -.51, p < .001), and concealment of sexual orientation ( r = -.38, p < .001). To examine the unique relation of each mi nority stressor with each mental health indicator, simultaneous multiple regression an alyses were conducted. In the first equation, experiences of prejudice, expect ations of stigma, internalized homophobia, and concealment of sexual orientation were regresse d on psychological distress. These predictors were associated significantly with psychological distress, R = .49, F (4, 389) = 31.19, p < .001, accounting for 24% of the variance in distress (see Table 2). Inspection of indi vidual variables indicated that reported experiences of prejudice ( = .30, t = 5.62, p < .001), internalized homophobia ( = .28, t = 5.38, p < .001), and concealment of sexual orientation ( = .12, t = 2.37, p < .05), but not expectations of stigma, each accounted for uni que variance in psychological distress. In the second equation, experiences of prejudice, expectations of stigma, internalized homophobia, and concealment of sexual orientation were regresse d on psychological well-being. These predictors

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56 were significantly associated with psychological well-being, R = .57, F (4, 389) = 45.59, p < .001, accounting for 32% of the variance (see Table 2). Inspection of individua l variables indicated that reported experiences of prejudice ( = -.11, t = -2.22, p < .05), expectations of stigma ( = .12, t = -2.50, p < .05), internalized homophobia ( = -.37, t = -7.50, p < .001), and concealment of sexual orientation ( = -.21, t = -4.36, p < .001) each accounted for unique variance in psychological well-being. Thus, Hypothesis 1 was mostly supported. Part icipants who reported greater experiences of prejudice, internal ized homophobia, and concealment of sexual orientation, but not expectation of stigma also reported more psyc hological distress. Additionally participants who reported greater experiences of prejudice, expectations of stig ma, internalized homophobia, and concealment of sexual orientation also reported less psychological well-being. The Roles of Spirituality and Religiosity: Hypothesis 2 Three competing hypotheses were presented fo r the potential roles of spirituality and religiosity in relation to psychol ogical distress and well-being: (a) that they are mental health promoters (i.e., related to lower distress and greater well-being), (b) buffers (i.e., moderators) in the stress-mental heal th relation, (c) or mental health stresso rs (i.e., related to greater distress and lower well-being). Spirituality and Religiosity as Mental Heal th P romoters (Hypothesis 2a) or Stressors (Hypothesis 2c) Zero-order correlations revealed that spir ituality and religiosit y were not correlated significantly with psycho logical distress. Furthermore, spirituality ( r = .25, p < .001), but not religiosity, was correlated positively with psyc hological well-being (see Table 1). Additional exploratory analyses indicated th at neither current nor childhood a ttendance at religious services was related to psychological distress or wellbeing. Lastly, there was no mean difference in

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57 psychological distress or well-be ing between participants who indicated that religion and spirituality are important parts of their lives a nd participants who indicated that religion and spirituality are not important parts of their lives. Additionally, Hypothesis 2a and 2c were te sted by conducting two hierarchical multiple regression analyses with the set of four minority stressors entered as step one and spirituality and religiosity entered as step 2 to determine their unique relations with psychological distress and well-being, above and beyond the set of minority stressors. In the first equation, with psychological distress as the criteri on variable, spiritua lity and religiosity did not account for unique variance, beyond that accounted for by the se t of minority stress variables (see Table 3). In the second equation, with psyc hological well-being as the crit erion variable, spirituality and religiosity accounted for an additional 7% of variance beyond that accounted for by minority stressors (see Table 3). Specifi cally, both spirituality ( = .37, t = 6.33, p < .001) and religiosity ( = -.18, t = -3.03, p < .01) accounted for unique variance in psychological well-being, with spirituality related uniquely and positively and re ligiosity related uniquely and negatively with psychological well-being. Thus, Hypotheses 2a and 2c were partially suppor ted in that the data were consistent with the view of spirituality as a well-being promoter and religiosity as a wellbeing stressor. Spirituality and Religiosity as Buffers in the Stress-Mental Health Relation (Hypothesis 2b) To test Hypothesis 2b, regarding the poten tial m oderating roles of spirituality and religiosity in the relations of perceived experien ces of prejudice and discrimination, expectations of stigma, internalized homophobia, and concealm ent of sexual orientat ion with psychological distress and well-being, the recommendations of Barron and Kenny (1989) to use moderator regression analyses were followed. Following recommendations by Aiken and West (1991), predictor and moderator variables were centered (i .e., mean deviation scores were computed) to

