Perfectionism, Shame, and Eating Disorder Symptoms

Home , Emotional eating

Eating disorders in lesbian and bisexual women: Relationship of binge eating to depressive symptoms, shame, distress tolerance, and internalized homophobia.

by Vanessa Bayer, M.A.

A Dissertation in Clinical Psychology

Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Approved James R. Clopton, Ph.D. Professor Committee Co-Chair

Darcy Reich, Ph.D. Associate Professor Committee Co-Chair

Susan Hendrick, Ph.D. Professor Committee Member

Jacalyn Robert-McComb, Ph.D. Professor Committee Member

Mark Sheridan Dean of the Graduate School

TABLE OF CONTENTS

ABSTRACT ...... ii LIST OF TABLES ...... iii I. INTRODUCTION ...... 1 Purpose and Hypotheses...... 7

II. METHOD ...... 11

Participants ...... 11

Measures ...... 13

Procedure ...... 23 III. RESULTS ...... 24

Preliminary Data Analyses ...... 24

Primary Data Analyses ...... 36 IV. DISCUSSION ...... 50 REFERENCES ...... 70 APPENDICES ...... 85

Appendix A: Extended Literature Review ...... 85 Appendix B: Sexual Orientation Questionnaire ...... 108 Appendix C: Eating Disorder Exam, Revised ...... 110 Appendix D: Personal Feelings Questionnaire (PFQ) ...... 112 Appendix E: Lesbian Internalized Homophobia Scale ...... 114 Bisexual Inclusive Appendix F: The Distress Tolerance Scale ...... 118 Appendix G: Depression, Anxiety, Stress Scale, Depressive Subscale ...... 120 Appendix H: The Outness Inventory ...... 121 Appendix I: Demographic Questionnaire ...... 122

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ABSTRACT

There is limited research on specific factors influencing disordered eating for lesbian and bisexual women. Such research would inform culturally sensitive treatment of eating disorders in these populations. Depressive symptoms, shame, and distress intolerance are associated with binge eating. Internalized homophobia is associated with negative affect and shame and may be associated with binge eating. Lesbian and bisexual women may binge eat as a way to cope with depressive symptoms and shame that result from internalized homophobia, particularly for women with distress intolerance. This study investigated the relationship between internalized homophobia, shame, depression, distress tolerance, and binge eating in a sample of lesbian and bisexual women. Two primary research hypotheses were developed. First, it was hypothesized that shame and depression would mediate the relationships between several facets of internalized homophobia and binge eating. Second, it was hypothesized that distress tolerance would moderate both the relationship between shame and binge eating and the relationship between depression and binge eating in the mediation relationships proposed in the first hypothesis. Results revealed that depression was not a significant mediator for the relationships between the internalized homophobia variables and binge eating. Shame was a significant mediator for six of the internalized homophobia and binge eating relationships. Distress tolerance did not moderate the significant mediation relationships.

The association of “outness” with internalized homophobia, depression, and shame was also investigated. Results revealed that the more an individual was out about her sexual orientation, the less depression, shame, and internalized homophobia she experienced.

Limitations to this study, implications for conducting therapy with lesbian and bisexual women, and suggestions for future research are discussed.

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LIST OF TABLES

Table 1: Percentage of Sample Engaging in Bulimic Behaviors ...... 29 at Least Once per Month

Table 2: Total and Group Means and Standard Deviations for ...... 31 Depression, Shame, Internalized Homophobia, Distress Tolerance, and “Outness”

Table 3: Bivariate Correlations between Independent, Dependent, ...... 38 and Mediator Variables

Table 4: Total and Direct Effects for Depression Mediating the Relationship ...... 40 between Measures of Internalized Homophobia and Objective Binge Eating

Table 5: Indirect Effects for Depression Mediating the Relationship ...... 40 between Measures of Internalized Homophobia and Objective Binge Eating

Table 6: Total and Direct effects for Depression Mediating the Relationship ...... 41 between Measures of Internalized Homophobia and Subjective Binge Eating

Table 7: Indirect effects for Depression Mediating the Relationship ...... 41 between Measures of Internalized Homophobia and Subjective Binge Eating

Table 8: Total and Direct Effects for Shame Mediating the Relationship ...... 42 between Measures of Internalized Homophobia and Objective Binge Eating

Table 9: Indirect Effects for Shame Mediating the Relationship ...... 42 between Measures of Internalized Homophobia and Objective Binge Eating

Table 10: Total and Direct Effects for Shame Mediating the Relationship ...... 44 between Measures of Internalized Homophobia and Subjective Binge Eating

Table 11: Indirect Effects for Shame Mediating the Relationship ...... 44 between Measures of Internalized Homophobia and Subjective Binge Eating

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Table 12: Moderated Mediation Models for Distress Tolerance...... 46 Moderating the Shame-Objective Binge Eating Relationship in the Mediation Models for Different Internalized Homophobia Variables

Table 13: Moderated Mediation Models for Distress Tolerance...... 46 Moderating the Shame-Subjective Binge Eating Relationship in the Mediation Models for Different Internalized Homophobia Variables

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CHAPTER I

INTRODUCTION About 2-4% of the population identify as gay, lesbian, or bisexual (GLB), with the rate increasing to about 10% when including individuals who report any attraction to someone of the same sex (Savin-Williams & Ream, 2007). Some research shows that

GLB individuals experience more psychological disturbances, such as depression and anxiety, and are at a greater risk for suicide and substance use than heterosexual individuals (Bolton & Sareen, 2011; Frisell, Lichtenstein, Rahman, & Langstrom, 2010;

Wichstrom & Hegna, 2003); however, not all studies have found GLB individuals to be at a greater risk for psychological disturbances (Hughes, Haas, Razzano, Cassidy, &

Matthews, 2000). A greater prevalence of psychological disturbances in GLB individuals may be due to distress caused by the stigma of being a sexual minority in a society that has traditionally viewed homosexuality and bisexuality as unacceptable, sinful, and disgusting (i.e., minority stress; Koh & Ross, 2006; Meyer, 1995; See Appendix A for an extended review).

Although there has been plenty of research investigating the prevalence of psychological disturbances in GLB individuals, research on eating disorders in this population, particularly among lesbian and bisexual women, is lacking. This may be due to the previous belief that eating disorders were almost exclusively experienced by heterosexual Caucasian women; however, research has begun to reveal that eating disorders are experienced by individuals of both genders and a wide range of ethnicities and sexual orientations (Cachelin, Veisel, Barzegarnazari, & Striegel-Moore, 2000;

French, Story, Remafedi, Resnick, & Blum, 1996; Regan & Cachelin, 2006). Although

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research on eating disorders has begun to focus more on minority groups and men, the majority of research has been conducted with heterosexual women.

Gay and bisexual men have consistently been found to report a greater prevalence of eating disorder symptoms and body dissatisfaction than heterosexual men (Feldman &

Meyer, 2007; Lakkis, Ricciardelli, & Williams, 1999; Williamson & Hartley, 1998).

They report an equivalent prevalence of eating disorder symptoms and body dissatisfaction as that of heterosexual women (Siever, 1994; Strong, Williamson,

Netemeyer, & Geer, 2000). The prevalence of eating disorder symptoms and body dissatisfaction in lesbian and bisexual women is less clear. Some studies have found equivalent rates of eating disorder symptoms in lesbian, bisexual, and heterosexual women (Feldman & Meyer, 2007; Strong et al., 2000), whereas other studies have reported mixed findings. Some studies have found higher rates of eating disorder symptoms in heterosexual women (Lakkis, Ricciardelli, & Williams, 1999; Siever, 1994).

Koh and Ross (2006) found bisexual women to be twice as likely as lesbian women to report a history of an eating disorder and, if “out” about their sexual orientation, twice as likely to report a history of an eating disorder as heterosexual women. Finally, Heffernan

(1996) found higher rates of binge eating disorder and equivalent rates of bulimia nervosa in lesbian women compared to heterosexual women.

These contradictory findings may be explained by the possibility that lesbian, bisexual, and heterosexual women report different types of eating disorder symptoms. In particular, it appears that lesbian women may be more likely than other women to report binge eating without the use of inappropriate compensatory behaviors, whereas bisexual and heterosexual women may be at risk for a wider range of eating disorder symptoms.

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For example, some studies have found that lesbian women report a lower drive for thinness, less concern about losing weight, and fewer attempts to diet and use exercise to control weight (Austin et al., 2004; Boehmer, Bowen, & Bauer, 2007; Herzog, Newman,

Yeh, & Warshaw, 1992; Moore & Keel, 2003; Striegel-Moore, Tucker, & Hsu, 1990;

Wagenbach, 2003). The lower likelihood of lesbian women reporting concern about losing weight and attempts at dieting than heterosexual women may be explained by the lesbian subculture’s adoption of feminist ideals that discourage adherence to the cultural thin ideal due to its oppression of women (Brown, 1987).

On the other hand, some studies have found similar amounts of dieting and weight and shape concerns in lesbian and heterosexual women (Heffernan, 1996; Heffernan,

1999; Moore & Keel, 2003; Sharp & Mintz, 2002; Strong et al., 2000). These contradictory findings may indicate that the lesbian subculture does not completely protect women from internalizing the cultural thin ideal. Instead, the pressure to be thin from the dominant society may trump the protection against disordered eating provided by the feminist ideals of the lesbian subculture. For example, many lesbian and bisexual women probably internalized the thin ideal before they became involved in the sexual minority community. They may strive to meet the idealized thin feminine body to gain acceptance from a society that tends to reject them for their sexual orientation (Pitman,

1999; for a review, see Appendix A).

Lesbian women often report similar or greater amounts of binge eating and concerns about overeating, and lower amounts of compensatory behaviors, than heterosexual women (Austin et al., 2004; Austin et al., 2009; French, Story, Remafedi,

Resnick, & Blum, 1996; Heffernan, 1996; Stout, 2001; Striegel-Moore, Tucker, & Hsu,

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1990; Wagenbach, 2003). One study found that a quarter of lesbian women reported binge eating at least once per week (Heffernan, 1996). Adolescent women who report same-sex sexual experiences have also been found to be at risk for greater levels of bulimic behaviors after a 5-year follow-up (Wichstrom, 2006). Although research findings on the relationships between dieting and the desire for weight loss in lesbian women are mixed, lesbian women appear to be more likely to report binge eating than to report dieting (Striegel-Moore et al., 1990). Furthermore, lesbian women appear to be more likely to binge eat as a result of negative affect, such as eating to avoid negative affect or for comfort, than as a result of dieting. It may be that these women eat to cope with internalization of negative stereotypes about lesbians, which may make them feel negatively about themselves (i.e., internalized homophobia; Heffernan, 1996; see

Appendix A for a review).

Bisexual women and “mostly heterosexual” women (i.e., women who identify as heterosexual but report some sexual attraction to women) may be at the greatest risk for symptoms of disordered eating. They have shown a greater prevalence of eating disorder symptoms (e.g., binge eating, dieting, unhealthy compensatory behaviors) than lesbian women and exclusively heterosexual women (Austin et al., 2004; Austin et al., 2009;

Polimeni, Austin, & Kavanagh, 2009). The greater risk for eating disorder symptoms seen in bisexual and mostly heterosexual women may result from these women experiencing greater pressure from the dominant heterosexual culture to conform to the thin ideal than is experienced by lesbian and exclusively heterosexual women (Herek,

Gillis, Cogan, & Glunt, 1997).

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Additional differences between lesbian, bisexual, and heterosexual women appear to exist in the risk for being overweight or obese. Some studies have found that lesbian women tend to have higher Body Mass Indexes (BMI) and greater rates of being overweight or obese than bisexual and heterosexual women, even after controlling for other variables associated with being overweight or obese (e.g., socioeconomic status, age, ethnicity; Boehmer & Bowen, 2009; Boehmer, Bowen, & Bauer, 2007). However, not all studies support this finding (for a review see Bowen, Balsam, & Ender, 2008). The differing rates of being overweight or obese may be related to lesbian women tending to report more satisfaction with their body, a heavier ideal weight, less concern about losing weight, less restrictive eating, and a greater likelihood of binge eating without the use of inappropriate compensatory behaviors than heterosexual women (Boehmer, Bowen, &

Bauer, 2007; Heffernan, 1996; Herzog et al., 1992). Differences in activity level and diet have been suggested as reasons for this difference; however, Boehmer and Bowen (2009) did not find that energy expenditure (physical activity and reported barriers to physical activity) or energy intake (i.e., fruit and vegetable intake and past diet attempts) mediated the relationship between sexual orientation and being overweight or obese.

