Dismantling the Role of Internalized Homophobia: Experiences of Prejudice and
Mental Health among Lesbian, Gay, and Bisexual Youth in the Netherlands
Master Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Pedagogical Sciences: Youth at Risk at the University of Amsterdam
Dismantling the Role of Internalized Homophobia: Experiences of Prejudice and Mental Health among Lesbian, Gay, and Bisexual Youth in the Netherlands
Supervisor: Prof. Henny Bos Second reader: Floor van Rooij
Student: Charlotte Loopuijt ID: 11004010 Program: Pedagogical Sciences (Youth at Risk) University of Amsterdam Date: 7 July 2019 Words: 5689
Abstract
We examined internalized homophobia (IH) as a mediator and moderator between experiences of prejudice events and negative mental health outcomes among lesbian, gay and bisexual (LGB) youth in the Netherlands. Participant data (N= 398) was obtained from a larger study on sexual health in the Netherlands. Bisexuals did not meet inclusion criteria and were excluded from the study. Participants (M age = 20.68 years; 78.3% gay) completed questions on experiences with prejudice, internalized
homophobia and mental health. We calculated bivariate associations among these factors. Which revealed inclusion criteria to run mediation analyses was not met. We were able to test IH as a moderator between the association of experiences with prejudice and negative mental health outcomes. Results: The final moderation models demonstrate negligible effects. From bivariate analyses, significant links emerged between experiences of prejudice events and negative mental health and between IH and negative mental health. Which is in line with previous research. LG youth in the Netherlands demonstrate high self-esteem (M=3.63), infrequent experiences of prejudice (M=1.39) and low levels of IH (M=1.67). Possibly due to positive societal integration of LGB individuals. Results underscore the importance of
understanding of the position of IH as a minority stressor and as a mechanism impacting mental health outcomes in order to better inform development of evidence-based interventions tailored to LGB persons.
Key words: internalized homophobia – internalized homonegativity – internalized stigma – minority stress – sexual minority youth – lesbian – gay – bisexual – mental health – self-esteem
Dismantling the Role of Internalized Homophobia: Experiences of Prejudice and Mental Health Problems among Lesbian, Gay and Bisexual Youth in the Netherlands
A burgeoning body of research unfailingly demonstrates high mental health disparities among lesbian, gay and bisexual (LGB) people, in comparison to their heterosexual counterparts (Bränström, 2017; Cox, Dewaele, van Houtte & Vincke, 2010; Bostwick, Boyd, Hughes, & McCabe, 2010; Newcomb & Mustanski, 2010; Russel & Fish, 2016; Sandford, Graaf, Bijl & Schnabel, 2001). A meta-analysis of 25 studies demonstrated that LGB people are at higher risk of psychological disorders, suicidal ideation, substance abuse, and self-harm relative to heterosexuals (King et al., 2008). In response scholars have sought to identify mechanisms to explain these outcomes (Feinstein, Goldfried & Davila, 2012). A widely used theory to account for such mental health disparities is the minority stress theory (Meyer, 1995; 2003). It contends that, in addition to general life stress, sexual minorities experience added and unique stress (=minority stress) as a result of their marginalized identity in a heterosexist society. Which may account for their increased risk for psychological disorders. Four minority stress processes have been identified: experiences of prejudice events such as discrimination or violence (a distal stressor) and proximal stressors; expectations of rejection, concealment (of one’s sexual orientation) and internalized homophobia (IH) (Meyer, 2003). IH is an LGB persons’ tendency to direct negative societal attitudes (stereotypes, stigmatization) inward (Herek, 2004). Minority stressors are the result of the uniquely stressful experiences that LGB individuals are confronted with (Chakraborty, McManus, Brugha, Bebbington & King, 2011; Kidd et al., 2016). They are chronic, socially based and result in adverse health outcomes (Cox, Dewaele, van Houtte & Vincke 2010; Meyer, 2003). Importantly also, minority stress theory identifies coping, social support and LGB networks as moderators and protective factors (Meyer, 2003).
Hatzenbuehler (2009) extends this theory by introducing the psychological mediation framework which accounts for possible mechanisms influencing the associations between minority stress processes,
for instance experiences with prejudice events and negative mental health outcomes. Potential mechanisms include psychological processes such as emotional regulation deficits or LGB-specific processes such as IH (Feinstein, Goldfried & Davila, 2012). Some studies suggest that IH is positively associated to internalizing problems (Newcomb & Mustanski, 2010), to the development of depression and anxiety symptoms, substance abuse, and suicidal ideation (Meyer, 2003). Contrary to the minority stress model, the psychological mediation framework suggests that experiences with prejudice events and IH function on different levels. For instance, it suggests IH as a potential mediator between the
association of experiences with prejudice events and negative mental health outcomes (Feinstein, Goldfried & Davila, 2012).