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58 reduce multicollinearity between th e interaction term and the ma in effects when testing for moderator effects. In order to test for modera tion, a series of hierarchical multiple regression analyses were conducted; eight to test spirituality as a moderator of the relation of each of the four minority stressors with (a) psychological distress and (b) psychological well-being and another eight to test religiosity as a moderator in these relations. For each analysis, the centered minority stressor was entered in Step 1 predicting psychological di stress or well-being. In Step 2 of each regression, centered scores for either spirituality or reli giosity were entered. Lastly, in Step 3, scores reflecting the in teraction between the respective centered minority stressor and centered spirituality or religiosity scores (e .g., experiences of prejudice scores multiplied by spirituality scores) were entered. Significant m oderation is indicated if adding the interaction term results in a significant change in R and the beta weight for the interaction term is significant. Given the difficulty in detecting inter action effects with correla tional research, use of liberal alphas (e.g., .10) has been recommended (McClelland & Judd, 1993). But, due to the number of regression equations conducted to test for moderati on in the present study, alpha was set at .05. None of the interaction terms em erged as significant in the regressions for psychological distress or well-bei ng. Thus Hypothesis 2b that spirituality and religiosity were buffers in the stress-mental he alth relation was not supported.

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59 Table 4-1. Summary statistics and correla tions among the variables of interest Variables 1 2 3 4 5 6 7 8 1. Psychological distress --2. Psychological well-being -.68**--3. Perceived experiences of prejudice .33** -.17** --4. Expectations of stigma .30** -.30** .49**--5. Internalized homophobia .38** -.51** .12* .25**--6. Concealment of sexual orientation .21** -.38** -.17** .09 .47** --7. Spirituality -.07 .25** .11* .02 -.01 -.06--8. Religiosity .02 .02 .11* .09 .14** -.03 .72**--M 1.70 4.53 2.22 4.31 1.54 3.584.69 2.16 SD .53 .79 .75 1.03 .78 1.561.16 1.14 .92 .97 .93 .79 .90 .91 .92 .95 Possible Range 1-4 1-6 1-6 1-7 1-5 1-7 1-7 1-5 Higher scores indicate higher levels of the construct assessed. *p <.05, **p <.01. Table 4-2. Simultaneous regression equati ons of minority stressors regressed on psychological distress and well-being Variable B SEB t R Total R Adjusted R F df Psychological distress Perceived experiences of prejudice .20.04 .305.62** .49.24 .24 31.19** 4, 389 Expectations of stigma .03.03 .051.02 Internalized homophobia .19.04 .285.38** Concealment of sexual orientation .04.02 .122.37* Psychological well-being Perceived experiences of prejudice -.11.05 -.11-2.22* .57.32 .31 45.59** 4, 389 Expectations of stigma -.09.04 -.12-2.50* Internalized homophobia -.37.05 -.37-7.50** Concealment of sexual orientation -.11.02 -.21-4.36** *p < .05. **p <.01.

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60 Table 4-3. Hierarchical regressi on equations examining unique links of spirituality and religios ity with psychological distress and well-being Step Predictor B t Total R Adjusted R R F df Psychological distress 1 .26 .25 .26 32.56** 4, 380 Perceived experiences of prejudice .21 .31 5.95** Expectations of stigma .03 .06 1.22 Internalized homophobia .18 .27 5.13** Concealment of sexual orientation .04 .12 2.30* 2 .27 .25 .01 2.42 6, 378 Spirituality -.05-.11 -1.76 Religiosity .01 .02 .36 Psychological well-being 1 .33 .32 .33 46.20** 4, 380 Perceived experiences of prejudice -.14-.14 -2.91** Expectations of stigma -.09-.12 -2.55* Internalized homophobia -.33-.33 -7.01** Concealment of sexual orientation -.11-.22 -4.66** 2 .40 .39 .07 22.59** 6, 378 Spirituality .25 .37 6.33** Religiosity -.12-.18 -3.03** Note. *p < .05. **p <.01. B, and t reflect valu es from the final regression equation.