A greater prevalence of binge eating without inappropriate compensatory behaviors (e.g., binge eating disorder, BED) and a greater prevalence of being overweight or obese in lesbian women than in heterosexual women would be compatible with research on the characteristics of lesbian women and individuals with BED. For example, individuals with BED and lesbian women tend to report lower drive for thinness and body dissatisfaction, less restrained eating, an infrequent or non-existent use of inappropriate compensatory behaviors, and a greater likelihood of being overweight or

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obese compared to individuals with BN or AN or heterosexual women (Austin et al.,

2004; Boehmer & Bowen, 2009; Latner & Clyne, 2008; Santonastaso, Ferrara, & Favaro,

1999; Sullivan, 2001; for a review see Appendix A).

Although research has found that lesbian and bisexual women report symptoms of disordered eating, fewer studies have investigated factors that might explain the presence of disordered eating in this population. The majority of the research investigating the causal factors of disordered eating has been conducted with samples of heterosexual women. In addition to symptoms of disordered eating varying based on sexual orientation, there may be heterogeneity in the causal factors of disordered eating in women of different sexual orientations. For example, the influence of dieting, the cultural thin ideal, and pressure to lose weight from friends, family members, or the media on the development of eating disorder symptoms may be greater in heterosexual and bisexual women than in lesbian women. Eating to regulate emotional states (e.g., depression and shame) and emotion regulation difficulties (e.g., low tolerance for distress) may be more relevant causal factors for lesbian women (Anestis, Fink, Smith, Selby, & Joiner, 2011;

Brown, 1987; Heatherton & Baumeister, 1991; Heffernan, 1996; Lynch & Mizon, 2011).

One cause of depressive symptoms and shame in lesbian and bisexual women may be internalized homophobia, a variable that has been associated with psychological distress in sexual minority populations (Szymanski & Kashubeck-West, 2008; see Appendix A for an extended review of the literature on these variables).

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PURPOSE AND HYPOTHESES

Much of the research on factors that influence eating disorder symptoms has been conducted with heterosexual women. Thus, the aim of this study was to investigate factors that influence binge eating in lesbian and bisexual women.

Binge Eating and Emotion Regulation

Binge eating sometimes occurs in response to emotions, including depression and shame. Specifically, individuals who experience higher levels of depression and shame report higher frequencies of binge eating than individuals low in depression and shame.

This relationship has consistently been found in samples of heterosexual women (e.g.,

Presnell, Stice, Seidel, & Madeley, 2009; Sanftner, Barlow, Marschall, & Tangney, 1995;

Sanftner & Crowther, 1998).

Binge Eating and Internalized Homophobia

Research on the relationship between internalized homophobia and binge eating is limited. Internalized homophobia has been associated with disordered eating attitudes and behaviors in gay men (Williamson, 1999; Williamson & Spence, 2001). Although a relationship between internalized homophobia and binge eating in lesbian and bisexual women has been hypothesized, such a relationship has not been empirically investigated

(Beren, Hayden, Wilfley, & Grilo, 1996; Brown, 1987; Pitman, 1999). Research has found internalized homophobia to be associated with correlates of disordered eating in lesbian women, including self-objectification and body shame (e.g., Haines et al., 2008).

Thus, internalized homophobia may increase the risk for binge eating for lesbian and bisexual women.

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Binge eating may function as a means to regulate emotions that result from internalized homophobia. Internalized homophobia has been found to relate to depression and shame in lesbian and bisexual women (e.g., Allen & Oleson, 1999; Szymanski,

Chung, & Balsam, 2001). Given that greater levels of depression and shame are associated with a higher frequency of binge eating, higher levels of internalized homophobia may be associated with higher levels of binge eating. Specifically, internalized homophobia may be associated with binge eating through its relationship with depression and shame. Thus, the following hypothesis is proposed:

Hypothesis 1: Internalized homophobia will be positively correlated with binge eating. This relationship will be mediated by depressive symptoms and shame.

Specifically, greater levels of internalized homophobia will be associated with greater levels of depressive symptoms and shame, which will be associated with greater amounts of binge eating.

Distress Tolerance

Escape theory predicts that binge eating may be used as a means to escape negative affect (Anestis et al., 2011; Heatherton & Baumeister, 1991). In previous research, low distress tolerance was associated with the avoidance of directly and effectively coping with negative affect, with eating disorder attitudes (Corstorphine,

Mountford, Tomilson, Waller, & Meyer, 2007), and with emotional eating (Kozak &

Fought, 2011). Anestis, Selby, Fink, & Joiner (2007) found that lower levels of distress tolerance were associated with higher levels of bulimic behaviors, even when controlling for several covariates (e.g., depressive symptoms, anxiety symptoms, anxiety sensitivity, negative affect, urgency, body dissatisfaction, interoceptive awareness, and sensation

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seeking). Lesbian and bisexual women who cannot tolerate negative affect associated with internalized homophobia may use binge eating to cope. In contrast, those who have higher distress tolerance may be able to cope with negative affect associated with internalized homophobia in more adaptive ways (see Appendix A for a review). Thus, the following hypothesis was proposed:

Hypothesis 2: In the mediation models proposed in Hypothesis 1, the relationship between depressive symptoms and binge eating and the relationship between shame and binge eating will be moderated by distress tolerance. Specifically, higher levels of depressive symptoms/shame will be associated with higher levels of binge eating when an individual has a low level of distress tolerance, but not when an individual has a high level of distress tolerance.

“Outness”

The degree to which other people are aware of a lesbian or bisexual woman’s sexual orientation (i.e., her level of “outness”) may influence whether she experiences distress, internalized homophobia, or disordered eating (Chow & Cheng, 2010; Siever,

1996). In particular, lesbian and bisexual women who are more “out” about their sexual orientation may receive more social support and be more involved in the lesbian community. Thus having more chances to dispute the negative societal views toward minority sexual orientations, experience lower levels of internalized homophobia, and develop a positive lesbian or bisexual identity (Chow & Cheng, 2010). Cox, Dewaele,

Van Houtte, and Vincke (2011) found that lesbian, bisexual, and gay individuals who are out about their sexual orientation to a larger number of people reported lower levels of internalized homophobia.

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In contrast, some research has indicated that a greater level of “outness” might not be protective from disordered eating or psychological distress for bisexual women (Koh

& Ross, 2006) or lesbian women (Liubovich, 2003). Being “out” about one’s sexual orientation could lead to more stress and mental health problems due to an increased risk of experiencing anti-lesbian discrimination and violence or, for bisexual women, due to not fitting into or being stigmatized by either the lesbian or heterosexual communities

(Herek et al., 1997; Lehavot, Balsam, & Ibrahim-Wells, 2009). Given the limited research in this area and the mixed findings on the influence of “outness” on well-being, exploratory analyses were performed to investigate the relationships between “outness,” depression, shame, and internalized homophobia.

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CHAPTER TWO

METHOD This section discusses the methods and procedures employed for our study. It is organized into three sections. The first section, “Participants,” provides a description of our sample and how participants were recruited. The second section, “Measures,” contains information about the questionnaires used in our study. The final section discusses the procedure we followed while conducting our study.

Participants

Cohen’s (1992) table was consulted to determine the sample size needed to conduct our analyses. We based our target sample size on the analysis that required the largest sample size; namely, a t-test comparing two groups given the expectation of a medium effect size at the .05 significance level. It was determined that a sample size of

128 participants (64 lesbian participants and 64 bisexual participants) provided adequate power for the analyses performed in this study (Cohen, 1992). One hundred and seventy- nine individuals participated in the study. Of those, the data from 20 participants were not included in the analyses due to being incomplete (i.e., participants did not complete all of the questionnaires necessary for the primary analyses). Three participants were not included because they identified their gender as male and one participant was not included because that individual identified as transsexual. The data from 17 individuals were not included because they identified their sexual orientation as something other than lesbian or bisexual (e.g., pansexual, queer, asexual, non-monosexual, and undecided).

They were not included given that it was not known whether these individuals differed from lesbian or bisexual women in a way that might change the results. Thus, the

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remaining sample of 138 participants included individuals who identified their sexual orientation as lesbian or bisexual, their sex as female, and their gender as female. This sample was comprised of 72 participants who identified as lesbian women and 66 participants who identified as bisexual women.

Most participants were Caucasian (73.2%). Approximately 7.2% of participants were Latina, 3.6% were African-American, 2.2% were Asian-American/Pacific Islander, and 10.1% were Multiethnic/Biracial. Less than 1% of the participants were Native-

American/American-Indian (.7%). Approximately 2.9% were another ethnic background.

Thirty-two lesbian participants and 38 bisexual participants reported their age. These participants’ ages ranged from 19 to 69 years, with an average age of 32 years (SD = 12 years). Of the participants who reported their ages, lesbian women tended to be older (M

= 35 years, SD = 13.6 years) than bisexual women (M = 29.3 years, SD = 9.8 years). This difference approached statistical significance, t(68) =2.10, p = .08.

Lesbian and bisexual women were recruited in two ways. First, community organizations geared towards gay, lesbian, and bisexual individuals (e.g., PFLAG, GSA) were contacted and asked to distribute information about the study to their members through flyers about the study, posts on their organization’s website or Facebook page, or e-mail messages. Individuals who chose to participate were asked to invite their friends who are lesbian or bisexual women to participate in the study. Participants were not provided with any compensation for their participation.

Second, students from General Psychology courses at Texas Tech University who identified as lesbian or bisexual were recruited. Students in these General Psychology courses are given the option each semester to participate in research or write a brief

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research paper as part of their required coursework. The students were prescreened by filling out a survey containing measures included by a variety of researchers with the goal of finding participants who match certain prerequisite criteria to participate in their studies. A measure of sexual orientation was included in this prescreening process.

College women who identified their sexual orientation as lesbian or bisexual based on the sexual orientation questionnaire were recruited through e-mail. This method of data collection was conducted for two semesters, but only four participants were recruited this way. This method was discontinued given the low number of students who qualified for the study.

Measures

Sexual Orientation. Sexual orientation identity was measured by asking participants to identify their sexual orientation as gay/lesbian, bisexual, heterosexual, or other. For supplemental information about sexual orientation, questions assessing sexual attraction were included. Same-sex and opposite-sex sexual attraction were measured separately with two questions from the Sell Assessment of Sexual Orientation (Sell,

1996) that assess the intensity of an individual’s sexual attraction to people of the same/opposite sex by having the individual rate it on a 7-point scale (1 = not at all sexually attracted; 7 = extremely sexually attracted). See Appendix B for a copy of this measure.

Eating Disorder Behaviors. The Eating Disorder Exam Questionnaire (EDE-Q;

Fairburn & Beglin, 1994) was adapted as a measure of binge eating and compensatory behaviors. The EDE-Q is the self-report version of the Eating Disorder Exam (EDE;

Fairburn & Wilson, 1993, cited in Fairburn & Beglin, 1994), an interview-based

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assessment of eating disorder symptomology. It contains questions about several disordered eating behaviors (e.g., binge eating, purging, and non-purging compensatory behaviors). It also has four subscales assessing eating concerns, weight concerns, shape concerns, and dietary restraint.

To assess bulimic symptoms, a shortened version of the EDE-Q, composed of only the questions asking about binge eating and inappropriate compensatory behaviors, was used. The questions asked about the frequency of engagement in binge eating and inappropriate compensatory behaviors over the past 28 days. Although the original EDE-

Q has separate questions for the purging behaviors it assesses (i.e., vomiting, using laxatives, using diuretics), these behaviors were assessed in the current study by a single question that asked about the frequency of any of the stated behaviors. The EDE-Q was shortened for two reasons. First, keeping the questionnaire brief would encourage participation in the study. Second, the assessment of the frequency of binge eating and inappropriate compensatory behaviors (i.e., purging and non-purging behaviors) was the only part of the EDE-Q relevant to the purposes of this investigation. Inappropriate compensatory behaviors were measured as a supplement to the main disordered eating variable of interest, binge eating. The questions assessing the frequency of disordered eating behaviors have shown adequate 2-week test-retest reliability (binge eating, r = .68; self-induced vomiting, r = .92, laxative misuse, r = .65, and diuretic misuse, r = .54;

Luce & Crowther, 1999).

