Racial Disparities in Health Behaviors and Conditions Among Lesbian and Bisexual Women: The Role of Internalized Stigma
Abstract
There are documented disparities in physical health behaviors and conditions, such as physical activity and obesity, with regard to both race/ethnicity and sexual orientation. However, physical health disparities for lesbian and bisexual (LB) women who are also racial minorities are relatively unexplored. Minority stressors, such as internalized stigma, may account for disparities in such multiply marginalized populations. We sought to (1) characterize inequalities among non-Hispanic white and African American LB women and (2) examine the roles of internalized sexism and homophobia in disparities. Data on health behaviors (diet, physical activity); physical health (hypertension, diabetes, overweight/obesity); internalized sexism; and internalized homophobia were collected via a web-based survey. Recruitment ads were sent electronically to over 200 listservs, online groups, and organizations serving the lesbian, gay, and bisexual community in all 50 U.S. states. The analytic sample consisted of 954 white and 75 African American LB women. African American participants were more likely than white participants to report low fruit/vegetable intake and physical activity, a higher body mass index, and a history of diabetes and hypertension. There were no racial differences in internalized homophobia, but African American women reported higher levels of internalized sexism. Internalized sexism partially mediated racial disparities in physical activity and diabetes, but not in the other outcomes. Findings suggest that African American LB women may be at greater risk than their white counterparts for poor health and that internalized sexism may be a mediator of racial differences for certain behaviors and conditions.
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References
1.
Gorman B, Read JNG: Gender disparities in adult health: An examination of three measures of morbidity. J Health Soc Behav 2006;47:95–110.
2.
Laditka SB, Laditka JN: Recent perspectives on active life expectancy for older women. J Women Age 2002;14:163–184.
3.
Mensah GA, Mokdad AH, Ford ES, et al.: State of disparities in cardiovascular health in the United States. Circulation 2005;111:1233–1241.
4.
Zhang Q, Wang YF, Huang ES: Changes in racial/ethnic disparities in the prevalence of Type 2 diabetes by obesity level among U.S. adults. Ethn Health 2009;14:439–457.
5.
McKay B. Lesbian, gay, bisexual, and transgender health issues, disparities, and information resources. Med Ref Services Q 2011;30:393–401.
6.
National Institutes of Health: Biennial Report of the Director, National Institutes of Health, Fiscal Years 2008 & 2009. Bethesda, MD: National Institutes of Health, 2010.
7.
U.S. Department of Health and Human Services: Healthy People 2020 Objectives: Lesbian, gay, bisexual, and transgender health. 2011. www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25 (last accessed October 26, 2011).
8.
Kertzner RM, Meyer IH, Frost DM, Stirrat MJ: Social and psychological well-being in lesbians, gay men, and bisexuals: The effects of race, gender, age, and sexual identity. Am J Orthopsychol 2009;79:500–510.
9.
Greene B: Lesbian women of color. J Lesbian Stud 1997;1:109–147.
10.
Mak WS, Poon CYM, Pun LYK, Cheung SF: Meta-analysis of stigma and mental health. Soc Sci Med 2007;65:245–261.
11.
Szymanski DM: Heterosexism and sexism as correlates of psychological distress in lesbians. J Counsel Dev 2005;83:355–360.
12.
Tull ES, Sheu YT, Butler C, Cornelious K: Relationships between perceived stress, coping behavior, and cortisol treatment in women with high and low levels of internalized racism. J Natl Med Assoc 2005;97:206–212.
13.
Troiano RP, Berrigan D, Dodd KW, et al.: Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40:181–188.
14.
Whitson HE, Landerman LR, Newman AB: Chronic medical conditions and the sex-based disparity in disability: The cardiovascular health study. J Gerontol 2010;65:1325–1331.
15.
Keyhani S, Scobie JV, Hebert PL, McLaughlin MA: Gender disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits. Hypertension 2008;51:1149–1155.
16.
McCollum M, Hansen LB, Sullivan PW: Gender differences in diabetes mellitus and effects on self-care activity. Gender Med 2005;2:246–254.