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61 CHAPTER 5 DISCUSSION Spirituality and religiosity m ay be important in the lives of many LGB persons (Barret & Barza, 1996; Sherkat, 2002), but there is limited a ttention to these variables in the LGB literature (Phillips, Ingram, Smiths, & Mi ndes, 2003). The present study addr esses this gap and contributes to the understanding of LGB persons experiences and mental health by examining the roles of spirituality and religiosity in the psychologica l distress and well-being of this population. Specifically, this study advances th e literature in three important wa ys. First, this study provides a test of the minority stress model by examining concomitantly the relati ons of (a) perceived experiences of prejudice, (b) expectations of stigma, (c) internalized homophobia, and (d) concealment of sexual orientation with psychological distress. Second, this study advances the current literature on minority stress by examining the relations of the set of minority stressors with psychological well-being, in addition to ps ychological distress. Third, this study examines three conceptualizations regarding the roles of spirituality and reli giosity in the mental health of LGB persons: (a) that they are mental health prom oters (i.e., related to lo wer distress and greater well-being), (b) buffers (i.e., moderators) in stress -mental health relations, or (c) mental health stressors (i.e., related to greater distress and lower well-being). Finally, by assessing spirituality and religiosity separately, this st udy explores the possibility that spirituality and religiosity have distinct, rather than parallel roles in the psyc hological distress and we ll-being of LGB persons. The results of this study provide further evid ence for the minority stress framework that Meyer (1995, 2003) outlined. Indeed, when examined separately with zero-order correlations, perceived experiences of prejud ice and discrimination, expectati ons of stigma, internalized homophobia, and concealment of sexual orientation each were correlated positively with psychological distress and negatively with psychological well-being. Additionally, when

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62 examined concomitantly, perceived experiences of prejudice and discri mination, internalized homophobia, and concealment of sexual orientation each were related uniquely to greater psychological distress and all four minority stressors were related uniquely to lower psychological well-being. This study demonstrated that minority stressors are not only linked with greater psychological distre ss, but also are linked with lo wer psychological well-being. In fact the minority stressors accounted for 24% of the variance in psychological distress and 32% of variance in psychological wellbeing. Thus, the posited stressors of living as a sexual minority person seem relevant to consider in unders tanding psychological distress as well as psychological well-being of LGB persons. As such, researchers and clinic ians should attend to the relations of minority stressors with psycholog ical well-being in addition to their relations with psychological di stress of LGB persons. Interestingly, when considered in the context of other minority stress ors, expectations of stigma did not account for unique variance in psychological distress. This finding is inconsistent with the minority stress framework and prior stud ies that did find a unique relationship between expectations of stigma and some negative outcom es. For instance, prior studies found that when expectations of stigma were examined concom itantly with reported experiences of prejudice events and internalized homophobia, expectations of stigma were relate d uniquely to (a) selfreported need to justify the quality of ones pa renthood to others for Dutch lesbian mothers (Bos et al., 2004), (b) body image dissatisfaction and dist ress about failing to meet the ideal muscular masculine body for gay men (Kimel & Mahali k, 2005), and (c) demoralization, guilt, and suicidal ideation and behaviors for gay and bi sexual men (Meyer, 1995). There are two major differences between these studies and the current study that could account for the different findings. First, the current study examined the relationship of minority stressors to overall

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63 psychological distress while the pr evious studies examined more specific negative outcomes. Second, the current study examined concealment of sexual orientati on concomitantly with perceived experiences of prejud ice, expectations of stigma and internalized homophobia, whereas the prior studies did not examin e concealment of sexual orientation. In one prior study, Lewis et al. (2003) examined concomitantly the relations of expectations of stigma, intern alized homophobia, and concealmen t of sexual orientation to depressive symptoms with a sample of LGB persons. Although Lewis et al. (2003) did not examine perceived experiences of prejudice directl y, they did examine perceived stressfulness of a range of sexual orientation-rela ted issues including prejudice and discrimination, internalized homophobia, expectations of stigma, concealment a nd disclosure of sexual orientation, rejection from family, and fear of HIV/AIDS. In contrast to the findings of the current study, Lewis et al. (2003) found that expectations of stigma and per ceived stressfulness of se xual orientation-related issues were related uniquely to depressive symptoms, but that internalized homophobia and concealment of sexual orientation were not related uniquely to depressive symptoms. Perhaps these mixed findings are due to the fact that Lewi s et al.s (2003) sample reflected restricted ranges of internalized homophobia and concealme nt of sexual orientation, with the sample scoring near the low end of both variables. This re striction in range many al so have restricted the observed covariation of internalized homophobia and concealment of sexual orientation with depressive symptoms, allowing gr eater variance to be accounted for by expectations of stigma. Furthermore, perceived frequency of experi ences of prejudice and discrimination was not examined in Lewis et al.s (2003) study, and th is difference also may have accounted for the different results found in that study and the present study. Although the current study does not support the unique role of expect ations of stigma to psychol ogical distress, researchers and