Most of the EDE-Q has shown convergent validity with the EDE (Grilo, Masheb,

& Wilson, 2001; Reas, Grilo, & Masheb, 2006); however, the EDE-Q does not consistently converge with the EDE when assessing the occurrence of objective binge

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episodes (Mond, Hay, Rodgers, Owen, & Beumont, 2004). This may be due to the interview method of the EDE, which allows the interviewer to provide more specific definitions of objective binge eating to participants than the self-report method of the

EDE-Q. This might be addressed by including detailed instructions on how to assess for the presence of objective binge episodes on the EDE-Q. Goldfein, Devlin, and Kamenetz

(2005) developed a version of the EDE-Q that provided more detailed instructions for defining objective binge eating. The EDE-Q with Instructions (i.e., EDE-Q-I) included definitions of a large amount of food and a loss of control, along with examples of binge versus non-binge episodes. They found that the EDE-Q-I significantly correlated with the

EDE, meaning that both measures found similar results when assessing the frequency of objective binge episodes. Without the instructions, the EDE-Q did not correlate significantly with the EDE. This provides evidence that individuals will vary in how they define binge episodes when completing the EDE-Q relative to the EDE, and that providing instructions for defining binge eating can reduce that variability (Goldfein,

Devlin, & Kamenetz, 2005).

To ensure that participants understood what was meant by the statements “an unusually large amount of food” and “a loss of control over eating,” participants in the current study were provided with the definitions of the unusually large amount of food and the loss of control criteria for an objective binge episode. These definitions were taken from Goldfein, Devlin, and Kamentz’s (2005) adapted version of the EDE-Q that includes instructions for defining an objective binge episode (i.e., the EDE-Q-I). The examples of eating episodes provided in the EDE-Q-I were not included due to the need to encourage participation by keeping the questionnaires brief.

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The presence of objective binge eating was defined as a participant indicating that she eats what other people would consider an unusually large amount of food with a loss of control. The presence of subjective binge eating was defined as having a sense of loss of control over an eating episode that did not involve eating an unusually large amount of food (see Appendix C for a copy of the adapted questionnaire).

Shame. The Personal Feelings Questionnaire (PFQ-2) is a 22-item measure of shame proneness and guilt proneness. The Shame subscale contains ten items that list feelings associated with shame (e.g., “feeling stupid”) and the Guilt subscale contains six items that list feelings associated with guilt (e.g., “regret”). There are also six filler items, or feeling words that do not describe shame or guilt (e.g., “sadness”). Items are rated on a

5-point scale for how often the individual experiences the feeling listed (0 = you never experience the feeling; 4 = you experience the feeling continuously or almost continuously). Only the Shame subscale and the filler items were used. The Shame and

Guilt subscales have shown adequate internal consistency (α = .78 and .72, respectively) and good 2-week test-retest reliability (.91 and .85, respectively; Harder & Zalma, 1990).

Support for the construct validity of the PFQ-2 Shame subscale has come from research finding the measure to significantly correlate with depression, self-derogation, shyness, and public self-consciousness (Harder, Cutler, & Rockhart, 1992). See Appendix D for a copy of this questionnaire.

Internalized Homophobia. The Lesbian Internalized Homophobia Scale, Short

Form, (LIHS) was used to measure internalized homophobia. The long version of the

LIHS, developed by Szymanski and Chung (2001), contains 52 items, and has been found to be internally consistent (α = .93; Szymanski, Kashubeck-West, & Meyer, 2008).

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Participants rate the extent to which they agree with statements (e.g., “I feel bad for acting on my lesbian desires.”) on a scale ranging from 1 (strongly disagree) to 7

(strongly agree). The scale contains 5 internally consistent subscales: Connection to the

Lesbian Community (α = .87), Public Identification as a Lesbian (α = .92), Personal

Feelings about Being a Lesbian (α = .79), Moral and Religious Attitudes Toward

Lesbianism (α = .74), and Attitudes Toward Other Lesbians (α = .77). Correlations between the total score and the subscale scores range from .60 to .87. Construct validity was evinced by significant correlations between the LIHS subscales and assessments of self-esteem, depression, social support, loneliness, passing for straight, membership in a

GLB group, and conflict about sexual orientation (Szymanski & Chung, 2001;

Szymanski, Chung, & Balsam, 2001).

Piggot (2004 cited in Szymanski, Kashubeck-West, & Meyer, 2008) developed a shorter (39-item) version of the LIHS that was found to be internally consistent (α = .93).

It has five internally consistent subscales: Personal Feelings about being Lesbian (PFL; α

= .76), Connection with the Lesbian Community-Interaction (CLCI; α = .80), Connection with the Lesbian Community-Knowledge of Resources (CLCK; α = .87), Public

Identification as a Lesbian (PIL; α = .92), and Attitudes toward Other Lesbians (ATOL; α

= .72).

The Personal Feelings about Being Lesbian/Bisexual subscale assesses the feelings participants have about being lesbian or bisexual. High scores indicate that the individual experiences negative feelings about being lesbian or bisexual (e.g., self-hatred, placing superior value on heterosexuality over homosexuality, and internalized beliefs about being unworthy, sick, or defective because one is lesbian or bisexual). Low scores

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indicate that the individual feels positive about and is accepting of her lesbian or bisexual identity (e.g., affirming one’s identity as lesbian or bisexual, having a strong sense of pride about being lesbian or bisexual; Szymanski & Chung, 2001).

The Connection to the Lesbian/Bisexual Community-Interaction subscale measures the degree to which a lesbian or bisexual woman interacts with the lesbian or bisexual community. High scores indicate that she does not interact with other lesbian or bisexual women, does not feel comfortable in social situations involving lesbian or bisexual women, or does not place a high value on having a support system of lesbian or bisexual women. Low scores suggest a high level of interaction with other lesbian or bisexual women and the lesbian or bisexual community (Szymanski & Chung, 2001).

The Connection to the Lesbian/Bisexual Community-Knowledge of Resources subscale measures the degree to which a lesbian or bisexual woman is aware of and familiar with the lesbian or bisexual culture and community (e.g., the history of the lesbian culture, cultural symbols, community resources, books, movies, festivals, etc.).

High scores indicate that the woman does not have a high level of knowledge about the lesbian or bisexual community or culture, whereas low scores indicate a high level of knowledge (Szymanski & Chung, 2001).

The Public Identification as Lesbian/Bisexual subscale assesses how a lesbian or bisexual woman manages her lesbian or bisexual identity. High scores indicate that the woman experiences a fear of her lesbian or bisexual identity being discovered. She may try to “pass” as heterosexual by talking and looking like a heterosexual woman. Low scores indicate that the individual identifies as a lesbian or bisexual publicly and openly discloses her lesbian or bisexual identity to others (Szymanski & Chung, 2001).

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The Attitudes toward Other Lesbians subscale measures the degree to which a lesbian or bisexual woman holds negative versus positive attitudes toward other lesbian women. High scores indicate that the individual holds negative attitudes toward other lesbian women (e.g., devaluation and disrespect of other lesbian women and their relationships, criticism of other lesbians). Low scores indicate positive and affirming attitudes toward other lesbian women (e.g., respect for other lesbian women and appreciation for differences within the lesbian community; Szymanski & Chung, 2001).

The shorter version of the LIHS has been found to have cross-cultural validity in sexual minority women from 20 different countries, and, as would be expected, it correlated positively with measures of depression and negatively with measures of self- esteem and psychosexual adjustment (Piggot, 2004 cited in Szymanski, Kashubeck-West,

& Meyer, 2008). No information on the correlation between the long and short form could be found.

The long and short versions of the LIHS have been modified to include bisexual women. The bisexual-inclusive long and short versions of the LIHS have adequate internal consistency (α = .89 and .94, respectively; Balsam & Szymanski, 2005;

Szymanski & Owens, 2008). This study used the shorter, bisexual inclusive version of the scale. See Appendix E for a copy of this measure.

Distress Tolerance. The Distress Tolerance Scale (DTS) is a 15-item self-report scale measuring perceived ability to tolerate negative affect. Questions are based on four factors hypothesized to be involved in distress tolerance: tolerance of negative affect

(e.g., “feeling distressed or upset is unbearable to me”), appraisal of negative affect (e.g.,

“my feelings of distress or being upset are not acceptable”), regulation of negative affect

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(e.g., “when I feel distressed or upset, I must do something about it immediately”), and attention absorbed by negative affect (e.g., “when I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels”). Each question is rated on a 5- point scale (1 = strongly agree; 5 = strongly disagree) with high scores indicating high distress tolerance. The DTS has good internal consistency (α = .82). The scale showed convergent and discriminant validity when compared to other measures of affective functioning (positive and negative affectivity, affect lability, negative mood regulation expectancies, mood acceptance, and mood typicality). Criterion validity was supported when the DTS was found to be negatively associated with the use of alcohol (r = -.23) or marijuana (r = -.21) for coping. Six-month test-retest reliability of the DTS was fairly stable (intra-class r = .61; Simons & Gaher, 2005). See Appendix F for a copy of this measure.

Depressive Symptoms. The Depression, Anxiety, and Stress Scale (DASS-21) was used to measure depression. The DASS-21 is a 21-item scale, based on an original 42- item scale, which measures the severity of core features of depression (e.g., self- depreciation, loss of interest, dysphoric mood, hopelessness, anhedonia), anxiety (e.g., autonomic arousal, muscular tension, situational anxiety, anxious affect), and stress (e.g., difficulty relaxing, nervous arousal, being easily upset, irritable, or overreactive;

Lovibond & Lovibond, 1995; Lovibond, 1998). The DASS-21 contains three, seven-item scales: Depression (e.g., “I felt that I had nothing to look forward to”), Anxiety (e.g., “I experienced trembling”), and Stress (e.g., “I found it hard to wind down”). On the DASS-

21, individuals are asked to indicate how much statements relate to their experience over

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the past week on a 4-point scale (0 = Did not apply to me; 3 = Applied to me very much, or most of the time).

The DASS-21 has been found to correlate in the expected directions with other measures of depression, anxiety, negative affect, and positive affect (Crawford & Henry,

2003). The Depression, Anxiety, and Stress scales have also shown good internal consistency reliability (α = .90, .84, and .90, respectively; Lovibond & Lovibond, 1995).

A trait version of the DASS-21 was developed by Lovibond (1998) by asking the individual to rate the experience of symptoms of depression, anxiety, and stress during a typical week in the past 12 months rather than over the past week. The trait version of the

DASS-21 had good 8-week test-retest validity (r = .60 - .70; Lovibond, 1997 cited in

Lovibond, 1998). The Depression scale was used for this study. Trait depression was measured rather than state depression in order to measure a more chronic tendency toward depression. For the Depression scale, cut-off scores for severity levels are as follows: scores within the range of 0-9 are classified as normal, scores ranging from 10 to

13 are classified as mild, scores in the range of 14-20 are classified as moderate, scores ranging from 21 to 27 are classified as severe, and a score of 28 or higher is classified as extremely severe (Lovibond & Lovibond, 1995). See Appendix G for a copy of this measure.

“Outness” about Sexual Orientation. The Outness Inventory (OI) contains 11 items that measure the degree to which an individual’s sexual orientation is known by and openly discussed with other people. Items are grouped into three internally consistent subscales based on groups of people in an individual’s life: (1) four items assess degree of “outness” to new heterosexual friends, co-workers, work supervisors, and strangers

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(i.e., Out to World; α = .79), (2) four items assess degree of “outness” to family members, including one’s father, mother, siblings, extended family, and relatives (Out to

Family; α = .74), and (3) two items measure degree of “outness” to members and leaders of the individual’s religious community (Out to Religion; α = .97). The eleventh item,

“outness” to old heterosexual friends, did not meet criteria to be included in the scale, but it was included in the questionnaire to see if responses to the item about “outness” to old heterosexual friends were similar to the responses to the other people an individual could be “out” to (e.g., to new heterosexual friends, co-workers, family members). Items are rated on a 7-point scale (1 = person definitely does not know about your sexual orientation status; 7 = person definitely knows about your sexual orientation status, and it is openly talked about) along with the additional option to indicate that an individual is not a part of the respondent’s life (i.e., by providing a rating of 0). In addition to the subscales, factor analyses found a higher order factor involving general levels of

“outness.” Thus, the scale can be used to assess “outness” in general in addition to the specific domains of the three subscales. Discriminant validity was evident in the finding that only the Out to Religion subscale was associated with involvement in religious organizations that are supportive versus non-supportive of GLB individuals. Higher scores on all three subscales were associated with greater identification with GLB communities and being in a higher stage of GLB identity development (Mohr &

Fassinger, 2000).