Evidence greatly supports the minority stress theory showing strong correlations between
experiences of prejudice events and negative mental health outcomes (Douglass, Conlin, Duffy, & Allan, 2017; Feinstein, Goldfried & Davlila, 2012; McCabe, Bostwick, Hughes, West, & Boyd, 2010). While the Netherlands is considered progressive, with the decriminalization of homosexuality in 1811 and the legalization of same-sex marriage in 2001 (Waaldijk, 2005), such trends are also observed in the Netherlands (Kuyper & Fokkema, 2011). Yet, to our knowledge, to date no research has tested a model where IH might function on a different level than that posited by Meyer (2003). Specifically, we have yet to explore the role of IH as a potential mediator and/or moderator of the association with experiences of prejudice and negative mental outcomes. We contend that conducting such analysis remains relevant. As despite the shift in greater societal tolerance toward LGB persons the unsettling trends in mental health disparities have continued to persist (Newcomb & Mustanski, 2010). Thus, the present study aims to dismantle the role of IH by answering two research questions: 1) What is the mediating role of
internalized homophobia in the association between experiences of prejudice events and negative mental outcomes among LGB youth in the Netherlands? 2) What is the moderating role of internalized
homophobia in the association between experiences of prejudice events and negative mental health outcomes among LGB youth in the Netherlands?
As acknowledged by Jackson (2018), much of the research suggesting mediating relations of minority stressors and mental health have been between-persons studies. Whereas only a dearth of
research has assessed within-person effects. As such this paper will consider the latter. Research on IH as a potential moderator or mediator of the link between experiences of prejudice and negative mental health outcomes might identify which links may be more significant. Which in turn could inform interventions targeted to these LGB populations.
Experiences of Prejudice and Mental Health Outcomes
Indeed, a disconcerting amount of research contends that LGB individuals suffer poorer mental health outcomes (Newcomb & Mustanski, 2010; Russel & Fish, 2016; Sandford, Graaf, Bijl & Schnabel, 2001). More so, LGB youth particularly are vulnerable to developing negative mental health outcomes. An impressive array of research consistently reveals that LGB’s experiences with prejudice events are associated to the development of psychosocial issues (Bränström, 2017; Marshal et al., 2008; Ueno, 2005). Experiences of prejudice events has been related to depression, maladjustment among LGB youth (Russell, Toomey, Ryan & Diaz, 2014), suicidal ideation, depressive episodes or substance abuse (Marx & Kettrey, 2016). Even more so, LGB youth increasingly disclose their sexual orientation at younger ages (M=14) (Russel & Fish, 2016). The average age for sexual orientation disclosure among LGB youth in the Netherlands is 16.3 years (van Beusekom, 2018). This overlaps with a critical developmental period making them especially vulnerable to adverse events (Russel & Fish, 2016). It is around the time of disclosure that sensitivity to IH is most vulnerable (van Beusekom, 2018).
A wealth of studies specifically find evidence for experiences with prejudice and alcohol abuse among LGB people (Austin & Irwin, 2011; Condit, Kitaji, Drabble & Trocki, 2011; Gilbert & Zemore, 2016; Igartua, Gill & Montoro, 2003) and frequent and high substance use (Valdiserri, Holtgrave, Poteat & Beyrer, 2019). A meta-analysis reveals conflicting results regarding the relationship between
experiences with prejudice events and alcohol use. Suggesting substance use outcomes may be mediated or moderated by other factors such as depression, IH, gender or age (Gilbert & Zemore, 2016).
Relatedly, IH may be associated to frequent and intense alcohol or substance abuse among
lesbians (Condit, Kitaji, Drabble & Trocki, 2011). Lesbians specifically report high frequency alcohol use relative to their heterosexual counterparts. Elevated alcohol use has been associated to all minority
stressors (Austin & Irwin, 2011) and IH is often cited as an explanatory factor for higher prevalence of alcohol use or other related issues among lesbians and gay men (Dorn-Medeiros & Doyle, 2018).
Undeniably lesbian, gay and bisexual persons experience higher levels of mental health issues compared to heterosexual counterparts. Though particularly worrying is the apparent mental health disparities observed among bisexual people. Bisexuals experience disproportionately higher psychosocial problems relative to heterosexuals as well as gay and lesbian people (Bostwick, 2012; Colledge et al., 2015; Friedman et al., 2014). It is posited this is the result of biphobia, which is experienced distinctly from homophobia. Bisexuals may experience discrimination from both heterosexual and lesbian or gay groups (Dyar & London, 2018). Further, bisexuals constitute the largest portion (52%) of the LGB community, with lesbians (17%) gay men (23%) constituting significantly less (Movement Advancement Project, 2016). Bisexuals, regardless of gsender, demonstrate the highest prevalence of mood or anxiety disorders (Bostwick, Boyd, Hughes, & McCabe, 2010; Semlyen, King, Varney & Hagger-Johnson, 2016). Considering this it is evident that bisexuals as well as lesbian and gay people are at high risk for developing psychosocial issues.