17.
Institute of Medicine: The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: Institute of Medicine, 2011.
18.
Williams DR: Racial/ethnic variations in women's health: The social embeddedness of health. Am J Public Health 2002;92:588–597.
19.
Case P, Austin SB, Hunter DJ, et al.: Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II. J Women Health 2004;13:1033–1047.
20.
Conron KJ, Mimiaga MJ, Landers SJ: A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health 2010;100:1953–1960.
21.
Dilley JA, Simmons KW, Boysun MJ, et al.: Demonstrating the importance and feasibility of including sexual orientation in public health surveys: Health disparities in the Pacific Northwest. Am J Public Health 2010;100:460–467.
22.
Kirkpatrick SI, Dodd KW, Reedy J, Krebs-Smith SM: Income and race/ethnicity are associated with adherence to food-based dietary guidance among US adults and children. J Acad Nutrit Diet 2012;112:624–635.
23.
Roberts SA, Dibble SL, Nussey B, Casey K: Cardiovascular disease risk in lesbian women. Women Health Issues 2003;13:167–174.
24.
Valanis BG, Bowen DJ, Bassford T, Whitlock E, Carney P: Sexual orientation and health: Comparisons in the Women's Health Initiative Sample. Arch Fam Med 2000;9:843–853.
25.
Aaron DJ, Markovic N, Danielson ME, et al.: Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health 2001;91:972–975.
26.
Bowen DJ, Balsam KF, Ender SR: A review of obesity issues in sexual minority women. Obesity 2008;16:221–228.
27.
Kant AK, Graubard BI, Kumanyika SK: Trends in Black-White differentials in dietary intakes of U.S. adults, 1971–2002. Am J Prev Med 2007;32:264–272.
28.
Ransdell LB, Wells CL: Physical activity in urban White, African-American, and Mexican-American women. Med Sci Sports Exerc 1998;30:1608–1615.
29.
Ogden CL: Disparities in obesity prevalence in the United States: Black women at risk. Am J Clin Nutr 2009;89:1001–1002.
30.
Brancati FL, Kao WHL, Folsom AR, et al.: Incident type 2 diabetes mellitus in African American and white adults: The Atherosclerosis Risk in Communities Study. JAMA 2000;283:2253–2259.
31.
Hertz RP, Unger AN, Cornell MS, Saunders E: Racial disparities in hypertension prevalence, awareness, and management. Arch Intern Med 2005;165:2098–2104.
32.
Thomas AJ, Speight SL, Witherspoon KM: Gendered racism, psychological symptoms, and coping styles of African American women. Cult Div Ethn Min Psychol 2008;14:307–314.
33.
Balsam KF, Molina Y, Beadnell B, Simoni J, Walters K: Measuring multiple minority stress: The LGBT people of color microaggressions subscale. Cultur Divers Ethnic Minor Psychol 2011;17:163–174.
34.
Mays VM, Yancey AK, Cochran SD, et al.: Heterogeneity of health disparities among African American, Hispanic, and Asian American women: Unrecognized influences of sexual orientation. Am J Public Health 2002;92:632–639.
35.
Herek GM, Capitanio JP, Widaman KF: Stigma, social risk, and health policy: Public attitudes toward HIV surveillance policies and social construction of illness. Health Psychol 2002;22:595.
36.
Jones CP: Levels of racism: A theoretic framework and a gardener's tale. Am J Public Health 2000;90:1212–1215.
37.
Bird CE, Rieker PP: Gender matters: An integrated model for understanding men's and women's health. Soc Sci Med 1999;48:745–755.
38.
Hatzenbuehler ML, McLaughlin KA, Keyes KM, et al.: The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. Am J Public Health 2010;100:452–459.
39.
Acevedo-Garcia D, Lochner KA, Osypuk TL, et al.: Future directions in residential segregation and health research: A multilevel approach. Am J Public Health 2003;93:214–221.
40.
Borrell C, Artacoz L, Gil-González D, et al.: Perceived sexism as a health determinant in Spain. J Womens Health 2010;19:741–750.