Demographic Questionnaire. Participants filled out a questionnaire developed by the principal investigator that included questions about their background such as their age, sex, relationship status, occupation, participation in athletics, and ethnicity. As

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supplemental information, participants were asked to indicate their weight and height.

See Appendix I for a copy of this measure.

Procedure

Approval from the Institutional Review Board at Texas Tech University was obtained prior to data collection. Data collection began in November 2011 and ended in

April 2013, when usable responses had been received from 138 lesbian and bisexual women (Cohen, 1992).

Participants were provided with a web-based link (using the Qualtrics Data

Collection software) that contained information about the study and the study’s questionnaires. First, participants saw a description of the study that included the purpose of the study and informed them that their participation was voluntary, that their responses would remain anonymous, and that it would take about 20-30 min to complete the questionnaires. They were also informed of possible risks and benefits for participating.

At the bottom of the page there was a link to the questionnaires that said “continue with the study.” Those who clicked on that link were connected to instructions about how to complete the questionnaires. At the end of the survey, participants were thanked for their participation and asked to forward a link to the study website to anyone who might qualify for and be interested in participating.

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CHAPTER THREE

RESULTS This section will first present the results from preliminary analyses that include the means (M) and standard deviations (SD) for each variable, comparison between lesbian and bisexual participants regarding their mean scores on each variable, and the degree to which variables correlated with each other. After these preliminary analyses, the results from the primary analyses that investigated the main hypotheses will be discussed. As mentioned earlier, this will provide more information on whether depression and shame mediate the relationship between internalized homophobia variables and binge eating, and whether distress tolerance moderates the shame/depression and binge eating relationships in the mediation models.

Preliminary analyses

Data were analyzed by using the Statistical Package for the Social Sciences

(SPSS) statistical software program. Typically, a statistical significance level of .05 was used; however, a more liberal statistical significance level was used for certain analyses

(more information will be provided in the respective descriptions of the analyses). All variables were tested for normality of their distribution of scores by examining their skewness and kurtosis. Objective binge eating episodes, subjective binge eating episodes, and the Personal Feelings about Being Lesbian/Bisexual subscale of the LIHS were non- normally distributed with positive skewness of 3.92 (SE = .206), 5.06 (SE = .206), and

3.00 (SE = .206), respectively, and kurtosis of 15.15 (SE = .410), 29.91 (SE = .410), and

11.71 (SE = .410), respectively. Positive skewness indicated that most participants did not report binge eating or negative feelings about being lesbian or bisexual. A logarithmic

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transformation was used to correct for the skewness and kurtosis observed in these variables. Following this transformation, the skewness for objective binge eating dropped to 2.44 (SE = .206), and the kurtosis dropped to 5.08 (SE = .41). For subjective binge eating, skewness dropped to 2.02 (SE = .206), and kurtosis dropped to 3.49 (SE = .41).

For Personal Feelings about Being Lesbian, skewness dropped to 1.51 (SE = .206), and kurtosis dropped to 1.79 (SE = .41).

Descriptive statistics were calculated for the following: binge eating, compensatory behaviors, depression, shame, internalized homophobia, distress tolerance, and “outness.” Lesbian and bisexual women’s responses on these variables were compared using chi-square analyses or independent samples t-tests. The results are as follows:

Binge Eating. The frequencies of overall, objective, and subjective binge eating over the past month were measured using the binge eating questions from the EDE-Q.

Some participants did not provide an exact number of binge eating episodes. Instead they reported engaging in binge eating “every day” or “every time I eat.” Specifically, three participants did this when reporting objective binge eating episodes and two did this when reporting subjective binge eating episodes. For these participants, the value of 28 binge episodes was used, given that the questionnaire asked for them to report the number of binge episodes over the past 28 days. It is possible that these individuals engaged in more than 28 binge eating episodes. In fact, the individual who reported binge eating every time she ate likely binged more than 28 times; however, we decided to be conservative in our estimate.

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In our sample, 20.3% of participants reported engaging in objective binge eating episodes at least once per month, 26.1% reported engaging in subjective binge eating episodes at least once per month, and 37.0% of participants reported engaging in some type of binge episode at least once per month (see Table 1). These frequencies are similar to those found in previous research that has measured the proportion of participants who reported at least one binge eating episode per week (e.g., Heffernan, 1996) and the proportion of participants who have reported engaging in binge eating at any point in their lives (e.g., French, Story, Remafedi, Resnick, & Blum, 1996).

Compensatory Behaviors. The frequencies of overall compensatory behaviors and specific compensatory behaviors (i.e., purging, fasting, and exercise) over the past month were measured by the EDE-Q. Approximately 10.1% of participants reported engaging in any type of compensatory behavior at least once over the past month, with 4.3% engaging in purging behaviors, 2.2% engaging in fasting behaviors, and 4.3% engaging in exercise as a means to compensate for a binge eating episode (see Table 1).

Binge eating with and without compensatory behaviors. The percentages of participants who participated in both binge eating and compensatory behaviors and the percentages of participants who engaged in binge eating without compensatory behaviors were calculated using the binge eating and compensatory behavior questions from the

EDE-Q. To do this, separate variables for binge eating with compensatory behaviors and binge eating without compensatory behaviors were created. Approximately 8.7% of participants reported engaging in some type of binge eating and compensatory behaviors, whereas 27.5% reported that they engaged in some type of binge eating without compensatory behaviors. Approximately 5.8% of participants reported engaging in

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objective binge eating and compensatory behaviors over the past month, whereas 14.5% reported engaging in objective binge eating without compensatory behaviors.

Approximately 6.6% of participants reported engaging in subjective binge eating and compensatory behaviors, whereas 19.6% engaged in subjective binge eating without compensatory behaviors. See Table 1 for the results.

Pearson chi-square analyses were conducted to compare the proportion of lesbian versus bisexual women who engaged in bulimic behaviors. No significant differences were found in the number of lesbian versus bisexual participants who reported engaging in objective binge eating, χ2 (1, N = 138) = .07, p > .05), subjective binge eating, χ2 (1, N

= 138) = 1.17, p > .05), or any type of compensatory behavior, χ2 (1, N = 138) = .54, p >

.05. The chi-square analysis comparing the proportion of lesbian versus bisexual women who reported both subjective binge eating and compensatory behaviors approached significance, with a higher proportion of bisexual participants (10.6%) than lesbian participants (2.8%) reporting that they engaged in both of these behaviors, χ2 (1, N = 138)

= 3.46, p = .09). There was no significant difference found between the proportion of lesbian participants and the proportion of bisexual participants who reported engaging in both objective binge eating and compensatory behaviors, χ2 (1, N = 138) = .73, p > .05).

Table 1

Percentage of Sample Engaging in Bulimic Behaviors at Least Once per Month

Total Lesbian Bisexual Any binge 37.0 36.1 37.9 Objective binge 20.3 19.4 21.2 Subjective binge 26.1 22.2 30.3 Any compensatory behavior 10.1 8.3 12.1 Purge 4.3 2.8 6.1 Fast 2.2 1.4 3.0 Exercise 4.3 4.2 4.5 (table continues)

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Total Lesbian Bisexual Any binge with compensatory behavior 8.7 5.5 12.1 Objective binge with compensatory behavior 5.8 4.2 7.6 Subjective binge with compensatory behavior 6.6 2.8 10.6 Any binge without compensatory behavior 27.5 29.2 25.8 Objective binge without compensatory behavior 14.5 15.3 13.6 Subjective binge without compensatory behavior 19.6 19.4 19.7

Depressive Symptoms. Depressive symptoms were measured using the DASS-21.

In our sample, the mean score for all participants was 10.19 (SD = 9.31), the mean for lesbian participants was 8.58 (SD = 9.26), and the mean for bisexual participants was

11.94 (SD = 9.12; see Table 2). Bisexual women showed significantly higher levels of depression than lesbian women, t(136) = -2.17, p < .05. On average, our sample’s level of depression fell in the mild range of impairment, and participants reported depressive symptoms that ranged from normal to extremely severe levels (Lovibond & Lovibond,

1995). Our sample reported a level of symptoms of depression above that of the general population. For example, Sinclair, Siefert, Slavin-Mulford, Stein, Renna, and Blais

(2012) found a mean depression score of 5.7 (SD = 8.2) on the DASS in a sample of the general population. This is consistent with previous findings that non-heterosexual individuals are more depressed than heterosexual individuals (Zietsch, Verwejj, Heath,

Madden, Martin, Nelson, & Lynskey, 2012).

Shame. In our sample, the mean score was 25.70 (SD = 6.1, range = 13-46).

Bisexual women reported significantly higher levels of shame (M = 26.82, SD = 6.44) than lesbian women (M = 24.67, SD = 5.62), t(136) = -2.10, p < .05, (see Table 2). Other studies have reported a mean score of 16.7 (SD = 4.40) in their samples of college undergraduates (Harder, Cutler, & Rockart, 1992). Thus, it appears that our sample of

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lesbian and bisexual women experiences higher levels of shame than the general population.

Internalized Homophobia. In our sample, the mean scores were 2.27 (SD = .905, range = 1-6) for total internalized homophobia, 1.50 (SD = .905, range = 1-7) on the

Personal Feelings about Being Lesbian/Bisexual subscale, 2.51 (SD = 1.26, range = 1-7) on the Public Identification as Lesbian/Bisexual subscale, 1.81 (SD = 1.22, range = 1-7) on the Attitudes toward Other Lesbians subscale, 2.93 (SD = 1.61, range = 1-7) on the

Connection to the Lesbian/Bisexual Community-Knowledge of Resources subscale, and

2.17 (SD = .88, range = 1-5) on the Connection to the Lesbian/Bisexual Community-

Interaction subscale (see Table 2). Other studies of lesbian and bisexual women from the general population have reported a mean total internalized homophobia score of 1.94 (SD

= .72) using the long form of the LIHS scale (Syzmanski, 2005) and 2.06 (SD = .80) using the short form of the LIHS (Szymanski & Kashubeck-West, 2008).

Bisexual women reported a significantly higher mean total internalized homophobia score, t(136) = -3.70, p < .001, Connection to the Lesbian/Bisexual

Community-Interaction score (higher mean = less interaction), t(136) = - 4.99, p < .001,

Connection to the Lesbian/Bisexual Community-Knowledge of Resources score (higher mean = less knowledge), t(136) = -2.35, p < .05, and Public Identification as

Lesbian/Bisexual score (higher mean = less public identification as lesbian/bisexual), t(136) = -4.09, p < .001, than lesbian women. Lesbian and bisexual women did not differ significantly with regard to their mean Personal Feelings about Being Lesbian/Bisexual score, t(136) = -.69, p > .05, or Attitudes toward Other Lesbians score, t(136) = 1.42, p >

.05.

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Table 2

Total and Group Means and Standard Deviations for Depression, Shame, Internalized Homophobia, Distress Tolerance, and “Outness”

Total Lesbian Bisexual M SD M SD M SD

Depression 10.19 9.31 8.58 9.26 11.94 9.12 Shame 25.70 6.10 24.67 5.62 26.82 6.44 LIHS Total* 2.27 .91 2.00 .82 2.50 .91 LIHS ATOL* 1.81 1.22 1.95 1.35 1.66 1.04 LIHS PIL* 2.51 1.26 2.10 1.06 3.00 1.32 LIHS PFL* 1.50 .91 1.46 .89 1.54 .93 LIHS CLCK* 2.93 1.61 2.60 1.57 3.30 1.60 LIHS CLCI* 2.17 .88 1.80 .67 2.50 .95 Distress Tolerance 3.53 1.05 3.65 1.03 3.40 1.07 Out to World 4.31 1.90 5.10 1.61 3.50 1.84 Out to Family 4.40 1.93 5.20 1.60 3.50 1.91 Out to Religion 1.69 2.65 2.30 3.00 1.00 2.10 Total “Outness” 3.47 1.62 4.20 1.43 2.70 1.50 Note. *LIHS = Lesbian Internalized Homophobia Scale; ATOL = Attitudes toward Other Lesbians; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection to the Lesbian/Bisexual Community- Knowledge of Resources; CLCI = Connection to the Lesbian/Bisexual Community- Interaction.

