Assessed 3 a priori defined cohorts of sexual minorities (born 1956–1963, b. 1974–1981, & b. 1990–1997): Psychological distress & suicide behavior were not improved, were worse for the younger than the older cohorts

Meyer IH, Russell ST, Hammack PL, Frost DM, Wilson BDM (2021) Minority stress, distress, and suicide attempts in three cohorts of sexual minority adults: A U.S. probability sample. PLoS ONE 16(3): e0246827. https://doi.org/10.1371/journal.pone.0246827

Abstract: During the past 50 years, there have been marked improvement in the social and legal environment of sexual minorities in the United States. Minority stress theory predicts that health of sexual minorities is predicated on the social environment. As the social environment improves, exposure to stress would decline and health outcomes would improve. We assessed how stress, identity, connectedness with the LGBT community, and psychological distress and suicide behavior varied across three distinct cohorts of sexual minority people in the United States. Using a national probability sample recruited in 2016 and 2017, we assessed three a priori defined cohorts of sexual minorities we labeled the pride (born 1956–1963), visibility (born 1974–1981), and equality (born 1990–1997) cohorts. We found significant and impressive cohort differences in coming out milestones, with members of the younger cohort coming out much earlier than members of the two older cohorts. But we found no signs that the improved social environment attenuated their exposure to minority stressors—both distal stressors, such as violence and discrimination, and proximal stressors, such as internalized homophobia and expectations of rejection. Psychological distress and suicide behavior also were not improved, and indeed were worse for the younger than the older cohorts. These findings suggest that changes in the social environment had limited impact on stress processes and mental health for sexual minority people. They speak to the endurance of cultural ideologies such as homophobia and heterosexism and accompanying rejection of and violence toward sexual minorities.

Discussion

We started this project with the hypothesis that younger cohorts of sexual minority people would fare better than their older peers, who grew up in a more hostile social and legal environment than that of the younger cohorts. We found a strong cohort impact on the age of same-sex attraction milestones: Each successive cohort had earlier sexual identity milestone experiences of identifying as a sexual minority person, first sexual experience, and coming out. This likely indicates both greater comfort in coming out and shifting social norms around sexuality and youth. On one hand, these trends suggest that the younger cohorts reached developmental milestones related to their sexuality earlier than older cohorts, which is generally understood to be positive for adjustment. On the other hand, identifying and coming out as a sexual minority can confer risk, including greater exposure to minority stressors and victimization [52].

Indeed, contrary to our hypothesis, we found little evidence that social and legal improvements during the past 50 years in the status of sexual minority people have altered the experiences of sexual minority people in terms of exposure to minority stressors and resultant adverse mental health outcomes. Most tellingly, younger sexual minority people did not have less psychological distress or fewer suicide attempts than older sexual minority people.

Regarding minority stress, we found that members of the younger cohort did not experience less minority stress than members of older cohorts. This was consistent across both distal minority stressors, which measure direct exposure to external conditions, such as antigay violence, and proximal stressors, which measure how homophobia is internalized and learned. Members of the younger cohort did experience fewer of the victimization experiences we studied. But the measure of lifetime exposure to victimization presents a challenge. By their nature, lifetime measures would show higher prevalence among older people simply because they have more years in their lifetime and therefore, more opportunities for experiencing victimization. It this context, it is notable that the younger sexual minority people experienced more extreme victimization in their shorter lifespan. More than 1 in 3 (37%) experienced being hit, beaten, physically attacked, or sexually assaulted; almost half (46%) had someone threaten them with violence; and almost 3 in 4 (72%) were verbally insulted or abused. In terms of proximal minority stressors—internalized homophobia and felt stigma—we found members of the younger cohort recorded as high or higher levels of stress relative to their older counterparts.

Consistent with findings on the experience of minority stressors, we found high scores of psychological distress in the younger cohort. Although some research has suggested that this may be a general trend for younger adults to have higher levels of depressive symptoms, there appears to be a U-shaped relationship in the general population, with younger and older people exhibiting high levels of depressive symptoms measured by the same scale we used [53]. We found a clear disadvantage to the younger cohort that seems unique to sexual minority people. Research has also shown that no significant bias in reporting patterns to this scale could explain the pattern of our results [54]. We also found that 30% of members of the younger cohort had attempted suicide. This is an alarming figure that was even higher than the high proportions of lifetime suicide attempts reported by the middle and older cohorts. By comparison, the proportion of young people aged 18–24 in the general population who have attempted suicide has been less than 4% [55].

Our findings are clearly inconsistent with the hypothesis. We started our hypothesis from a theoretical perspective that suggests that as social conditions improve, exposure to minority stressors and mental health problems would decrease. Our hypothesis was optimistic, but we were not blind to evidence to the contrary. As Russell and Fish [56] have shown, disparities by sexual identity have not been declining, but instead increasing. Most foretelling has been findings by the Centers for Disease Control and Prevention about exposure to stress among youth in high schools. Reports have consistently indicated that sexual minority youth experience significantly more stressful experiences than heterosexual youth and suffer significantly greater adverse health outcomes, including suicide ideation and attempts [57–60]. Our findings, thus, are consistent with studies that showed that minority stress and health disparities based on sexual orientation have not dissipated [56,61–64], despite the significant social and legal gains of the last decades.