Further even, LGB youth are reportedly more sexually active compared to heterosexual peers. Given this it is concerning they report more diagnoses of sexually transmitted diseases, higher perceived risk for HIV/AIDS and have forgone more medical care (Williams & Chapman, 2011). It is hypothesized that minority stressors, such as experiences of prejudice events, may result in increased levels of IH and thus poorer mental health outcomes. IH might involve some cognitive processes that affect
self-perception (self-appraisals) which negatively result in mental health problems, such as depression (Feinstein, Goldfried & Davila, 2012). IH is correlated with lower self-esteem thus individuals may undermine their value for their personal safety thereby increasing sexual risk behavior. Sexual risk
behaviors such as engaging in unprotected sex increase risk for sexually transmitted infections (STI) or human immunodeficiency virus (HIV) (Williamson, 2000). Some studies contend that IH is related to negative body image and low self-esteem. Low self-esteem is recognized as a precursor for developing body dissatisfaction (Reilly & Rudd, 2006). There are differences in body satisfaction between lesbian and gay men where the latter are more likely than heterosexual men to experience body image related problems (Peplau et al., 2009). For these reasons, it is especially relevant to consider the consequences of IH on mental health. So, in order to assess mental health across LGB youth in the Netherlands the present study operationalizes self-esteem, body satisfaction and substance use before sex as indicators for
negative mental health outcomes. For the operationalization of mental health our choice is limited based on what is available to us in the data provided.
Internalized Homophobia as a potential moderator and/or mediator
Moderators consider whether a variable impacts an outcome variable and can increase our
understanding of potential predictors and outcomes (Frazier et al., 2004). To conduct moderation analysis will allow us to conclude whether the size of the effect of experiences of prejudice events on negative mental health outcomes interacts with, or is in some way dependent, on IH (Hayes, 2018). In contrast, mediation analyses will enable us to determine the extent to which association of experiences of prejudice events and negative mental health outcomes is influenced by IH (Hayes, 2018). It is suggested that most sexual minorities experience some degree of IH as a result of heterosexism (Syzmanski, Chung &
Balsam, 2001), which is the discrimination of sexual minorities within social systems (Robinson, 2016). Importantly, IH is a suggested cause for developing internalizing and externalizing problems among lesbian and gay people (Syzmanski, Chung & Balsam, 2001). So, we contend that conducting mediation and moderation analyses will help us reach a more nuanced understanding of the position of IH in the association of LGB youths’ experiences with prejudice and negative mental health outcomes. This is relevant as reducing IH is considered an important objective of therapy (Syzmanski, Chung & Balsam, 2001).
Studying the reviewed literature and considering the persistent body of research demonstrating increased risk for psychological disorders among LGB people (Feinstein, Goldfried & Davila, 2012) we posit that a possible explanatory factor for mental health disparities among lesbian and gay minorities is IH. With other words, we assume that there is a mediating and/or moderating effect of IH in the
association between experiences of prejudice and negative mental health outcomes (see Figure1; Figure 2).
Methods Procedure
Participant data was obtained from the study ‘Seks onder je 25e” (English: Sex under the age of 25), a research done by Rutgers and SOA Aids Nederland and consisted of 21,216 respondents. Sex under the age of 25 is a large-scale nationally representative study of sexual health among youth (aged 12-25) in the Netherlands. The statistics were selected and weighted by Statistics Netherlands (CBS). The study consisted of a separate section of questions for LGB individuals where participants responded to questions regarding LGB-specific experiences. The sample was convenience-based and the largest proportion of participants were recruited through the Personal Records Database (BRP) in the Netherlands.
Participants
A total of N=398 lesbian and gay participants were included in the analytic sample of this study (gay: n=311; lesbian: n=86). Unfortunately, bisexuals were excluded from the study as not all bisexual-identified participants received the questions regarding IH. So, in order to maintain study reliability, they are excluded from the sample. The mean age of participants was 20.68 (SD= 2.305) and ranged from 16-24. While in the original study the age of participants ranged from 12-24, very few participants (n=13) between the age 12-15 completed the LGB-specific questions. Therefore, they are excluded from the present study. A total of 87% of participants reported having a Dutch or Western ethnic background and 13% of the participants reported having a non-Western ethnic background. The two most common
reported non-Western ethnic backgrounds were Surinamese (4.5%) and Turkish (1.9%). Participant religion varied as follows: 15.8% were Christian (n=63) and 81% (n=321) reported having no religion. Participants level of current education varied as follows: 16% (n=63) are currently completing or having completed University level education and 49% are not currently in University level education. Education level of n=260 (34.6%) is unknown. Table 1 at the end of this document demonstrates a more
comprehensive overview of participant demographics. Measures
The focus of this study is to examine the effects of experiences with prejudice on negative mental health outcomes. Based on the ‘Sex under the age of 25’ research several measurements were selected to provide an indication of mental health. Among these are self-esteem, body satisfaction and substance use before sex. Based on what was available to us in the data scales were selected to measure experiences of prejudice events and IH.