Distress Tolerance. In our sample, the overall mean score for distress tolerance was 3.53 (SD = 1.05, range = 1-5), the mean score for lesbian women was 3.65 (SD =

1.03), and the mean score for bisexual women was 3.40 (SD = 1.07; see Table 2). Other studies have reported a mean score of 3.09 (SD = 0.75) in their sample of women from the general population (Simon & Gaher, 2005). Thus, our sample’s level of distress tolerance was similar to that seen in the general population of women. Lesbian and bisexual women in the current study did not significantly differ in their ability to tolerate distress, t(136) = 1.39, p > .05.

“Outness” about Sexual Orientation. In our sample, the mean scores were 3.47

(SD = 1.62, range = 0-7) for total “outness”, 4.31 (SD = 1.90, range = 1-7) for “outness”

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to the world, 4.40 (SD = 1.93, range = 0-7) for “outness” to family, and 1.69 (SD = 2.65, range = 0-7) for “outness” to religion (see Table 2). Other studies have reported mean scores of 5.33 (SD = 1.27) for “outness” to family, 5.10 (SD = 1.39) for “outness” to the world, and 5.20 (SD = 2.34) for “outness” to religion in their sample of lesbian women from the general population (Mohr & Fassinger, 2000). Compared to lesbian women, bisexual women were less likely to be “out” about their sexual orientation overall, t(136)

= 6.13, p < .001, to their family members, t(136) = 5.46, p < .001, to the world, t(136) =

5.49, p < .001, and to members of their religious organization, if applicable, t(136) =

2.90, p < .01.

Internalized Homophobia, Depression, Shame, and Distress Tolerance. Pearson product-moment correlations were performed to analyze the relationships between the internalized homophobia variables and depression, shame, and distress tolerance. Total internalized homophobia was positively correlated with depression, r(136) = .49, p <

.001, and shame, r(136) = .44, p < .001. Higher internalization of society’s negative views on homosexuality and bisexuality was associated with higher levels of depression and shame. Attitudes toward Other Lesbians were positively correlated with depression, r(136) = .17, p < .05. More negative attitudes toward other lesbians were associated with higher levels of depression. Attitudes toward Other Lesbians did not correlate significantly with feelings of shame, r(136) = .06, p > .05. Personal Feelings about Being

Lesbian/Bisexual were positively correlated with depression, r(136) = .41, p < .001), and shame, r(136) = .39 p < .001. More negative feelings about being lesbian or bisexual

(e.g., feelings of self-hatred, placing superior value on heterosexuality, feeling unworthy, sick, or defective because one is lesbian or bisexual) were associated with higher levels

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of depression and shame. Public Identification as Lesbian/Bisexual was positively correlated with depression, r(136) = .46, p < .001), and shame, r(136) = .45, p < .001.

Less open identification as lesbian/bisexual was associated with higher levels of depression and shame. Connection to the Lesbian/Bisexual Community-Knowledge of

Resources was positively correlated with feelings of depression, r(136) = .40, p < .001), and shame, r(136) = .27, p < .01. Less awareness of and familiarity with lesbian culture and products of the lesbian community (e.g., history, cultural symbols, community resources, books, movies, festivals, etc.) was associated with higher levels of depression and shame. Connection to the Lesbian/Bisexual Community-Interaction was positively correlated with depression, r(136) = .28, p < .01, and shame, r(136) = .27, p < .01. Lower amounts of interaction with other lesbians and bisexual women were associated with higher levels of depression and shame.

Significant negative relationships were found between distress tolerance and total internalized homophobia, r(136) = -.45, p < .001, Connection to the Lesbian/Bisexual

Community-Interaction, r(136) = -.29, p < .001, Connection to the Lesbian/Bisexual

Community-Knowledge of Resources, r(136) = -.30, p < .001, Public Identification as

Lesbian/Bisexual, r(136) = -.42, p < .001, Personal Feelings about Being

Lesbian/Bisexual, r(136) = -.34, p < .001, and Attitudes toward Other Lesbians, r(136) =

-.22, p < .05. In other words, higher levels of distress tolerance were associated with lower levels of internalized homophobia, greater interaction with the lesbian or bisexual community, a greater knowledge of resources in the lesbian or bisexual community, a greater likelihood of publicly identifying as lesbian or bisexual, more positive feelings about being lesbian or bisexual, and more positive attitudes toward other lesbian women.

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Distress Tolerance, Depression, and Shame. Pearson product-moment correlations were performed to analyze the relationships of distress tolerance to shame and depression. Distress tolerance was significantly negatively correlated with depression, r(136) = -.62, p < .001, and shame, r(136) = -.66, p < .001. Thus, having higher levels of distress tolerance was associated with experiencing lower levels of depression and shame.

Binge Eating’s Association with Depression, Shame, and Distress Tolerance.

Pearson product-moment correlations were performed to analyze the relationships of binge eating to depression, shame, and distress tolerance. The frequencies of objective and subjective binge eating were positively correlated with levels of depression, r(136) =

.18, p < .05, and r(136) = .21, p < .05, and shame, r(136) = .19, p < .05, and r(136) = .27, p < .01). Consistent with previous research, greater levels of binge eating were associated with greater levels of depression and shame (Presnell et al., 2009; Sanftner et al, 1995;

Sanftner & Crowther, 1998). Negative correlations were found between distress tolerance and the frequency of objective, r(136) = -.17, p = .05, and subjective, r(136) = -.30, p <

.001, binge eating. Thus, a higher tolerance of distress was associated with a lower frequency of binge eating.

Binge Eating and Internalized Homophobia. Pearson product-moment correlations were performed to analyze the relationships between objective and subjective binge eating and the internalized homophobia variables. A significant positive relationship was found between the frequency of objective binge eating and Personal

Feelings about Being Lesbian/Bisexual, r(136) = .18, p < .05. In other words, more negative feelings about being lesbian/bisexual were associated with a higher frequency of

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objective binge eating. A positive relationship between the frequency of objective binge eating and Public Identification as Lesbian/Bisexual approached significance, r(136) =

.15, p = .08. There were no significant relationships between objective binge eating and total internalized homophobia, r(136) = .13, p > .05, Connection to the Lesbian/Bisexual

Community-Interaction, r(136) = -.01, p > .05, Connection to the Lesbian/Bisexual

Community-Knowledge of Resources, r(136) = .08, p > .05, and Attitudes toward Other

Lesbians, r(136) = -.01, p > .05.

Significant positive relationships were found between the frequency of subjective binge eating and total internalized homophobia, r(136) = .31, p < .01, Connection to the

Lesbian/Bisexual Community-Knowledge of Resources, r(136) = .21, p < .05, Public

Identification as Lesbian/Bisexual, r(136) = .27, p < .01, and Personal Feelings about

Being Lesbian/Bisexual, r(136) = .33, p < .001. The relationships between subjective binge eating and Connection to the Lesbian/Bisexual Community-Interaction, r(136) =

.15, p = .08, and Attitudes toward Other Lesbians, r(136) = .15, p = .08, approached significance.

“Outness.” Pearson product-moment correlations were performed to analyze how overall “outness,” “outness” to family, “outness” to the world (e.g., co-workers, friends, strangers), and “outness” to people in the religious community (e.g., clergy members, members of their congregation) correlated with depression, shame, distress tolerance, and the internalized homophobia variables.

“Outness” and Depression. Overall “outness,” r(136) = -.42, p < .001, “outness” to family, r(136) = -.38, p < .001, “outness” to the world, r(136) = -.46, p < .001, and

“outness” to religion, r(136) = -.165, p = .05, were negatively correlated with depression.

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Thus, the more a lesbian or bisexual women was out to family members, people in her religious community, co-workers, acquaintances, strangers, and friends, the less likely she was to report feelings of depression.

“Outness” and Shame. Overall “outness,” r(136) = -.43, p < .001, “outness” to family, r(136) = -.40, p < .001, “outness” to the world, r(136) = -.35, p < .001, and

“outness” to religion, r(136) = -.24, p < .01, were negatively correlated with shame. Thus, lesbian or bisexual women who were “out” to other people were less likely to report feelings of shame than women who were less “out” to other people.

“Outness” and Distress Tolerance. Overall “outness,” r(136) = .40, p < .001,

“outness” to family, r(136) = .37, p < .001, “outness” to the world, r(136) = .36, p < .001, and “outness” to religion, r(136) = .21, p = .01, were positively correlated with distress tolerance. In other words, having higher levels of distress tolerance was associated with a greater likelihood of being “out” about one’s sexual orientation.

“Outness” and Internalized Homophobia. Total “outness” was negatively correlated with total internalized homophobia, r(136) = -.53, p < .001, Connection to the

Lesbian/Bisexual Community-Interaction, r (136) = -.40, p < .001, Connection to the

Lesbian/Bisexual Community-Knowledge of Resources, r(136) = -.31, p < .001, Public

Identification as Lesbian/Bisexual, r(136) = -.65, p < .001, and Personal Feelings about

Being Lesbian/Bisexual, r(136) = -.29, p = .001. “Outness” to family was negatively correlated with total internalized homophobia, r(136) = -.58, p < .001, Connection to the

Lesbian/Bisexual Community-Interaction, r (136) = -.38, p < .001, Connection to the

Lesbian/Bisexual Community-Knowledge of Resources, r(136) = -.31, p < .001, Public

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Identification as Lesbian/Bisexual, r(136) = -.64, p < .001, and Personal Feelings about

Being Lesbian/Bisexual, r(136) = -.41, p < .001.

“Outness” to the world was negatively correlated with total internalized homophobia, r(136) = -.61, p < .001, Connection to the Lesbian/Bisexual Community-

Interaction, r(136) = -.45, p < .001, Connection to the Lesbian/Bisexual Community-

Knowledge of Resources, r(136) = -.37, p < .001, Public Identification as

Lesbian/Bisexual, r(136) = -.59, p < .001, and Personal Feelings about Being

Lesbian/Bisexual, r(136) = -.32, p < .001; however, “outness” to religion did not correlate significantly with any of the internalized homophobia variables. Attitudes toward Other Lesbians were not significantly correlated with the “outness” variables.

Primary Data Analyses

Hypothesis 1: Depression and shame will mediate the relationship between internalized homophobia and binge eating. Initially, Baron and Kenny’s (1986) model for analyzing mediation was going to be used. Specifically, binge eating would be regressed onto internalized homophobia and shame/depression. Complete mediation would occur if the relationship between internalized homophobia and binge eating dropped to a non-significant p-value when shame/depression were included in the model, and partial mediation would occur if the relationship dropped significantly, but not all the way to a non-significant p-value.

To increase the power and robustness of the mediation analyses, Preacher and

Hayes’ (2008) bootstrapping procedure for mediation analyses was used. Specifically, the

PROCESS macro for SPSS was used (Hayes, 2012). The bootstrapping method is a non- parametric test that does not require the assumption of normality of the sampling

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distribution. Bootstrapping involves repeatedly taking random samples from the observed data with replacement of the sampled data to the original dataset after each sampling. For each sample, the estimate for the effect being tested is calculated and a distribution of the bootstrap sample estimates is created to approximate that of the population.

Preacher and Hayes’ bootstrapping procedure for mediation analyses calculates the total effect of the independent variable (i.e., internalized homophobia) on the dependent variable (i.e., binge eating) when the mediator (i.e., shame or depression) is not accounted for, the direct effect of the independent variable on the dependent variable when accounting for the variance in the dependent variable attributed to the mediator, and the indirect effect of the independent variable on the dependent variable through the mediator. Significant mediation is found when the confidence interval for the indirect effect does not include 0 (Preacher & Hayes, 2008; D. Reich, personal communication,

12/18/2013). Of note, there does not appear to be a set rule on how many decimal places to round to when interpreting results of the mediation models. A review of previous peer- reviewed research using the PROCESS approach revealed that some investigators have rounded to three decimal places rather than two in order to capture significant mediation models (e.g., Chang, Jarry, & Kong, 2014; White & Turner, 2014). Thus, we chose to round to three decimal places as well.

Before mediation analyses were performed, the bivariate correlation relationships between the variables in the mediation model were reviewed for significance (see Table

3). Variables that correlated significantly at the p = .10 level or lower were included in the mediation analyses. A more liberal p-value was chosen to reduce the possibility of

Type II error when conducting the mediation analyses.