41.
Burgess D, Lee R, Tran A, et al.: Effects of perceived discrimination on mental health and mental health services utilization among gay, lesbian, bisexual, and transgender persons. J LGBT Health 2008;3:1–14.
42.
Williams DR, Mohammed SA: Discrimination and racial disparities in health: Evidence and needed research. J Behav Med 2009;32:20–47.
43.
Butler C, Tull ES, Chambers EC, et al.: Internalized racism, body fat distribution, and abnormal fasting glucose among African-Caribbean women in Dominica, West Indies. J Natl Med Assoc 2002;94:143–148.
44.
Chambers EC, Tull ES, Fraser HS, et al.: The relationship of internalized racism to body fat distribution and insulin resistance among African adolescent youth. J Natl Med Assoc 2004;96:1594–1598.
45.
Tull ES, Cort MA, Gwebu ET, et al.: Internalized racism is associated with elevated fasting glucose in a sample of adult women but not men in Zimbabwe. Ethn Dis 2007;17:731.
46.
Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav 1995;36:38–56.
47.
Szymanski DM, Kashubeck-West S, Meyer J: Internalized heterosexism: Measurement, psychosocial correlates, and research directions. Counsel Psychol 2008;36:525–574.
48.
Amadio DM: Internalized heterosexism, alcohol use, and alcohol-related problems among lesbians and gay men. Addict Behav 2006;31:1153–1162.
49.
Piggot M: Double jeopardy: Lesbians and the legacy of multiple stigmatized identities. Unpublished thesis. Psychology Strand at Swinburne University of Technology, Australia, 2004.
50.
Bridges SK, Selvidge M, Matthews CR: Lesbian women of color: Therapeutic issues and challenges. J Multicult Counsel Dev 2003;31:113–130.
51.
Dubé EM, Savin-Williams RC: Sexual identity development among ethnic sexual-minority male youths. Dev Psychol 1999;35:1389–1398.
52.
Moradi B, Wiseman MC, DeBlaere C, et al.: LGB of color and White individuals' perceptions of heterosexuist stigma, internalized homophobia, and outness: Comparison of levels and links. Counsel Psychol 2010;38:397–424.
53.
Lehman P: A validity study of the femininity ideology scale. Master's thesis. Florida Institute of Technology, 2000.
54.
Sekayi D: Aesthetic resistance to commercial influences: The impact of Eurocentric beauty standard on Black college women. J Negro Ed 2003;72:467–477.
55.
West CM. Mammy, Sapphire, and Jezebel: Historical images of Black women and their implications for psychotherapy. Psychotherapy 1995;32:458–466.
56.
Hancock AM: The Politics of Disgust: The Public Identity of the Welfare Queen. New York: New York University Press, 2004.
57.
Block G, Gillespie C, Rosenbaum EH, Jenson C: A rapid food screener to assess fat and fruit and vegetable intake. Am J Prev Med 2000;18:284–288.
58.
Baker AH, Wardle J: Sex differences in fruit and vegetable intake in older adults. Appetite 2003;40:269–275.
59.
Watters JL, Satia JS, Galanko JA: Associations of psychosocial factors with fruit and vegetable intake among African-Americans. Public Health Assoc 2007;10:701–711.
60.
Hallal PC, Victora CG: Reliability and validity of the international physical activity questionnaire (IPAQ). Med Sci Sports Exerc 2004;36:556.
61.
Hagstromer M, Oja P, Sjostrom M: The International Physical Activity Questionnaire (IPAQ): A study of concurrent and construct validity. Public Health Nutr 2006;9:755–762.
62.
Wolin KY, Heil DP, Askew S, Matthews CE, Bennett GG: Validation of the international physical activity questionnaire-short among blacks. J Phys Act Health 2008;5:746.
63.
Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW: Body-mass index and mortality in a prospective cohort of U.S. adults. N Eng J Med 1999;341:1097–1105.
64.
National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute, 1998.
65.