Experiences of Prejudice. We assessed experiences of prejudice events over the past year. The scale consisted of 6-items (verbal harassment, isolation, victimization, name calling, being threatened and being physically harassed). Participant responses were anchored on 5-point scale (1 = never and 5= very often). A mean score of experiences of prejudice events was created by averaging the responses on the 6-items. Higher scores indicated higher prevalence of experiences of prejudice. Cronbach’s alpha for this scale was .89.
Internalized homophobia. We used an IH scale previously used in Sexual Health in the
Netherlands to assess participants’ IH. The items were established based on previously used instruments (Herek & Glunt,1995; Vanwesenbeeck & Kuypers, 2011;) and measured LG persons negative attitudes toward their own sexual orientation and that of others (van Beusekom, Bos, Kuyper, Overbeek & Sandfort, 2018). The scale consists of 6-items. The same questions were used for female and male respondents. An example item is “I do not find it problematic to share that I am (also) attracted to members of the same-sex”. Response options ranged from 1-5 (1= completely agree and 5= completely
disagree). Mean scores were used as an indicator of IH, where higher scores indicated higher levels of
IH. Cronbach’s alpha for this scale was .72.
Self-Esteem. An adapted version of the Rosenberg Self-Esteem Scale (RES) was used to measure a component of mental health. The RES is a measurement scale used to assess global self-esteem among adolescents. It is a 10-item scale with questions pertaining to self-worth and self-acceptance (Rosenberg, 1965). Example items include ‘Sometimes I feel that I am good for nothing’ and ‘In general I am satisfied with myself.” Using a 5-point scale, response options ranged from 1 = completely disagree to 5 =
completely agree. The mean score was computed with higher scores indicating higher self-esteem;
Cronbach’s alpha for this scale was .90.
Substance Use Before Sex. A component of mental health was assessed as substance use before sex. Substance use before sex was measured on an 8-item scale. Example items include: “Have you ever had sex after consuming alcohol?” or “Have you ever had sex after taking cocaine?” Response options were anchored on a 4-point scale (1= never, 2=sometimes, 3= often, 4=I don’t know what this is). For the analysis response options were coded from response options 1-3. The mean score was computed with higher scores indicating more substance use before sex; Cronbach’s alpha for this scale was .68.
Body Satisfaction. An additional component of mental health was operationalized as body satisfaction, assessed on a 4-item scale. Example items are: “How satisfied are you with your facial features?” or “How satisfied are you with your chest”. The response options ranged 1= very satisfied to 5 = very unsatisfied. The mean score was computed, which higher score indicating greater dissatisfaction with the body; Cronbach’s alpha for this scale was .81.
Data Analysis Plan
All statistical analyses will be performed using IBM SPPS version 25. Primarily, descriptive analyses (mean scores, minimum and maximum scores and standard deviations) on all the studied variables calculated and reported (Table 2). To ensure that the effects on mental health and sexual health variables (body satisfaction, substance use before sex, self-esteem) could not be attributed to
demographics preliminary analyses will be carried out. One-way analysis of variance (ANOVA) and Pearson r tests will be conducted to check this.
Pearson r correlation tests will be calculated to investigate the associations between experiences of prejudice, IH and mental health. Partial Pearson r correlations will be calculated where necessary (Table 3). Next, to answer the first research question bootstrapped mediation analyses will be run using the computational procedure for mediation analysis PROCESS macro (model 4) (Hayes, 2018).
PROCESS is used because it is able to generate direct and indirect effects in mediation models with single or multiple mediators (Hayes, 2018). Bootstrapping is preferred over the Sobel test with smaller sample sizes (Hayes, 2018). Bootstrapped mediation will be done with 10,000 resamples. Mediation effects will be computed for each random sample and the distribution of these effects is used to obtain a 95% confidence interval (CI). Mediation can be considered significant when the CI does not contain the value zero (Hayes, 2018). The inclusion criteria to calculate the bootstrapped mediation is that paths a and b must be significant, whereas path c’ (experiences of prejudice and negative mental health
outcomes) does not need to be significant. The partial Pearson r correlations will calculate this. Then, to answer the second research question the PROCESS macro (model 1) will be used (Hayes, 2018). There are no inclusion criteria to run the moderation analysis.