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64 clinicians should continue to pa y attention to expecta tions of stigma in LGB persons given its unique relationship to ps ychological well-being. It is important to note that prior research has yielded mixed findings regarding the link between sexual orientation concealment and psyc hological distress, with some studies finding a positive relationship (Ayala & Coleman, 2000; Cole Kemeny, Taylor, & Visscher, 1996; Cole, Kemeny, Taylor, Visscher, & Fahey, 1996; Diplac ido, 1998; Lewis et al., 2001; Szymanski et al., 2001) and other studies finding no significant link (DAugelli et al., 2001; Lewis et al., 2003; McGregor et al., 2001). The current study supports the hypothe sis that sexual orientation concealment is related uniquely to greater psyc hological distress and lower psychological wellbeing. One possible explanation for mixed findings across studies regard ing sexual orientation concealment is the observed restriction in range of sexual orientation concealment in many prior studies, with sample averages typically near the high end of the outness continuum (Lewis et al., 2003; McGregor et al., 2001). A nother consideration is that some researchers assess sexual orientation concealment with a single item (DA ugelli et al., 2001), which may not adequately capture participants levels of outness across contexts. In the current study, disclosure concealment of sexual orientation scores were near the mid-point of possible scores, demonstrating a greater range of reported con cealment versus outness th an has been typically represented in prior stud ies. Thus, attention to sample char acteristics and range restriction in level of outness is important in interpreting prior and future findings regarding the link of sexual orientation concealment with mental health indi cators. Findings of the current study support the posited role of concealment of sexual orientation as a minority stressor. In addition to testing and generally providing support for the tenets of the minority stress model, the present study also examined severa l competing hypotheses re garding the roles of

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65 spirituality and religiosity in the mental health of LGB pers ons. First, the hypothesis that spirituality and religiosity would be buffers of the stress and psychological distress and wellbeing relationship was not supported. Therefor e minority stress is related to positively to psychological distress and negatively to psyc hological well-being rega rdless of level of spirituality and religiosity. By contrast, BowenReid & Harrell (2002) found that for African American college students, spiritua lity moderated the relationship between racist stressful events and psychological distress. For participants with high levels of spirituality, there was no significant relation between perceived racist stressful events and psychological distress, whereas, for participants with low levels of spirituality, there was a significant and positive relation between perceived racist stressfu l events and psychological distre ss. Perhaps spirituality serves as a buffer of minority stress fo r African American persons becau se in the African American community, spirituality and religiosity are also connected with a sense of family, community, and history of strength. However, spirituality and religiosity may not have the same meaning in the LGB community as they do in the African American community because many religions are condemning of homosexuality. Additionally, many LG B persons struggle with their spirituality and religion and many LGB persons may have split from the spirituality or religion that they were raised in (Ritter & ONeill, 1998). For instan ce, in the current sample, 69% of participants reported that their current re ligion is not the religion that they were raised in. Despite lack of support for a buffering or m oderating effect, results of this study were consistent with the view of spir ituality as a mental health promot er. Specifically, spirituality was not related significantly to psychological distress, but it was correlated positively with psychological well-being. Additionally, spiritua lity accounted for unique variance in well-being above and beyond that accounted for by the minority stressors and religiosity. On the other hand,

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66 results were consistent with the view of religio sity as a mental health stressor. Specifically, religiosity was not correlated significantly with either psychological di stress or well-being, but religiosity accounted for unique negative variance in ps ychological well-being when entered into a regression analysis with the minority stressors and spirituality. This pattern of findings suggests that religiosity is not related to psychological distress, but that it is related to lower well-being for LGB persons when the positive effects of spiritu ality are accounted for. The different patterns of findings for spirituality and religiosity also support the perspective that spirituality and religiosity have distinct, rather than parallel roles in the psycho logical distress and well-being of LGB persons. Limitations The present findings m ust be in terpreted in light of a number of limitations. For example, overall, the sample reported fairly low levels of distress and high levels of well-being. Also, this study did not assess whether part icipants are currently or have ever sought therapy. Therefore these results may not generalize to LGB persons w ho have greater levels of distress, diagnosable mental illnesses, or are seeking therapy. Future research should examine if minority stress is significantly related to mental illnesses such as depression, a nxiety, and substance abuse with clinical populations of LGB persons. An additional potential limitation is use of the Internet to collect data. Thus, persons who did not have access to a computer and the Internet were excluded from this study. This limitation should be considered in light of the fact that over two-thirds of Americans have access to the Internet at home, school, work, or in other venues, and that LGB persons spent more time on the Internet than their heterosexual counterparts (R iggle et al., 2005). Anot her concern about using an online study is the po tential vulnerability to random re sponding. In the curre nt study validity check items were utilized to ensure that partic ipants were not randomly responding and that they