Martin JL, Dean L: Summary of measures: Mental health effects of AIDS on at-risk homosexual men. Unpublished manuscript. Mailman School of Public Health, Columbia University, 1992.
66.
Herek GM, Cogan JC, Gillis JR, Glunt EK: Correlates of internalized homophobia in a community sample of lesbians and gay men. J Gay Lesbian Med Assoc 1998;2:17–25.
67.
Lewis RJ, Derlega VJ, Griffin JL, Krowinski AC: Stressors for gay men and lesbians: Life stress, gay-related stress, stigma consciousness, and depressive symptoms. J Soc Clin Psychol 2003;22:716–729.
68.
Fischer AR, Tokar DM, Mergl MM, Good GE, Hill MS, Blum SA: Assessing women's feminist identity development: Studies of convergent, discriminant, structural validity. Psychol Women Q 2000;24:15–29.
69.
Szymanski DM, Gupta A: Examining the relationship between multiple internalized oppressions and African American lesbian, gay, bisexual, and questioning persons' self-esteem and psychological distress. J Counsel Psychol 2009;59:110–118.
70.
Hayes AF: Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Comm Monogr 2009;76:408–420.
71.
Preacher KJ, Hayes AF: Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Met 2008;40:87–91.
72.
Schafer JL, Graham JW: Missing data: Our view of the state of the art. Psychol Methods 2002;7:142–177.
73.
Hill SA: Teaching and doing gender in African American families. Sex Roles 2002;47:493–506.
74.
Szymanski DM: Feminist identity and theories as correlates of feminist supervision practices. Counsel Psychol 2005;33:729–747.
75.
Moradi B, Subich LM: Feminist identity development measures comparing the psychometrics of three instruments. Counsel Psychol 2002;30:66–86.
76.
Krane V, Choi PY, Baird SM, et al.: Living the paradox: Female athletes negotiate femininity and muscularity. Sex Roles 2004;50:315–329.
77.
Sartore ML, Cunningham GB: The lesbian stigma in the sport context: Implications for women of every sexual orientation. Quest 2009;61:289–305.
78.
LaVeist TA: Race, Ethnicity, and Health, 1st ed. San Francisco, CA: Jossey-Bass, 2002.
79.
Krieger N, Smith GD: “Bodies count,” and body counts: Social epidemiology and embodying inequality. Epid Rev 2004;26:92–103.
80.
Adler NE, Rehkopf DH: US disparities in health: Descriptions, causes, and mechanisms. Annu Rev Public Health 2008;29:235–252.
81.
Link BG, Phelan JC: Social conditions as fundamental causes of disease. J Health Soc Behav 1995;Spec No:80–94.
82.
Williams DR, Jackson PB. Social sources of racial disparities in health. Health Affairs 2005;24:325–334.
83.
Krieger N, Williams DR, Moss NE: Measuring social class in US public health research: Concepts, methodologies, guidelines. Ann Rev Public Health 1997;18:341–378.
84.
Wilson PA, Yoshikawa H: Improving access to healthcare among African-American, Asian, and Pacific Islander, and Latino lesbian, gay, and bisexual populations. In: The Health of Sexual Minorities. Edited by Meyer IH and Northridge ME. New York: Mailman School of Public Health, 2007, pp. 607–632.
85.
Katznelson I: When Affirmative Action Was White: An Untold History of Racial Inequality in Twentieth-Century America. New York: W.W. Norton, 2005.
86.
Massey DS: Categorically Unequal: The American Stratification System. New York: Russell Sage Foundation, 2007.
87.
Packard GM: American Nightmare: The History of Jim Crow. New York: St. Martin's Press, 2002.
88.
Braveman P. Health disparities and health equity: Concepts and measurement. Annu Rev Public Health 2006;27:167–194.
89.
Veenstra G: Race, gender, class, sexuality (RGCS) and hypertension. Soc Sci Med 2013;89:16–24.
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Copyright 2014, Mary Ann Liebert, Inc.
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Published in print: June 2014
Published online: 13 March 2014
Published ahead of print: 12 October 2013
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