Finally, contradicting writings about the declining significance of the LGBT community and sexual minority identity for the young cohort of sexual minority people, we found as high a sense of centrality of sexual minority identity and sense of connection with the LGBT community [35,36]. This is an important finding because it suggests that the LGBT community is still an important locale for connecting with LGBT identities, values that denounce homophobia, and role models for healthy sexual minority lives. As has been shown with older cohorts of sexual minorities, these are important resilience factors that allow sexual minority people to grow and overcome homophobia [2,65–69]. Connection with the LGBT community is also important for health information and the public health of LGBT communities, because resources serving sexual minorities have been organized under the LGBT banner for decades [70]. Studies have shown, for example, that gay and bisexual men who were connected to LGBT health resources were more likely than those who were not to use preexposure prophylaxis as HIV prevention [40]. However, this should not obscure the many challenges facing LGBT community organizers to overcome intracommunity rejection across race, social class, and other attributes [71].

There are many reasons why our hypothesis was not supported, and it is beyond our scope to explore these. Our approach was to examine cohort-wide patterns of change. In that, we may have missed the impact on specific segments of the populations. For example, we do not know whether White sexual minority people fared differently than ethnic minorities or how gender impacted the patterns we studied. This was, of course, purposeful because our theory was that the entire cohort would be affected by historical changes (even if not in equal ways). Also, it is plausible that social conditions, looked at as broadly as we did, do not reveal many other influences on stress exposure and mental health outcomes. For example, even if the social environment improved overall, it may have not improved in all microenvironments. Furthermore, it is possible that even as the social environment improves, the lived experience of sexual minority people continues to be challenging [72]. For example, a gay or lesbian teenager may be more accepted now than their older cohort peers had been when they were teenagers, but they were still a minority in their high school, deprived of opportunities for developing intimate relations. Also, a “developmental collision” may occur as sexual minority identity disclosure at younger ages coincides with normative developmental processes associated with adolescence [56]. Although the larger social context may have improved in such a way that emboldens younger generations to be out, the normative developmental context of adolescence remains one in which conformity is prized. Compulsions to conform to gender and sexual norms that privilege heterosexuality may continue to characterize adolescence in the United States [73]. Future analysis could determine whether some segments of the population benefited more than others from the improved social conditions and how improved social conditions impact the lived experience of sexual minority people.

Study limitations

Our study was limited in several important ways that are relevant to drawing conclusions about cohort differences. First, our purpose was to provide an overview of the status of stress and health in three cohorts of sexual minority people at one point using cross-sectional data. Obviously, this one-time picture limits our ability to discuss historical differences and trajectories, but we interpret the results to suggest that they reflect the impact of historical changes in the status of sexual minority people in society. Our interpretation is based on theory and our a priori categorization of the three cohorts. Because we aimed to capture the impact of historical context, we erred by ignoring potential differences among members of any age cohort that could have affected variability in cohorts. We assessed differences among three cohorts of sexual minority people but not differences by gender, race and ethnicity, socioeconomic status, neighborhood context, etc. This is consistent with our hypothesis about cohort differences. Regardless of variability in each cohort, we tested the hypothesis that the younger cohort, as a whole, fared better than older cohorts because members of the young cohort, across all strata, enjoyed better social conditions than members of older cohorts.

Second, like all measures, our measures of stress, coping, and health were limited in that each measure has its limitations and represents only a portion of complex constructs. For example, we assessed depressive symptoms and suicide attempts as proxies for the construct of mental health. Nonetheless, we present a variety of stress measures that include victimization and everyday discrimination, internalized minority stressors (felt stigma and internalized homophobia), and generalized distress, which is associated with mental health and suicide attempts—a clear and serious outcome and significant gauge of sexual minority health. The two measures that represent resilience assessed connection with the community and centrality of identity—two important elements of coping with minority stress.

Third, cohort (and the historical periods of interest) and age were confounded. That is, there was no way to avoid the fact that respondents who came of age in more distant historical periods are also older than respondents who grew up in the context of recent and improved social conditions. Therefore, it is plausible that some differences that we observed resulted from developmental or age-related changes rather than the impact of the different historical social environments. For example, internalized homophobia typically is expected to decline with age, as a person comes to terms with their same-sex attraction and comes out [32]. Our finding that internalized homophobia was higher in the younger than older cohort is consistent with that theory and could reflect the younger developmental stage of the younger cohort members. On the other hand, if social conditions have improved so greatly, we could have expected that internalized homophobia—which denotes rejection of oneself because of one’s same-sex attraction and identity—would cease to be an issue for younger people altogether. That is definitely not the case. Our findings show that some younger people still struggle with self-acceptance. So, although we cannot say with certainty that there is no age effect, we certainly can say that internalized homophobia has not ended in young sexual minority people.