Results Descriptive analyses
ANOVA tests were conducted for preliminary analyses. Table 2 shows the means, standard deviations and correlations between the studied variables and demographics. Body satisfaction was very highly significantly positively associated with both the demographics ethnicity and religion. Substance use before sex was very highly significantly positively associated to ethnicity and religion. Substance use before sex was also highly significantly positively associated to age. We also observe a significant
The bivariate (Pearson) correlation analysis calculated the associations between all studied
variables (substance use before sex, body satisfaction, internalized homophobia, experiences of prejudice and self-esteem). Based on the results of the ANOVA tests (Table 2) we controlled for the various
demographics in the bivariate correlation analyses. In the partial Pearson’s r correlation analyses substance use before sex was controlled for by age, ethnicity and religion. Body Satisfaction was controlled for by ethnicity and religion. Self-esteem was controlled for by gender and education level.
The bivariate correlation investigated the relations between all our variables. These results were calculated and reported (Table 3). The relation between experiences of prejudice and self-esteem was very highly significant with a weak positive relation to each other r = .21, p = .001. Meaning those who score high on experiences of prejudice are likely to score low on self-esteem. For the relation between IH and self-esteem we observed a very highly significant weak positive correlation r = .25, p = .000.
Meaning those who score high on IH are likely to score low on self-esteem. Body satisfaction and substance use before sex was very highly significantly positively related to each other but correlates were weak r = .21, p = .000. Meaning those who score high on body satisfaction (=more dissatisfaction) also score high on substance use before sex. The association between IH and body satisfaction was also very highly significantly related to each other though weakly correlated r = .23, p = .000. Meaning those who score high on IH are likely to score high on body satisfaction. Finally, a very highly significant positively moderate positive correlation was observed for the association between self-esteem and body satisfaction
r = .44, p = .000. Meaning those who score low on self-esteem are likely to score high on body
satisfaction. The remainder of the bivariate correlations were found insignificant.
Internalized Homophobia as a Mediator of the Association Between Experiences of Prejudice and Negative Mental Health Outcomes
The inclusion criteria for running the bootstrapped mediation for any of the dependent variables (body satisfaction, substance use before sex and self-esteem) was not met. Therefore, we were unable to test for mediation. Path a was not significant at r = .09, p= .067. Path b for the relation between the
mediator (IH) and the dependent outcome (substance use before sex) was insignificant at r = .02, p = .694. Path b for the relation between the mediator (IH) and the dependent outcome (body satisfaction) was significant at r = .23, p = .000. Path b for the relation between the mediator (IH) and the dependent outcome (self-esteem) was significant at r = .25, p = .000. Since paths a and b are both insignificant criteria to run mediation analyses was not met.
Internalized Homophobia as a Moderator of the Association Between Experiences of Prejudice and Negative Mental Health Outcomes
We tested IH as a moderator on the relation between experiences of prejudice and negative mental health using by testing our three dependent variables (self-esteem, substance use before sex, body
satisfaction) separately. We tested the models using PROCESS macro (model 1) (Hayes, 2018). Evidence was not found for the moderating effect of IH on the link between experiences of prejudice and self-esteem, F (1, 262) = .6131, p = .4343, which was a non-significant negligible effect. Nor was there evidence to suggest a moderating effect of IH on the link between experiences of prejudice substance use before sex, F (1, 288) = 1.2689, p = .2609. A non-significant negligible effect was also found for the link between experiences of prejudice and body satisfaction, F (1, 347) = .2241, p = .6363.
Discussion
This study, among a nationally representative sample of 398 gay and lesbian (LG) identified youth in the Netherlands, did not yield any significant results when assessing IH as a potential mediator on the association between experiences of prejudice and negative mental outcomes. This is because inclusion criteria to run mediation analyses was not met. Moderation analysis was run to examine IH as a moderator on the relationship between experiences of prejudice and negative mental health outcomes. However, no significant effects were observed. Significant associations between experiences of prejudice events and negative mental health outcomes are seen. Specifically, highly significant positive associations are observed between experiences of prejudice and self-esteem. Though significant associations are not
observed in the link between experiences of prejudice events and body satisfaction and experiences of prejudice events and substance use before sex.
Important also for our study are the highly significant positive associations observed between IH and self-esteem and IH and body satisfaction. Results show a strong likelihood of higher scores on IH relating to higher scores on body satisfaction. It is also suggested that higher scores on IH result in lower scores on self-esteem. Findings of the Pearson’s r suggest that there is an increase in substance use before sex with age. Considering the association between experiences of prejudice events and self-esteem our findings are consistent with a robust portion of research demonstrating a highly significant relationship between LGB people’s experiences with discrimination and deleterious mental health outcomes
(Bränström, 2017;Marshal et al., 2008; Ueno, 2005). The results of this study are in line with Meyer’s (2003) theory supporting associations between IH and negative mental health outcomes (self-esteem and body satisfaction). As well as supporting the link between experience of prejudice and negative mental health outcomes. Examining the effects of minority stress and the consequences on health outcomes has been rare outside of the United States (Kuyper, & Fokkema, 2011). While the study results suggest LG youth in the Netherlands are not exposed to chronic or daily sexual orientation discrimination; we do demonstrate that in the presence of minority stressors (experiences of prejudice events and IH), though infrequent, LG youth in the Netherlands are also negatively affected by minority stress.