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Table 3

Bivariate Correlations between Independent, Dependent, and Mediator Variables

Internalized Homophobia Binge Total PIL PFL CLCK CLCI ATOL Obj. Subj. Depression .49* .46* .41* .40* .28* .17* .18* .21*

Shame .44* .45* .39* .27* .27* .06 .19* .27*

Obj. binge .13 .15† .18* .08 -.01 -.01 -- --

Subj. binge .31* .27* .33* .21* .15† .15† -- -- Note. Total = Total amount of internalized homophobia; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community-Knowledge of Resources; CLCI = Connection with the Lesbian/Bisexual Community-Interaction; ATOL = Attitudes toward Other Lesbians; Obj. = Objective; Subj. = Subjective †p ≤ .10; * p ≤ .05

Given the significant correlations observed above, eight mediation models were run with depression as a mediator in the relationship between internalized homophobia and binge eating variables. Two of these models involved internalized homophobia variables (i.e., Public Identification as Lesbian/Bisexual and Personal Feelings about

Being Lesbian/Bisexual) predicting objective binge eating. The other six models involved internalized homophobia variables (total internalized homophobia, Public Identification as Lesbian/Bisexual, Personal Feelings about Being Lesbian/Bisexual, Attitudes toward

Other Lesbians, Connection to the Lesbian/Bisexual Community-Knowledge of

Resources, and Connection to the Lesbian/Bisexual Community-Interaction) predicting subjective binge eating.

Seven models were run with shame as a mediator. Two of these models involved internalized homophobia variables (Public Identification as Lesbian/Bisexual and

Personal Feelings about Being Lesbian/Bisexual) predicting objective binge eating. The

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other five models involved internalized homophobia variables (total internalized homophobia, Public Identification as Lesbian/Bisexual, Personal Feelings about Being

Lesbian/Bisexual, Connection to the Lesbian/Bisexual Community-Knowledge of

Resources, and Connection to the Lesbian/Bisexual Community-Interaction) predicting subjective binge eating.

Depression as a mediator in the relationships between internalized homophobia variables and objective binge eating. In the first two models, after accounting for the indirect effect of Personal Feelings about Being Lesbian/Bisexual on objective binge eating and the indirect effect of Public Identification as Lesbian/Bisexual on objective binge eating through depression, neither the direct effect of Public Identification as

Lesbian/Bisexual or Personal Feelings about Being Lesbian/Bisexual on objective binge eating were significant (see Table 4). The bias-corrected bootstrap estimates of the indirect effects of Personal Feelings about Being Lesbian/Bisexual and Public

Identification as Lesbian/Bisexual on objective binge eating through depression were not significant given that their 95% confidence intervals for the indirect effects included zero

(95% confidence intervals = -.030 to .306, and -.003 to .052, respectively; See Table 5).

Thus, depression did not mediate the relationship between Public Identification as

Lesbian/Bisexual and objective binge eating or the relationship between Personal

Feelings about Being Lesbian/Bisexual and objective binge eating.

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Table 4

Total and Direct Effects for Depression Mediating the Relationship between Measures of Internalized Homophobia and Objective Binge Eating

Total Effect Direct Effect

b SE t 95% CI B SE t 95% CI Upper Upper Lower Lower PIL .044 .025 1.76 .093 .026 .028 .913 .081 -.005 -.030 PFL .369 .169 2.19* .703 .270 .184 1.46 .634 .036 -.095 Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual. Significant results are in bold font. * p ≤ .05

Table 5

Indirect Effects for Depression Mediating the Relationship between Measures of Internalized Homophobia and Objective Binge Eating

Indirect Effect 95% CI Effect SE Upper Lower

PIL .018 .014 .052 -.003

PFL .100 .084 .306 -.030

Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual. Significant results are in bold font.

Depression mediating the relationships between internalized homophobia variables and subjective binge eating. In the six additional models, after accounting for the indirect effect of the internalized homophobia variables on subjective binge eating through depression, the direct effects of total internalized homophobia (b = .102; SE = .035), t(136) = 2.93; p < .01, Public Identification as Lesbian/Bisexual (b = .060; SE = .025),

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t(136) = 2.41; p < .05, and Personal Feelings about Being Lesbian/Bisexual (b = .533; SE

= .162), t(136) = 3.29; p = .001, on subjective binge eating were significant. In contrast, the direct effects of Connection to the Lesbian/Bisexual Community-Knowledge of

Resources (b = .032; SE = .019), t(136) = 1.68; p > .05, Connection to the

Lesbian/Bisexual Community-Interaction (b = .037; SE = .033), t(136) = 1.12; p > .05, and Attitudes toward Other Lesbians (b = .032; SE = .023), t(136) = 1.36; p > .05, on subjective binge eating were not significant (See Table 6). None of the bias-corrected bootstrap estimates of the indirect effects of the internalized homophobia variables on subjective binge eating through depression were significant given that the 95% confidence intervals contained the number zero (see Table 7).

Table 6

Total and Direct Effects for Depression Mediating the Relationship between Measures of Internalized Homophobia and Subjective Binge Eating

Total Effect Direct Effect 95% CI 95% CI

b SE t Upper b SE t Upper Lower Lower

Total .116 .030 3.83** .176 .102 .035 2.93** .171 .056 .033

PIL .073 .022 3.31** .117 .060 .025 2.41* .109 .030 .011

PFL .602 .148 4.07** .894 .533 .162 3.29** .854 .309 .213

CLCK .045 .018 2.54** .079 .032 .019 1.68 .070 .010 -.006

CLCI .057 .032 1.76 .121 .037 .033 1.12 .103 -.007 -.028 (table continues)

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Total Effect Direct Effect 95% CI 95% CI

b SE t Upper b SE t Upper Lower Lower

ATOL .041 .023 1.74 .087 .032 .023 1.36 .078 -.006 -.015 Note. Total = Total amount of internalized homophobia; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community-Knowledge of Resources; CLCI = Connection with the Lesbian/Bisexual Community-Interaction; ATOL = Attitudes toward Other Lesbians. Significant results are in bold font. * p ≤ .05; ** p ≤ .01

Table 7

Indirect Effects for Depression Mediating the Relationship between Measures of Internalized Homophobia and Subjective Binge Eating

Indirect Effect 95% CI Effect SE Upper Lower

Total .014 .021 .061 -.023

PIL .013 .014 .044 -.010

PFL .069 .078 .247 -.070

CLCK .013 .010 .035 -.004

CLCI .020 .015 .058 -.003

ATOL .009 .010 .032 0 Note. Total = Total amount of internalized homophobia; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community-Knowledge of Resources; CLCI = Connection with the Lesbian/Bisexual Community-Interaction; ATOL = Attitudes toward Other Lesbians. Significant results are in bold font.

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Shame mediating the relationships between the internalized homophobia variables and objective binge eating. After accounting for the indirect effect of the internalized homophobia variables on objective binge eating through shame, the direct effects of Public Identification as Lesbian/Bisexual on objective binge eating (b = .023;

SE = .028), t(136) = .828; p > .05, and Personal Feelings about Being Lesbian/Bisexual on objective binge eating (b = .256; SE = .183), t(136) = 1.40; p > .05, were not significant (see Table 8). The bias-corrected bootstrap estimates of the indirect effects of the internalized homophobia variables on objective binge eating through shame were significant for Public Identification as Lesbian/Bisexual (.023) and Personal Feelings about Being Lesbian/Bisexual (.113) given that the 95% confidence interval did not contain zero (95% confidence interval = .004 to .048 and .009 to .289, respectively; see

Table 9). Thus, shame mediated the effects of Public Identification as Lesbian/Bisexual and Personal Feelings about Being Lesbian/Bisexual on objective binge eating.

Table 8

Total and Direct Effects for Shame Mediating the Relationship between Measures of Internalized Homophobia and Objective Binge Eating

Total Effect Direct Effect

95% CI 95% CI b SE t Upper b SE t Upper Lower Lower

PIL .044 .025 1.76 .093 .023 .028 .828 .078 -.005 -.032 PFL .370 .169 2.19* .703 .256 .183 1.40 .617 .036 -.105 Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual. Significant results are in bold font. * p ≤ .05; ** p ≤ .01

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Table 9

Indirect Effects for Shame Mediating the Relationship between Measures of Internalized Homophobia and Objective Binge Eating

Indirect Effect

Effect SE 95% CI Upper Lower

PIL .023 .011 .048 .004

PFL .113 .069 .289 .009

Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual. Significant results are in bold font.

Shame mediating the relationships between the internalized homophobia variables and subjective binge eating. After accounting for the indirect effect of the internalized homophobia variables on subjective binge eating through shame, the direct effects of total internalized homophobia (b = .090; SE = .034), t(136) = 2.67; p < .01,

Public Identification as Lesbian/Bisexual (b = .052; SE = .025), t(136) = 2.10; p < .05, and Personal Feelings about Being Lesbian/Bisexual (b = .485; SE = .160), t(136) = 3.04; p < .01, on subjective binge eating were significant. In contrast, the direct effects of

Connection to the Lesbian/Bisexual Community-Knowledge of Resources (b = .032; SE

= .018), t(136) = 1.80; p > .05, and Connection to the Lesbian/Bisexual Community-

Interaction (b = .032; SE = .033), t(136) = .978; p > .05, on subjective binge eating were not significant (see Table 10).

The bias-corrected bootstrap estimates of the indirect effect of the internalized homophobia variables on subjective binge eating through shame were significant for

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Public Identification as Lesbian/Bisexual (.022), Personal Feelings about Being

Lesbian/Bisexual (.117), Connection to the Lesbian/Bisexual Community-Knowledge of

Resources (.013), and Connection to the Lesbian/Bisexual Community-Interaction (.025) given that the 95% confidence interval of the indirect effects did not contain zero (95% confidence intervals = .001 to .053; .005 to .297; .001 to .035; .003 to .073, respectively; see Table 11). Given the significant direct effects of Public Identification as

Lesbian/Bisexual and Personal Feelings about Being Lesbian/Bisexual on subjective binge eating, shame partially mediated the relationships between those variables and subjective binge eating. Shame fully mediated the relationships between Connection to the Lesbian/Bisexual Community-Knowledge of Resources and subjective binge eating and Connection to the Lesbian/Bisexual Community-Interaction and subjective binge eating because there was not a direct effect of those internalized homophobia variables on subjective binge eating when shame was included in the model.

Table 10

Total and Direct Effects for Shame Mediating the Relationship between Measures of Internalized Homophobia and Subjective Binge Eating

Total Effect Direct Effect 95% CI 95% CI b SE t Upper b SE t Upper

Lower Lower

Total .117 .030 3.83 .176 .090 .034 2.67 .156 .056 .023

PIL .073 .022 3.31** .117 .052 .025 2.10* .100 .030 .003

PFL .602 .148 4.07** .894 .485 .160 3.04** .801 .309 .169 (table continues)

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Total Effect Direct Effect 95% CI 95% CI

b SE t Upper b SE t Upper Lower Lower

CLCK .045 .018 2.54** .079 .032 .018 1.80 .067 .001 -.003

CLCI .057 .032 1.76 .121 .032 .033 .978 .097 -.007 -.033 Note. *Total = Total amount of internalized homophobia; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community-Knowledge of Resources; CLCI = Connection with Lesbian/Bisexual Community-Interaction; SE = Standard Error. Significant results are in bold font. * p ≤ .05; ** p ≤ .01

Table 11

Indirect Effects for Shame Mediating the Relationship between Measures of Internalized Homophobia and Subjective Binge Eating Indirect Effect

Effect S E 95% CI Upper Lower

Total .026 .0 17 .068

-.002

PIL .022 .0 13 .053 .001

PFL .117 .0 71 .297 .005

CLCK .013 .0 08 .035 .001

CLCI .025 .0 17 .073 .003 Note. *Total = Total amount of internalized homophobia; PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community-Knowledge of Resources; CLCI = Connection with Lesbian/Bisexual Community-Interaction. Significant results are in bold font.

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Hypothesis 1 proposed that the relationships between internalized homophobia variables and subjective/objective binge eating would be mediated by depression and shame. This hypothesis was partially supported. Shame significantly mediated the relationships of several internalized homophobia variables to subjective and objective binge eating, whereas depression did not. In particular, shame fully mediated the relationship between Personal Feelings about Being Lesbian/Bisexual and objective binge eating and the relationship between Public Identification as Lesbian/Bisexual and objective binge eating. Shame partially mediated the relationship between those variables and subjective binge eating. Shame also fully mediated the relationship between

Connection with the Lesbian/Bisexual Community-Knowledge of Resources and subjective binge eating and Connection with Lesbian/Bisexual Community-Interaction and subjective binge eating.