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67 were reading and understanding th e questions. Despite concerns about sample restriction and random responding, use of the Inte rnet to collect data in the present study was deemed appropriate given some of the benefits of Intern et data collection, specifically for LGB research. Specifically, online recruitment does not require that participants come out in person to researchers, and this may result in greater representation of part icipants who are less out about their sexual orientation (Epste in & Klinkenberg, 2002). Additi onally, online recruitment has been shown to be geographically diverse (Gosling et al., 2004) which circumvents the challenge of oversampling LGB participants from a few large metropolitan areas. Instead with online data collection, researchers are able to recruit participants from a broader geographic area. For instance, the current study had participants that came from over 40 states and from 15 countries. Despite these benefits of online recruitment, it is important to highlight that about half of the participants who attempted the study did not complete the study. Although it is impossible to know the reasons that participants did not comp leted the study, one potential explanation is the length of time it took to complete the study. The on-line survey took approximately 25 minutes to complete which may have created study fatigue and increased the drop out rate. Future on-line studies should aim to reduce the length of the research survey. Bu t such decisions need to be balanced against the loss of potentially important information. It is also possible that some of the participants who did not complete the study initially, may have come back to complete it at a later time. For instance, some participants may have wanted to see what the study was about first, and then completed the survey at a time that was more convenient for them. Lastly, it is impossible to know if there are any important differences between the group of persons who completed the study and the group that did not.

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68 Another limitation of this study is that while participants we re diverse in terms of age, religion, and social class, the sample was largely White/Caucasian and most participants reported having at least a college degree. Additionally, this study recruited participants who identified as lesbian, gay, or bisexual. This study did not r ecruit participants who engage in same-gender sexual behaviors but do not identify as LGB. There may be different levels of minority stress for persons who identify as LGB and are open about their sexual orientation than for persons who identify as heterosexual but engage in same-gender sexual behaviors. The relations among minority stressors, psychological distress and well-b eing, spirituality, and re ligiosity may also be different for these different groups. For instan ce, for persons who identify as heterosexual, internalized homophobia may play a larger ro le in accounting for psychological distress and well-being, and experiences of prejudice, expectations of stig ma, and concealment of sexual orientation may play smaller ro les given that these individua ls do not have public sexual minority identities. These issues limit the generali zeability of the present findings to individuals of the racial/ethnic backgrounds and sexual orient ation identifications reflected in the present sample. Future studies are needed to assess the ro les of spirituality, religiosity, minority stress, and psychology distress and well-being with racia l/ethnic minority samples of LGB persons and with persons who do not identify as LGB but engage in same-gender sexual activity. Implications for Future Research and Practice The current study found that spirituality was related to lower psyc hological distress and greater psychological well-being. Future resear ch should explore what specific aspects of spirituality (e.g. a belief in a higher p ower, a daily meditative practice, or a relationship with a spiritual leader) are protective features for LGB persons. This information would not only increase our scientific unders tanding of spiritualit y, but could also be used to inform development of interventions fo r the LGB community and society at large. Additionally, future