The observed average score (M=3.63) of participants self-esteem is considerably high and levels of IH low (M=1.67). We may infer that IH and self-esteem are related as they are very highly
significantly related to each another as lower levels of IH imply higher levels of self-esteem. A future study may benefit from investigating this relationship and possible resilience factors attributed to the link. As in order to promote these positive mental health outcomes among LGB youth a more nuanced
understanding of resilience factors is warranted (Kwon, 2013).
Further, our analyses suggest that mental health among LG youth in the Netherlands is not necessarily poor. Interestingly also, the average reported score for experiences with prejudice events was
fairly low (M=1.39), with lower scores relating to less experiences with prejudice events. So, while our results support an association between experiences of prejudice and poor mental health, they also imply LG youths’ experiences with prejudice are infrequent and their mental health outcomes are moderate. This may be due to positive societal integration of LGBT individuals. For instance, in 2008 only 8% of inhabitants in the Netherlands reported feeling that homosexuality is never justified. Which was an
atypical result in relation to other Western countries. In general, the Netherlands has achieved a high level of tolerance for lesbian and gay individuals in earlier decades while in other countries attitudes remained relatively intolerant (Kuyper, Iedema & Keuzenkamp, 2013).
More so, a widely used intervention program in high schools in the Netherlands for relationships and sexuality education is Long Live Love (LLL). It was first implemented in 1993 (Ferguson,
Vanwesenbeeck & Knijn, 2008) which is already indicative of the Netherlands’ liberal attitudes regarding sexuality. LLL has been revised since. The revised version includes a section on relationships where homosexuality is discussed. Studies have shown that the revised version of LLL has yielded more positive and liberal attitudes toward homosexuality among Dutch youth receiving LLL (Ferguson, Vanwesenbeeck & Knijn, 2008). We posit that discussing such issues in a high school setting may be related to the low levels of IH observed within our sample as well as the low levels of experiences with prejudice events.
Though we did not find evidence to support the mediating or moderating role of IH it is plausible to suggest that other elements influence the link between experiences of prejudice and negative mental health outcomes. Meyer’s (2003) minority stress model suggests coping and community support as two possible moderators of minority stressors and negative mental health outcomes. Previous research shows social support increases LGB people’s sense of worth, security and meaning. Connections to LGB
communities improves mental health and feelings of belonging (Kwon, 2013). Our findings suggest IH is significantly though weakly correlated to negative mental health outcomes. Thus, still providing evidence for the association put forth in the minority stress model (Meyer, 2003). We suggest future studies may
benefit from examining a link between experiences of prejudice events and IH with other possible moderators and mediators, such as social support and connections to LGB communities.
Previous research demonstrates frequent substance use and substance use disorders among lesbian, gay and bisexual people is associated to experiences with discrimination (McCabe, Bostwick, Hughes, West & Boyd, 2010). Research is starting to suggest that these trends begin in adolescence but studies of substance use among LGB youth have enjoyed less attention. A meta-analysis examining this suggests higher rates of substance use among LGB youth in comparison to their heterosexual counterparts (Marshal et al., 2008). Our study results demonstrate that as age increases there is also an increase in substance use before sex. Considering that LG youth are at higher risk for substance use and abuse (Marshal et al., 2008) this finding underscores the necessity for future research to examine sexual orientation as a potential risk factor for substance use and the possible mechanisms influencing this.
In addition, IH is said to be a stressor for all gay and lesbian youth in Western cultures as belonging to a minority group about which one feels negativity will likely influence mental health. Previous studies have supported the link between IH and negative mental health outcomes (Igartua, Gill, & Montoro, 2009). Findings in other studies have also shown that IH might involve some cognitive processes that negatively affect self-perception. Which in turn lead to problematic mental health issues, such as depression (Feinstein, Goldfried & Davila, 2012) or low self-esteem (Reilly & Rudd, 2006). Importantly, the findings of the present study support the significant link between IH and psychological distress which has been previously identified (Igartua, Gill, & Montoro, 2009). Our analyses also show the link between IH and negative mental health outcomes is more highly significant than that of
experiences of prejudice events and negative mental health outcomes. Prompting us to consider the importance of dedicating future research to understanding the position and role of IH in outcomes of minority stress.