Hypothesis 2: For the significant mediation models supporting Hypothesis 1, the relationship between depressive symptoms and binge eating and the relationship between shame and binge eating will be moderated by distress tolerance. Initially, hierarchical regression analyses were going to be performed to determine moderation. To increase the power and robustness of the analyses, Preacher and Hayes’ (2008) bootstrapping procedure for moderated mediation analyses was used to determine whether distress tolerance significantly moderated the indirect effects found in the mediation models.

Significant moderated mediation would be indicated if the confidence interval of the indirect effect at the highest order interaction did not contain zero.

A total of six models were run. Models were run for distress tolerance moderating the shame-objective binge eating relationship in the mediation models, which included

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the following internalized homophobia variables: Public Identification as

Lesbian/Bisexual and Personal Feelings about Being Lesbian/Bisexual. Models were run for distress tolerance moderating the shame-subjective binge eating relationship in the mediation models which included the following internalized homophobia variables:

Personal Feelings about Being Lesbian/Bisexual, Public Identification as

Lesbian/Bisexual, Connection to the Lesbian/Bisexual Community-Interaction, and

Connection to the Lesbian/Bisexual Community-Knowledge of Resources. Distress tolerance did not significantly moderate the shame-binge eating relationships when included in the mediation models (see Tables 12 and 13).

Table 12

Moderated Mediation Models for Distress Tolerance Moderating the Shame-Objective Binge Eating Relationship in the Mediation Models for Different Internalized Homophobia Variables

Indirect effect of highest order interaction 95% CI Effect SE (Lower/ Upper)

PIL -.002 .003 -.009/ .002

PFL -.013 .021 -.063/ .023

Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual

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Table 13

Moderated Mediation Models for Distress Tolerance Moderating the Shame-Subjective Binge Eating Relationship in the Mediation Models for Different Internalized Homophobia Variables

Indirect effect of highest order interaction 95% CI Effect SE (Lower/ Upper)

PIL -.001 .003 -.007/ .004

PFL 0 .022 -.042/ .050

CLCK -.001 .002 -.005/ .003

CLCI -.001 .004 -.011/ .007

Note. PIL = Public Identification as Lesbian/Bisexual; PFL = Personal Feelings about Being Lesbian/Bisexual; CLCK = Connection with the Lesbian/Bisexual Community- Knowledge of Resources; CLCI = Connection with Lesbian/Bisexual Community- Interaction

Hypothesis 2 had predicted that distress tolerance would moderate both the relationship between depression and binge eating and the relationship between shame and binge eating in the significant mediation models from Hypothesis 1. Specifically, it was hypothesized that the presence of significant relationships between shame and binge eating and between depression and binge eating would depend on an individual’s ability to tolerate distress. It was expected that significant relationships between shame and binge eating and between depression and binge eating would not be as likely in individuals who have higher levels of distress tolerance relative to those with lower levels of distress tolerance. This hypothesis was not supported for any of the significant mediation models. Thus, the relationship between shame and binge eating was not significantly influenced by the degree to which an individual can tolerate distress.

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CHAPTER FOUR

DISCUSSION Results from our study provide greater insight into factors associated with binge eating in lesbian and bisexual women, an area of research that has received little attention. In this section, the following will be discussed: 1) the meaning of our findings,

2) implications for the provision of culturally sensitive treatment for lesbian and bisexual women, 3) limitations to our study, and 4) implications for future research.

Risk for Disordered Eating

Findings on the degree of risk that lesbian and bisexual women have for experiencing disordered eating have been mixed. Some suggest that lesbian and bisexual women are at less of a risk than heterosexual women (Lakkis, Ricciardelli, & Williams,

1999; Siever, 1994), while others have suggested that they are at equal risk (e.g.,

Feldman & Meyer, 2007; Heffernan, 1997; Strong et al., 2000). Although our study did not compare lesbian and bisexual women to heterosexual women, our results suggest that some lesbian and bisexual women report binge eating and that their binge eating behaviors are associated with psychological distress.

Depression and Shame’s Association with Binge Eating

Depression and shame were significantly associated with subjective and objective binge eating in our sample of lesbian and bisexual women. Specifically, higher levels of depression and shame were associated with higher levels of binge eating. It is possible that binge eating is used as a method to cope with depression and shame, perhaps as a means to temporarily distract individuals from those feelings. It is also possible that binge eating results in feelings of depression and shame. Research has consistently found a link

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between negative affect and binge eating in the general population (e.g., Presnell et al.,

2009; Stice, 2001; Stice, Presnell, & Spangler, 2002). Some studies have found psychological distress to precede and follow binge eating episodes in individuals with binge eating disorder and bulimia nervosa (Mitchell et al., 1999) and the general population (Presnell et al., 2009). However, Spoor et al. (2006) did not find binge eating to predict future depressive symptoms. Deaver, Miltenberger, Smyth, Meidinger, and

Crosby (2003) found that binge eating resulted in a temporary increase in feelings of pleasantness during the binge episode, which decreased after the binge episode. It is possible that binge eating provides a brief improvement in mood, but remains an ineffective coping mechanism overall.

Internalized Homophobia’s Association with Depression and Shame

The results from our study support findings that minority stress, particularly internalized homophobia, has an effect on the well-being of lesbian and bisexual women

(Meyer, 1995; Meyer, 2003; Szymanski & Kashubeck-West, 2008). The internalized homophobia variables investigated in our study correlated in the expected positive direction with depression and shame (Allen & Oleson, 1999; Greene & Britton, 2012;

Szymansk et al., 2001).

When the lesbian or bisexual women in our study felt more negatively about their sexual orientation, they were more likely to experience feelings of depression or shame.

Fearing public disclosure of one’s sexual orientation and trying to pass as heterosexual were also associated with depression and shame. Fearing disclosure and trying to pass as heterosexual may reinforce the stigma attached to homosexuality or bisexuality, which may result in feelings of shame and depression. It is also possible that experiencing high

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levels of shame or depression may prevent lesbian or bisexual women from feeling comfortable with publicly disclosing their sexual orientation. Less interaction with the lesbian or bisexual communities and less knowledge about resources in the lesbian or bisexual community also were associated with feelings of depression and shame. It is possible that having less exposure to the lesbian and bisexual community results in feelings of depression or shame. It could also be possible that feeling higher levels of depression and shame prevents participation in the sexual minority community. Finally, more negative attitudes toward other lesbians were associated with higher levels of depression and shame.

Internalized Homophobia’s Association with Binge Eating

Only some of the internalized homophobia variables were associated with objective and subjective binge eating. Specifically, personal feelings about being lesbian or bisexual were significantly, positively correlated with objective binge eating and subjective binge eating. The more negatively participants felt about being lesbian or bisexual, the more likely they were to engage in objective or subjective binge eating.

Public identification as lesbian/bisexual was significantly, positively correlated with subjective binge eating. Public identification as lesbian/bisexual’s positive correlation with objective binge eating approached significance. Thus, the more participants feared public identification as lesbian or bisexual and tried to “pass” as heterosexual, the more likely they were to engage in subjective and/or objective binge eating. A qualitative study found that lesbian women with a history of bulimia nervosa or anorexia nervosa reported that their bulimic behaviors functioned as a means to escape their emerging lesbian identity given the pressure to conform to heterosexual norms (Jones & Malson, 2013).

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Thus, binge eating could function as a way to escape negative feelings about one’s lesbian or bisexual identity or the fear of having one’s sexual orientation discovered.

Knowledge of resources in the lesbian/bisexual community was significantly correlated with subjective binge eating. Specifically, less knowledge about the resources available in the lesbian or bisexual community was associated with higher levels of subjective binge eating. Interaction with the lesbian/bisexual community and attitudes toward other lesbians approached significant positive correlations with subjective binge eating. Thus, the less interaction individuals had with the lesbian or bisexual community and the more negatively they felt toward lesbians, the more likely they were to engage in subjective binge eating. In line with the findings from Jones and Malson’s (2013) qualitative study of lesbian women with a history of disordered eating, developing connections with other lesbian and bisexual women may be an important factor in reducing the risk for eating disorder behaviors. Specifically, connecting with members of the sexual minority community may provide lesbian and bisexual women with opportunities to receive social support, dispute homophobic views, and develop a more positive lesbian or bisexual identity.

Depression and Shame as Mediators

Hypothesis 1 of our study suggested that depression and shame might mediate the relationships between the internalized homophobia variables and binge eating. Results from the mediation analyses did not support the hypothesis that depression mediates the relationship between the internalized homophobia variables and binge eating. In contrast, shame was found to be a significant mediator in several of the relationships between the internalized homophobia variables and subjective and objective binge eating.

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First, shame fully mediated the relationship between an individual’s personal feelings about being lesbian or bisexual and objective binge eating. Specifically, lesbian and bisexual women who reported negative feelings about being lesbian or bisexual reported higher amounts of objective binge eating because they experienced higher levels of shame. Shame partially mediated the relationship between personal feelings about being lesbian or bisexual and subjective binge eating. Thus, lesbian and bisexual women who reported more negative feelings about being lesbian or bisexual reported higher levels of subjective binge eating, in part due to experiencing higher levels of shame.

With regard to the degree to which an individual publicly identifies as lesbian or bisexual, its relationship with objective binge eating was fully mediated by shame and its relationship with subjective binge eating was partially mediated by shame. Thus, lesbian and bisexual women who experienced more fear about publicly identifying as lesbian or bisexual reported higher levels of subjective binge eating, in part due their experience of higher levels of shame. They reported higher levels of objective binge eating because they experienced higher levels of shame.

Shame also fully mediated the relationship between the degree to which an individual interacts with the lesbian or bisexual community and subjective binge eating and between the degree of knowledge one has about the resources available in the lesbian or bisexual communities and subjective binge eating. This suggests that lesbian or bisexual women who interact with the lesbian or bisexual community less often and have less knowledge about resources available in the lesbian and bisexual community report higher levels of subjective binge eating because they are experiencing higher levels of shame.

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Distress Tolerance as a Moderator

Given the significant mediation models discussed above, the possibility that distress tolerance would moderate the shame and binge eating relationship in the mediation models (i.e., Hypothesis 2) was tested. Previous research has suggested that people who binge eat may be more apt to cope with emotions in an ineffective manner

(e.g., Fassinger, Piero, Gramaglia, & Abbate-Daga, 2004; Heatherton & Baumeister,

2001; Spoor et al., 2007). Previous research has found sexual minority adolescents to report greater difficulty with emotion regulation than heterosexual adolescents

(Hatzenbuehler, McLaughlin, & Nolen-Hoeksema, 2008). Lesbian women have also been found to report binge eating as a means to regulate affect (Heffernan, 1996). Distress tolerance may play a role in one’s ability to regulate affect. Individuals who are not able to tolerate distress well may be more likely to become overwhelmed by negative affect and use binge eating as a way to escape the negative affective state (Anestis et al., 2011).

Results from the moderated mediation analyses revealed that distress tolerance was not a significant moderator in any of the mediation models. Thus, regardless of their ability to tolerate distress, individuals who reported higher levels of shame in relation to internalized homophobia also reported higher levels of binge eating.

Bivariate correlational analyses revealed that, outside of the moderated mediation model, distress tolerance was significantly and negatively correlated with shame, objective binge eating, and subjective binge eating. Individuals who were high in distress tolerance were less likely to report high levels of shame. Thus, distress tolerance may not have affected the shame and binge eating relationship in the mediation models because individuals with higher levels of distress tolerance are less likely to experience shame to

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begin with. It appears that distress tolerance may serve as a protective factor against experiencing shame and binge eating. However, it is also possible that experiencing lower levels of shame allows individuals to better tolerate distress.

The Association of “Outness” to Depression and Shame

In this study, we were also interested in associations between the degree to which lesbian and bisexual women are out about their sexual orientation (“outness”) and depression, shame, internalized homophobia, and distress tolerance. Results revealed that a higher degree of “outness” about one’s sexual orientation to family, friends, strangers, co-workers, and people in one’s religious community was associated with lower levels of depression and shame. This finding is consistent with previous research with gay men and lesbian women that found a greater degree of “outness” was associated with lower levels of psychological distress (Morris, Waldo, & Rothblum, 2001). Thus, “outness” about one’s sexual orientation may serve as a protective factor against depression and shame. However, given the bidirectionality of correlational relationships, it is also possible that depression and shame predict a lower degree of “outness.” Perhaps individuals who experience higher levels of depression and shame do not feel comfortable about being out about their sexual orientation because they feel more self- conscious about their sexual orientation or because disclosing their sexual orientation may put them at risk for being rejected or a target for homophobic violence.