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69 investigations could explore ways that LGB pers ons can increase their spir ituality without being exposed to potentially harmful aspects of some religions that condemn homosexuality as a sin. Furthermore, a critical direction for future resear ch is to continue to explore variables that may act as protective factors for LGB persons. Althou gh research has suggested that LGB people are at increased risk for some mental health conc erns (Cochran & Mays 2000a; Gilman et al., 2001; Meyer, 2003; Sandfort et al., 2001), the majority of LGB persons do not have a mental illness. In fact, the current sample reported relatively low le vels of psychological distress and high levels of psychological well-being. Thus, many LGB persons appear to cope adaptively with minority stress. This study identified spirit uality as one potential mental health promoter. Future research is needed to explore additional mental health promoters and buffe rs of minority stress for LGB persons. This line of research will be essential in creating preventi on and mental health promotion programs for the LGB community. By advancing scientific unde rstanding of the roles of mi nority stressors, as well as spirituality and religiosity in the mental health of LGB persons, the present study can inform theoretically and empirically based therapies and interventions that aim to improve the mental health of LGB persons. More spec ifically, the present data suggest that th e roles of minority stressors in the psychological di stress and well-being of LGB pers ons are important to address in therapy. When working with LGB c lients, therapists s hould assess clients perceived experiences of prejudice and discriminati on, expectations of stigma, internalized homophobia, and concealment of sexual orientation. Therapists can inform clients of the relationship between these minority stressors and psyc hology distresses and work to re duce their client s exposure to such stress. To this end, social justice promo tion efforts aiming to in crease protection of LGB persons rights and reduce societal prejudice against LGB persons continue to be needed.

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70 However, clinicians should be aware that expecting stigma from others and concealing sexual orientation might be an effective way for LGB persons to cope with societal stigma. Thus, reducing stigma vigilance and sexual orientati on concealment may not necessarily be adaptive for clients in a cultural context of anti-LGB prejudice and stimgatization. But, helping clients to make informed decisions about when and how to disclose their sexual orientation and how to protect themselves from potential stigma might foster some sens e of perceived control in the context of societal stigma. Indeed, perceived control has been found to mediate the link of perceived prejudice with psychological distress in racial/ethnic minority samples (Moradi & Hasan, 2004; Moradi & Risco, 2006). In addition to social justice efforts to reduce societal stigma against LGB individuals, it is also important for therapists to work with th eir clients to develop tools for mitigating the potentially negative effects of current minority st ressors in their clients lives. The present findings regarding the role of spirituality provide one potentially useful tool for therapists and clients to consider. Specificall y, spirituality was found to be linked uniquely and positively with psychological well-being. Therefore aspects of spirit uality may be used in therapy as a tool to help clients cope with minority stress or can be incorporated into prev ention programs that might promote health for LGB persons. Specificall y, with clients who are open to considering spirituality as a resource, clinicians can explore th e role of spirituality in the clients lives and psychological well-being, encourage clients to se t aside time for meditation or prayer, and help clients identify resources for spiritual guidance. Additionally, since reli giosity was found to be related uniquely and negatively w ith psychological well-being, clin icians should assess for and work to reduce the impact of religious wounding for LGB persons Specifically, clinicians may educate clients about the distin ction between spirituality and religiosity. Additionally, they may

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71 assess for maladaptive religious beliefs, such as inappropriate deferral to or feeling punished by God or a Higher Power (Pragament et al., 1998) and offer alternative messages. For instance, therapists can inform clients about religious orga nizations and recourses th at take an affirming stance toward LGB individuals (e.g. Metropolita n Community Churches, The World Congress of Gay, Lesbian, Bisexual, and Transgendered Jews). An important consideration is that research has shown that therapis ts are less religious than the general population (Begin & Jensen, 1990) although therapists do view religiosity and spirituality as important areas of functioning (Hathaway, Scott, & Garver, 2004). Despite the value that therapists may place on spirituality, most do not routinely assess the domain or address it in treatment planning (Hathaway, Scott, & Garver, 2004). Indeed, Lindgren and Coursey (1995) found that for a sample of adults with mental illness, two thirds wanted to discuss spiritual concerns with their th erapists, but only half of the sample was doing so. The limited attention given to spirituality in therapy may be because therapists receive little training in spirituality or religiosity (Brawer, Hangal, Fabr icatore, Roberts, & Wajda-Johnston, 2002). Thus it seems important for training prog rams to incorporate education about spirituality into their curricula and for current therapists to receive training on how to address spirituality with both LGB and heterosexual clients. To this e nd, Fukuyama (2007) made a number of training recommendations for the inclusion of spirituality into multicultural therapy that include clinicians (1) becoming self aw are of their own issues or bi ases, (2) learning about diverse religious and spiritual traditions (3) discussing spiritual topics with colleagues or supervisors, (4) having a personal spiritual pract ice, and (5) having spiritual/religious referrals or consultants. Lastly, clinicians should base th eir integrations of spiritually into therapy in th e burgeoning body of theory and research on spirituality (Pargament, Murray-Swank, & Tarakeshwar, 2005). For