This study has several strengths, including that the sample is nationally representative as it was obtained from a population-based study providing information on sexual orientation, experiences of
prejudice events and mental health. This means that findings in our study are generalizable to young adult LG populations in the Netherlands. Further, a multitude of studies assessing mediating roles in minority stress have been between-persons studies (Jackson, 2018). This study contributes to the emerging body of research that assessed within-person effects, a notable strength. By assessing within-person differences we were able to observe the mental health disparities within the young adult lesbian and gay population in the Netherlands.
Our study results should of course also be considered in light of limitations. Perhaps the most notable limitation in this study was that the measurement scales in the received data set were
predetermined. Meaning we were not involved in the selection process. The 6-item IH scale in this study was based on questions previously used to measure IH (Herek & Glunt,1995; Vanwesenbeeck &
Kuypers, 2011). More recent research suggests that the Implicit Association Test (IAT) might be better suited to measure certain aspects of IH that individuals are not able to acknowledge in self-report (Millar, Wang & Pachankis, 2016). We may also consider using the revised Internalized Homonegativity subscale of the Lesbian Gay Bisexual Identity Scale (LGBIS) (Mohr & Kendra, 2011). The revised and extended version of the LGBIS uses less stigmatizing language and offers researchers means to measure multiple constructs of LGB identities (Mohr & Kendra, 2011). We speculate that a more comprehensive scale of IH may have yielded a more holistic overview of levels of IH among LG youth in the Netherlands. The scale used might have restricted our findings.
Relatedly, while our study assessed within-person effects, we did not examine LG identities in distinct categories. LG people experience unique types of discrimination as different prejudices and stereotypes are associated to these identities. Lumping them together into a single category may cause us to overlook certain identity-specific experiences (Elia, Eliason, and Beemyn, 2018). Future research may benefit from assessing LG persons distinctly.
Importantly also, research contends that bisexual people face some of the highest health disparities, namely mood or anxiety disorders, in comparison to both their monosexual counterparts
(Bostwick, Boyd, Hughes, & McCabe, 2010). Bisexuals did not meet the criteria to be included in our study as not all bisexuals were directed to answer questions regarding IH in the study questionnaire distributed in Sex under the age of 25. This is unfortunate as bisexuals make up a large majority of the sexual minority population (Movement Advancement Project, 2016). This is a population that would benefit greatly from advancements in understanding the role of certain sexual minority specific stressors and LGB-specific mechanisms causing disparities in mental health.
LGB youth suffer more discrimination relative to heterosexual youth (Hong & Garbarino, 2012). Considering this, the experiences of LGB youth have attracted increasingly more attention of educators, parents, counselors and policy makers however there is limited evidence-based research to assist these agents (Russell, Seif & Truong, 2003). Additionally, information regarding experiences of LGB youth in the Netherlands is particularly lacking (Kuyper, & Fokkema, 2011). Therefore, present study results assist our understanding f the experiences of LGB youth in the Netherlands.
More so, we contend that study observations may help better inform the development of effective interventions tailored to the needs of LGB people in order to reduce health disparities. For instance, some studies suggest that individuals with higher levels of IH are less likely to receive the treatment they require by standard health promotion interventions which makes them more vulnerable to negative minority stress outcomes. Previous research demonstrates that individuals with higher IH are more responsive to LGB-affirmative therapy (Millar, Wang & Pachankis, 2016). This underscores the need to assess the role and position of IH in minority stress. As IH may be an important predictor for success in LGB-affirmative therapy (Millar, Wang & Pachankis, 2016). Our current study contributes to this body of research as we believe understanding the position of IH will help inform how to best tailor interventions to diverse LGB populations.
Conclusion
The findings of this study underscore the importance and urgency to investigate the sexual minority-specific stressors that might result in deleterious mental health outcomes to also better inform
interventions. We find support for the impact of minority stress among LG youth in the Netherlands. The study demonstrates a significant association between experiences of prejudice events and negative mental health outcomes and a significant link between IH and negative mental health outcomes. Suggesting that the role of IH remains important. The study findings also suggest that in general experiences of prejudice among LG youth in the Netherlands is infrequent, low levels of IH are demonstrated and high levels of self-esteem are observed. Possibly due to positive societal LGBT integration. Future research might consider examining other possible mechanisms influencing the association of experiences of prejudice and negative mental health outcomes among sexual minority youth as well as possible resilience factors. To better inform educators, parents, counselors and policy makers and to create better targeted
interventions addressing effects of minority stress. To this end it is essential to develop a more nuanced understanding of the position of IH and its’ role in deleterious mental health outcomes.
Acknowledgements
Many thanks to Professor dr. Henny Bos, Professor of Sexual and Gender Diversity in Families and Youth from the Faculty of Social and Behavioral Sciences at the University of Amsterdam, for her insight, guidance, and patient support.
