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The transgender population is makes up about 0.3% of the U.S. population (Gates 2011). The term transgender is both an identity and an umbrella term used to describe people who do not adhere to traditional gender norms (Institute of Medicine 2011). Transgender people experience many barriers to services, negative health outcomes, and discrimination (Fredrikson-Goldsen et al. 2013; Institute of Medicine 2011; Eliason et al. 2009; Hendricks & Testa 2012). Mental health clinics are an important site for understanding transgender peoples' experiences due to being a gatekeeper for other medical services and their role in helping transpeople with issues surrounding coming out, victimization, and discrimination (Grant et al. 2011; Youth Suicide Prevention Program 2011). The mental health field has a contested relationship with the transgender population due to a history of pathologizing gender variance, barriers to accessing services, and insensitivity from mental health providers (American Psychiatric Association 2013; Eliason et al. 2009). I conducted secondary data analysis using the National Transgender Discrimination Survey (2008) in order to understand the relationships between gender non-conforming identities, others' perception of one's gender identity, and discrimination at mental health clinics. Results suggest that there is an association between gender identity, others' perception of one's gender identity, and discrimination. This association depends on which gender identity, the degree to which an individual identifies with each term, and the type of discrimination. Logistic regression results reveal that identity and others' perception are not significant predictors for experiencing discrimination. Rather, income and race are significant predictors for experiencing discrimination at metal health clinics.

Background: Sexual minority women (SMW; e.g., lesbian, bisexual women) are at substantially higher risk for hazardous drinking (HD) than their heterosexual, cisgender counterparts. There is considerable evidence that minority stressors at the individual (e.g., internalized stigma) and interpersonal (e.g., discrimination) levels are associated with HD among SMW, but minority stressors at the structural level (e.g., structural stigma) are understudied. Further, there is a wide gap in the literature on the relationships between multilevel minority stressors and HD. Additionally, there is evidence that these associations may differ by race/ethnicity and sexual identity, but relatively little is known about these differences, particularly in a multilevel context. Methods: This dissertation includes three studies that were guided by an adaptation of the minority stress model and the social ecological model. In the first study we conducted a systematic review of quantitative research studies that examined associations between structural stigma and alcohol-related outcomes among sexual and gender minority (SGM) adults in the United States. In the second study we used data from a diverse sample of SMW enrolled in the Chicago Health and Life Experiences of Women (CHLEW) study to determine whether structural stigma at Wave 4 (2017-2019) was prospectively associated with HD at Wave 5 (2019-2022), and whether this association was attenuated when accounting for individual- (i.e., internalized stigma, stigma consciousness) and interpersonal- (i.e., discrimination, sexual identity concealment) level minority stressors. In the third study we used data from Waves 4 and 5 of the CHLEW study to examine whether associations between multilevel minority stressors (i.e., internalized stigma, stigma consciousness, discrimination, sexual identity concealment, structural stigma) and HD varied by race/ethnicity and sexual identity. Results: The systematic review included 11 studies. There was moderate to strong support for a positive association between structural stigma and poor alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Multilevel stigma and resiliency factors were understudied. In the second study, structural stigma was positively associated with HD alone, and when combined with interpersonal-level minority stressors. With the addition of individual-level minority stressors, the association between structural stigma and HD was attenuated, with partial attenuation (i.e., structural stigma was still significant) in the model combining all three levels, and full attenuation (i.e., structural stigma was no longer significant) in the model with only structural stigma and individual-level stressors. Discrimination was negatively associated with HD in the fully combined model and was not associated with HD in any other models. In the third study, we found that associations between structural stigma and HD did not vary by race/ethnicity or sexual identity. However, the associations between individual-level minority stressors (i.e., internalized stigma, stigma consciousness) and interpersonal-level minority stressors (i.e., sexual identity concealment) with HD varied somewhat by race/ethnicity and sexual identity. Conclusions: Findings from this dissertation highlight the importance of structural stigma in SMW’s HD and underscore the importance of both structural-level and multilevel minority stressors in designing interventions to effectively address HD drinking disparities and inequities among SMW. Future research is needed using intersectional approaches with probability samples, longitudinal designs, expanded measures of structural stigma, and samples that reflect the diversity of SGM people.

The purpose of this research was to explore social hardships of non-gay identifying, [behaviorally] bisexual, and “other” marginal LGBTQ+ men who are sexually intimate with men in a heteronormative and [toxic] masculine world. Relatedly, hegemonic masculinity dominates the patriarch through regulating behavioral norms that often stigmatize and discriminate opposing traits, ideologies, or groups, such as LGBTQ+. This has been known to affect and mediate health outcomes and “outness.” Therefore, this study explored how minority stressors impact self-concept, mental health, well-being, and motivations to disclose and/or conceal. Data collection involved survey and interview formats (mixed-methods cross-sectional design) that assessed internalized homophobia, conformity to masculine norms, subjective masculinity stress, disclosure, and concealment in relation to lifestyle and social context. While all variables had expected linear associations, not all were causal. Those who conformed to masculine norms significantly experienced internalized stigma/homophobia. Hence, it can be hypothesized that participants who conformed sought to conceal stigma under pressure of heteronormative culture and the patriarch. However, subjective masculinity stress was nonsignificant, exemplifying hegemonic influence as more defining to their self-concept than their own. Further, minority stress constructs (masculine norms, internalized stigma/homophobia, and subjective masculinity stress), when age, regional location, and faith were controlled, significantly predicted less disclosure and more concealment in social contexts. This reinforces the power of modern patriarchy/masculine norms/minority stress and its adverse effects on mental health, well-being, and outness in marginalized populations of LGBTQ+. Relatedly, qualitative data validated these quantitative findings but generally over the lifecycle of “coming out” as opposed to respondents’ current growth and development in outness, mental health, and well-being. However, to further affirm such quantitative findings, both survey and interview data did report distress regarding modern day masculinity and its ill standards that place unrealistic expectations on men, which continue to create disparities among and between many communities and humanity.

The purpose of this study was to explore the religion – health link in a sample of adults and undergraduate students (N = 555) that identified as lesbian, gay, or bisexual (LGB), and to explore how perceptions of cultural humility of religious individuals and groups toward LGB individuals affect the relationship between religion and health. First, I found religious commitment among LGB individuals was positively correlated with satisfaction in life, but it was negatively correlated with physical health. Second, I found that cultural humility moderated the relationship between religious commitment and satisfaction in life for LGB individuals involved in a religious community. The lowest levels of satisfaction with life were found for individuals with low religious commitment and perceived the cultural humility of their religious community to be low. However, cultural humility did not moderate the relationship between religious commitment and mental and physical health outcomes. Third, I found cultural humility did not moderate the relationship between religious commitment and minority stress (i.e., internalized homophobia). Fourth, I found that cultural humility was a significant positive predictor of motivations to forgive a hurt caused by a religious individual. I conclude by discussing limitations, areas for future research, and implications for counseling.