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72 instance, clinicians could examine a clients level of spiritual development based on the Experience Based Stages of Spiritual Deve lopment (Sandhu, 2007), a developmental stage model of spirituality that is comparable to other identity st age models used in counseling psychology (e.g. Model of Homosexua l Identity Formation; Cass, 1979). Also, when appropriate clinicians could utilize a manualized spiritually in tegrated treatment (Avants, Beitel, & Margolin, 2005; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992). Summary The findings of the current study are largely supportive of the m inor ity stress theory and the posited relations of minority stressors wi th greater psychologica l distress and lower psychological well-being. The findings also suggest different roles for spirituality and religiosity, such that spirituality is linked with greater psyc hological well-being whereas religiosity is linked with lower psychological well-being of LGB indi viduals. Future studies should expand on the current findings by exploring what aspects of spirituality promote mental health and by identifying additional mental health promoters for LGB populations.

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74 Baron, R. M., & Kenny, D. A. (1986). The moderato r-mediator variable di stinction in social psychological research: Conceptual, stra tegic, and statisti cal considerations Journal of Personality and Social Psychology, 51, 1173-1182. Bowen-Reid, T. L., & Harrell, J. P. (2002). R acist experiences and health outcomes: An examination of spirituality as a buffer. Journal of Black Psychology, 28, 18-35. Brawer, P. A., Handal, P. J., Fabricatore, R. R., & Wajda-Johnston, V. A. (2002). Training and education in religion/spirituality within APA-accredited clinical psychology programs. Professional Psychology: Re search and Practice, 33, 203-206 Brady, M. J., Peterman, A. H., Fitchett, G., Mo, M., & Cella, D. (1999). A case for including spirituality in quality of life measurement in oncology. Psycho-Oncology, 8, 417-428. Branscombe, N. R., Schmitt, M. T., & Harvey, R. D. (1999). Perceiving pervasive discrimination among African Americans: Implications for group identification and well-being. Journal of Personality and Social Psychology, 77, 135-149. Brooks, V. R. (1981). Minority stress and lesbian women. Lexington, MA: Lexington Books. Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, 219-235. Cochran, S. D., & Mays, V. M. (2000a). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. American Journal of Public Health, 90, 573-578. Cochran, S. D., & Mays, V. M. (2000b). Relation between psychiatric syndromes and behaviorally defined sexual orientat ion in a sample of the US population. American Journal of Epidemiology, 151, 516-523. Cole, S. W., Kemeny, M. E., Taylor, S. E., & Vi sscher, B. R. (1996). Elevated physical health risk among gay men who conceal their homosexual identity. Health Psychology, 15, 243251. Cole, S. W., Kemeny, M. E., Taylor, S. E., Vissc her, B. R., & Fahey, J. L. (1996). Accelerated course of Human Immunodefici ency Virus infection in gay men who conceal their homosexual identity. Psychosomatic Medicine, 58, 219-231. Crocker, J., & Major, B. (1989). Social stigma a nd self-esteem: The self-p rotective properties of stigma. Psychological Review, 96, 608-630. DAugelli, A. R. (1989). Lesbians and gay men s experiences of discrimination and harassment in a university community. American Journal of Community Psychology, 17, 317-321.

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75 DAugelli, A. R., Grossman, S. L., Hershberger, S. L., & OConnell, T. S. (2001). Aspects of mental health among older lesbian, gay, and bisexual adults. Aging and Mental Health, 5, 149-158. Davidson, M. G. (2000). Religion and spirituality. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counseling and psychothe rapy with lesbian, gay, and bisexual clients, 409-433. Washington, DC: American Psychological Association. Declan, B. T., & Mizrahi, T. C. (2005). Guarde d self-disclosure predic ts psychological distress and willingness to use psychol ogical services among East Asian immigrants in the United States. Journal of Nervous and Mental Disease, 193, 535-539. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Cove, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, 1-15. Diaz, R. M., Ayala, G., Bein, E., Henne, J., & Marin, V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual latino men: Findings from 3 US cities. American Journal of Public Health, 91, 927-932. DiPlacido, J. (1998). Minority stress among lesbians gay men, and bisexuals: A consequence of heterosexism, homophobia, and stig matization. In G. M. Herek (Ed.), Stigma and sexual orientation: Understanding prejudice agai nst lesbians, gay men, and bisexuals (pp. 138159). Thousand Oaks, CA: Sage. Dohrenwend, B. S. (1973). Social status and stressful life events. Journal of Personality and Social Psychology, 28, 225-235. Downey, L., Rosengren, D. B., & Donovan, D. M. (2003). Gender, waitlis ts, and outcomes for public-sector drug treatment. Journal of Substance Abuse Treatment, 25, 19-28. Eliis, L., & Wagemann, B. M. (1993). The religiosity of mothers and their offspring as related to offsprings sex and sexual orientation. Adolescence, 28, 227-234. Ellison, C. W., Gay, D. A., & Glass, T. A. ( 1989). Does religious commitment contribute to individual life satisfaction? Social Forces, 68, 100-123. Ellison, M. M. (1993). Homosexuality and Pr otestantism. In A. Swindler (Ed.), Homosexuality and World Religions, (pp. 149-180). Valley Forge, PA: Trinity. Epstein, J., & Klinkenberg, W. D. (2002). Collecti ng data via the interne t: The development and deployment of a web-based survey. Journal of Technology in Human Services. 19, 33-47. Fabricatore, A. N., Handal, P. J., & Fenzel, L. M. (2000). Personal spirituality as a moderator of the relationship between stress ors and subjective well-being. Journal of Psychology and Theology, 28, 221-228.