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path b path a
Table 1
Description of analytic sample
Gender, n (%) Female 86 (21.7%) Male 311 (78.3%) Sexual Orientation, n (%) Lesbian 86 (21.7%) Gay 311 (78.3%) Age, M (SD) 20.68 (2.305) Education, n (%) University 63(16%) No University 196 (49%)1 Ethnicity, n (%) Dutch/Western 346 (87%) Non-Western 52 (13%)2 Religion, n (%) Religious 77 (19%)3 Not Religious 321 (81%)
Note: 1 Those under ‘No University’ are currently completing or have completed n (%): 4 (1.1%) Praktijkonderwijs; 5 (1.3%) vmbo basisberopesgericht; 6 (1.5%) havo;
14 (3.6%) vwo, antehneum or gymnasium; 100 (25%) mbo (i.e. roc, bol or bbl) and; 67 (17%) hbo. Each of which are varying levels of education within the Dutch system.
2 Those under ‘Non-Western’ reported various backgrounds: 1.9% were Turkish, 0.4% Moroccan, 4.5% Surinamese and 1.5% were from the Antilleans and the remaining
4.7% selected ‘Other’. 3 Those under ‘Religious’ had varying religious backgrounds: 63 (15.8%) were Christian, 7(1.8%) Islamic, 1 Hindu, 7(0.2%) said Other. 321(81%)
Table 2
Social Demographics and Dependent Variables (N = 398)
Analysis of variance and Pearson's r
Body Satisfaction Substance Use Before Sex Self-Esteem
M (SD) F / r p M (SD) F / r p M (SD) F / r p Gender .049 .824 .890 .346 5.096 .025 Female 2.64(0.81) 1.24(0.16) 3.47 (0.79) Male 2.66(0.75) 1.28(0.35) 3.67 (0.71) Age Pearson’s r 2.66(0.76) -.041 .415 1.27 (0.32) .149 .006 3.63 (0.73) .057 .261 Education .255 .614 .093 .761 4.646 .032 University 2.67(0.60) 1.28 (0.22) 3.83 (0.65) No University 2.61(0.74) 1.29 (0.38) 3.62 (0.68) Ethnicity 13.312 .000 45.009 .000 2.534 .112 Dutch/Western 2.71(0.75) 1.23 (0.21) 3.60 (0.75) Non-Western 2.30(0.73) 1.57 (0.66) 3.78 (0.62) Religion 14.544 .000 25.945 .000 3.354 .068 Religious Not Religious 2.36(0.65) 2.72(0.77) 1.45(0.54) 1.23(0.22) 3.76 (0.56) 3.59 (0.76)
Table 3
Mean (standard deviation), observed minimal and maximal scores, and (partial) correlations between studied variables (N=398)
Variables 1 2 3 4 5 M SD Min Max
1. Substance Use Before Sex - 1.27 0.32 1.00 3.00
2. Body Satisfaction -.21*** - 2.66 0.76 1.00 5.00
3. Internalized Homophobia .02 .23*** - 1.67 0.55 1.00 2.83
4. Experiences of prejudice -.02 .04 .09 - 1.39 0.61 1.00 4.67
5. Self-Esteem .05 .44*** .25*** .21** - 3.63 0.73 1.30 5.00
Note: *p < .05. **p < .01. ***p < .001. Substance Use Before Sex was controlled for by Age, Ethnicity and Religion. Body Satisfaction was controlled for by Ethnicity and Religion, and Self-Esteem was controlled for by Gender and Education level.
Table 4
Moderation analyses among all variables while controlling for demographics
Note: N= 398, *p < .05. **p < .01. ***p < .001. Variable N R2 p ΔR2 p b SE (b) t p Self-Esteem 398 .1457 .0000 .0020 .4343 Education Level .2428 .0856 2.8361 .0049 Gender .2668 .0863 3.0916 .0022 EP (A) .2708 .0710 3.8119 .0002 IH (B) .2569 .0748 3.4319 .0007 A x B -.0988 .1262 -.7830 .4343 Body Satisfaction 398 .0629 .0004*** .0006 .6363 Ethnicity -.2938 .1358 -2.1636 .0312* Religion -.1156 .1029 -1.1229 .2622 EP (A) .0965 .0670 1.4397 .1509 IH (B) .2502 .0684 3.6578 .0003*** A x B -.0581 .1228 -.4734 .6363
Substance Use Before Sex 398 .0530 .0149* .0042 .2609
Ethnicity .1499 .0577 2.5953 .0099 Religion .0203 .0402 .5049 .6140 Age .0136 .0063 2.1615 .0315 EP (A) .0048 .0258 .1845 .8537 IH (B) -.0134 .0271 -.4951 .6209 A x B .0662 .0588 1.1265 .2609