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76 Fergusson, D. M., Horwood, J. L., & Beautrais, A. L. (1999). Is sexual orientation related to mental health problems and suicidality in young people? Archives of General Psychiatry, 56, 876-880. Forthus, L. F., Pidcock, B., W., & Fischer, J. L. (2003). Religiousness and disordered eating: Does religiousness modify family risk? Eating Behaviors, 4, 7-26. Fukuyama, M. A. (2007). Weaving sacred threads into multicultural counseling. In. O. J. Morgan (Ed.) Counseling and spirituality (pp. 93-109). Boston: Lahaska Press. Gilman, S. E., Cochran, S. D., Mays, V. M., Hughes, M., Ostrow, D., & Kessler, R. C. (2001). Risk of psychiatric disorders among individuals reporting same -sex sexual partners in the national comorbidity survey. American Journal of Public Health, 91, 933-939. Goodman, L. A., Liang, B., Helms, J. E., Latta, R. E., Sparks, E., & Weintraub, S. R. (2004). Training counseling psychologists as social justice agents: Feminist and multicultural principles in action. The Counseling Psychologist, 32, 793-837. Goodman, M. B., Moradi, B., Risco, C., Massa, J., DeBlaere, C., & Hadjez, D. (August, 2005). Minority stress and psychological dist ress of lesbian and gay persons. Poster presented at the annual meeting of the American Ps ychological Association, Washington, D.C. Gosling, S. D., Vazire, S., Srivastava, S., & John, O. P. (2004). Should we trust web-based studies? A comparative analysis of six pr econceptions about internet questionnaires. American Psychologist, 59, 93-104. Green, D. E., Walkey, F. H., McCormick, I. A., & Taylor, J. W. (1998) Development and evaluation of a 21-item version of the Hopkins Symptom Checklist w ith New Zealand ad United States respondents. Australian Journal of Psychology, 40, 61-70. Hatch, R. L., Burg, M. A., Naberhaus, D. S., & Hellmich, L. K. (1998). The Spiritual Involvement and Beliefs Scale: Developm ent and testing of a new instrument. Journal of Family Practice, 46, 476-487. Hathaway, W. L., Scott, Y. S., & Garver, S. A. (2004). Assessing religious/spiritu al functioning: A neglected domain in clinical practice? Professional Psychology: Research and Practice, 35, 97-104. Herek, G. M. (1993). Documenting prejudice agai nst lesbians and gay men on campus: The Yale sexual orientation survey. Journal of Homosexuality, 25, 15-30. Herek, G. M., Cogan, J. C., Gillis, J. R., & Gl unt, E. K. (1997). Correlates of internalized homophobia in a community sample of lesbian and gay men. Journal of the Gay and Lesbian Medical Association, 2, 17-25.

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83 BIOGRAPHICAL SKETCH Melinda B. Goodm an was born and raised in Silver Spring, Maryland. She graduated magna cum laude with a Bachelor of Science in psychology from the University of Maryland in 2002. After graduating she spent a year working with autistic children and traveling overseas. In August 2003 she moved to Gainesville to enter into University of Floridas Counseling Psychology program. She is currently completing he r Predoctoral Internship at the Virginia Commonwealth University Counseling Services.