The Association between “Outness” and Internalized Homophobia

Consistent with previous research, greater levels of internalized homophobia were associated with a lower degree of “outness” (Cox et al., 2011). Lesbian and bisexual women who reported a greater degree of “outness” about their sexual orientation to

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family, friends, strangers, and co-workers were more likely to publicly identify as lesbian or bisexual and openly disclose their lesbian or bisexual identity to others. Individuals who were less out about their sexual orientation were more likely to feel afraid of other people finding out about their sexual orientation and feel the need to “pass” as heterosexual by talking or looking like a heterosexual woman. Thus, a fear of others finding out about one’s sexual orientation may preclude being open to other people about one’s sexual orientation. As previously mentioned, lesbian and bisexual women may be fearful of possible negative consequences that could result from disclosing their sexual orientation, such as experiencing prejudice and discrimination at work, being cut-off from family members, and losing friends. Consequentially, they may view hiding their sexual orientation as being protective against such risks (Weber-Gilmore, Rose, &

Rubinstein, 2011).

Being out about one’s sexual orientation to family, friends, strangers, and co- workers was associated with greater interaction with the lesbian or bisexual community and having a greater awareness of the resources available in the lesbian or bisexual community. Balsam and Mohr (2007) also found greater levels of “outness” to be associated with a higher level of connection to sexual minority community organizations.

Individuals who are more connected with the lesbian or bisexual community may receive more social support with regard to their sexual orientation identity. This greater degree of support may lead these individuals to feel more confident about disclosing their sexual orientation to family members, friends, co-workers, and strangers. It is also possible that the relationship between “outness” and interaction with the sexual minority community works the other way. Specifically, lesbian or bisexual women may have to “come out”

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about their sexual orientation before they feel comfortable participating in sexual minority group community organizations (Balsam & Mohr, 2007).

Greater “outness” about one’s sexual orientation to family members, friends, co- workers, and strangers was associated with experiencing more positive feelings about being lesbian or bisexual. As mentioned above, a greater degree of “outness” about one’s sexual orientation may lead lesbian or bisexual women to develop more connections to the lesbian or bisexual community. This increase in supportive interactions regarding their sexual orientation might provide more opportunities to dispute homophobic views and allow them to feel more positive about their lesbian or bisexual identity as a result

(Chow & Cheng, 2010). On the other hand, it is possible that, in order to feel comfortable enough to “come out” about their sexual orientation, lesbian and bisexual women must first develop more positive feelings about their sexual orientation identity.

“Outness” to members of one’s religious organization was not associated with any of the internalized homophobia variables. Not all of our participants reported having relationships with members of a religious organization. These participants were not included in the analysis investigating the relationship between internalized homophobia and “outness” to religion. It is possible that individuals who experience greater levels of internalized homophobia are less likely to associate with a religious community, perhaps due to a fear of being persecuted for their sexual orientation. This is merely speculation; the difference in levels of internalized homophobia between participants who reported versus did not report being affiliated with a religious organization was not analyzed. It is just as possible that individuals in our study were not out about their sexual orientation to

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members of their religious community regardless of their levels of internalized homophobia.

The Association of “Outness” with Distress Tolerance

“Outness” was positively correlated with distress tolerance. Thus, participants who were better able to tolerate distress were more likely to be out about their sexual orientation. In contrast, those who were less able to tolerate distress were less likely to be out about their sexual orientation. Individuals with higher levels of distress tolerance may be more likely to be out about their sexual orientation because they feel confident in their ability to tolerate any distress that may result from disclosing their sexual orientation to others. As previously mentioned, fearing negative consequences that may result from coming out about one’s sexual orientation may inhibit lesbian and bisexual women from disclosing their sexual orientation to other people (Weber-Gilmore et al., 2011). This may be particularly relevant for lesbian and bisexual women with low distress tolerance who may not feel confident in their ability to cope with distress resulting from such negative consequences. Concealing one’s sexual orientation may also interfere with emotion regulation abilities, such as the ability to tolerate distress, by depleting available coping resources such as social support (Pachankis, 2007; Ross & Rosser, 1996).

Differences between Lesbian and Bisexual Women

The results of our study revealed several differences between lesbian and bisexual women that deserve further discussion. Our finding that lesbian and bisexual women did not differ with regard to the frequency of binge eating is consistent with previous findings

(Feldman & Meyer, 2007; Strong et al., 2000); however, some studies have found bisexual women to be at a higher risk for eating disorder behaviors than lesbian women

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(e.g., Koh & Ross, 2006). Lesbian and bisexual women differed with regard to the degree to which they were out about their sexual orientation. Consistent with previous research, bisexual women were less likely to be out about their sexual orientation than were lesbian women (Balsam & Mohr, 2007; Morris et al., 2001; Rosario et al., 2001). Balsam and

Mohr (2007) suggested factors that may explain this difference. First, if bisexual women have a male romantic partner, people may assume that they are heterosexual. Thus, they cannot disclose their sexual orientation through having a same-sex partner and may find disclosing their bisexual sexual orientation as awkward or irrelevant. Second, bisexual individuals may experience a higher level of stigma compared to lesbian and gay individuals (Herek, 2002 cited in Balsam & Mohr, 2007). Thus, disclosure of their bisexual sexual orientation may put them at risk of having stereotypes about bisexuality

(e.g., the assumption that bisexual individuals are non-monogamous) applied to them or being rejected by both heterosexual and homosexual friends. Third, some people may question whether bisexuality exists. Thus, bisexual individuals may avoid disclosing their sexual orientation to avoid having to defend the validity of their sexual orientation to others. Additionally, Weber-Gilmore et al. (2011) suggested that bisexual individuals who disclose their sexual orientation may experience pressure from lesbian or gay friends to adopt a homosexual lifestyle and pressure from heterosexual friends to adopt the heterosexual lifestyle.

Consistent with previous research, bisexual women were less likely than lesbian women to interact with the lesbian or bisexual communities (Balsam & Mohr, 2007;

Rosario et al., 2001). Bisexual women also had less knowledge about resources available in the lesbian or bisexual community than lesbian women. Bisexual women may not

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attempt to connect with the sexual minority community (through interaction or through knowledge of resources available in the community) if they do not perceive the lesbian community as being accepting of bisexuality or if there is not an established community for bisexual individuals. Balsam and Mohr (2007) suggested that the lower likelihood of bisexual women being connected to sexual minority communities may be due to there being fewer community organizations geared toward bisexual individuals than there are for lesbian and gay individuals. They also suggested that the risk of being stigmatized because of their sexual orientation or rejected by lesbian and gay individuals may prevent bisexual individuals from participating in sexual minority organizations, even if there is the possibility of receiving social support.

Lesbian and bisexual women did not differ with regard to their personal feelings about their sexual orientation identity. Balsam and Mohr (2007) also found lesbian and bisexual to not differ with regard to internalized homonegativity (i.e., the degree to which lesbian or bisexual women internalized negative societal beliefs about homosexuality and felt negatively about their sexual orientation identity). Lesbian and bisexual women also did not differ in their attitudes toward other lesbian women. In contrast to these findings,

Rosario et al. (2001) found that lesbian women, compared to bisexual women, were more comfortable with and had more positive attitudes about homosexuality.

Consistent with previous research, bisexual women reported higher levels of depression and shame than lesbian women (Maloch, Bieschke, McAleavey, & Locke,

2013). This may be a result of not feeling like they have a support group within the sexual minority community or feeling stigmatized by the lesbian and heterosexual communities (Herek et al., 1997; Lehavot, Balsam, & Ibrahim-Wells, 2009). As found in

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our study, less connection to the lesbian or bisexual community was associated with higher levels of depression and shame.

Implications for Therapists

These results provide insight into how mental healthcare workers may be able to help reduce binge eating in lesbian and bisexual women. Given shame’s role as a mediator in the relationship between internalized homophobia and binge eating, the reduction of internalized homophobia and shame may be an important goal for therapy when working with lesbian and bisexual women who binge eat. To help lesbian and bisexual women develop a more positive identity and decrease shame, it is recommended that therapists provide a supportive and accepting environment where lesbian and bisexual women feel safe to explore feelings of shame about their sexual orientation identity, how shame promotes fear about disclosing their sexual orientation, and how shame prevents them from connecting to the lesbian or bisexual communities (Pachankis,

2007; Weber-Gilmore et al., 2011).

Therapists could also talk with lesbian and bisexual women about stress and disconnection from others that may result from concealing their sexual orientation. One way to develop a positive lesbian or bisexual identity is through social support. The coming out process is important for gaining social support because doing so provides the chance to disprove stigma and feel accepted. Indeed, greater social support has been found to be associated with less internalized homophobia (Szymanski & Kashubeck-

West, 2008). Thus, therapists could help lesbian and bisexual women identify people in their lives to whom they would feel safe disclosing their sexual orientation.

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Therapists could also help lesbian and bisexual women connect to the sexual minority community. By having a greater connection to the lesbian and bisexual communities, lesbian and bisexual women may see the positive attributes of the sexual minority community, dispute society’s homophobic views, feel more supported in the development of their sexual orientation identity and the coming out process, and experience less depression and shame as a result. Indeed, having a fear of disclosing one’s sexual orientation and trying to “pass” as heterosexual were associated with higher levels of depression and shame in our study. Ways for lesbian and bisexual women to connect to the sexual minority community include participation in LGB support groups,

LGB chat rooms, LGB list-servs, LGB community centers, or LGB-sponsored events

(Pachankis, 2007; Weber-Gilmore et al., 2011).

“Coming out” can be major source of stress. Negative consequences of disclosing one’s sexual orientation can include loss of friendships, family conflict or rejection, discrimination at work, or violence. On the other hand, not “coming out” can mean that a lesbian or bisexual woman will not be able to be her genuine self and may have to maintain social and emotional distance from the people she loves in order to prevent her sexual orientation from being revealed (Weber-Gilmore et al., 2011). Thus, when discussing the “coming out” process with a lesbian or bisexual woman, it is important to consider contextual factors that may affect how beneficial disclosure and connection to the sexual minority community may be. The geographical region in which lesbian or bisexual women live, the degree of social support they have available, their work environments, membership in different racial or ethnic groups, and family situations will

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likely influence how safe and comfortable they feel about disclosing their sexual orientation (Weber, 2008).

Our results suggest that being mindful of differences in the experiences of lesbian and bisexual women may better inform assessment of a client’s concerns and alert clinicians to important areas to address in treatment (Maloch et al., 2013). Compared to lesbian women, bisexual women may be less likely to disclose their sexual orientation and more likely to experience depression and shame as a result of experiencing discrimination and invalidation from both the lesbian and heterosexual communities.

Disclosure of their sexual orientation may be difficult because bisexual women may not have identified a community that has shared experiences and personal understandings of their sexual orientation identity. This lack of connection and invalidation of their bisexual identity may contribute to the higher levels of depression and shame and to the lower levels of “outness” seen in the bisexual community. Helping bisexual women connect to a bisexual-inclusive community group is recommended.

Strengths and Limitations

Several limitations to this study should be considered. Given the differences found between lesbian and bisexual women with regard to depression, shame, and internalized homophobia, the role that depression and shame play as a mediator in the internalized homophobia and binge eating relationships may differ between lesbian and bisexual women. Perhaps more of the mediation models would have been significant for a larger sample of bisexual women, given that they reported higher levels of depression, shame, and internalized homophobia. These differences point to the importance of investigating the experiences of lesbian and bisexual women separately in future studies

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rather than combining them into one group. Findings from research on lesbian women should not be generalized to bisexual women, and vice versa.

There are also a few limitations to the methodology of our study that are important to note. First, the cross-sectional nature of our data collection limits the conclusions that can be made. Although many interesting associations between depression, shame, internalized homophobia, binge eating, “outness,” and distress tolerance were found, causation cannot be determined from these relationships. Further research using longitudinal designs is needed to examine causal effects of internalized homophobia, depression, and shame on binge eating.

Second, computer-based assessments, such as those used in our study, may be less precise than interview-based methods in that participants may misunderstand questions that are asked. For example, we did not explicitly ask participants to provide a numerical value for the number of binge episodes they engaged in. As a result, not all participants provided a precise numerical value for the number of binge episodes they experienced.

Some participants reported that they binged “every day.” To address this, we entered the number 28 to represent binge eating “every day” given that the questionnaire asked about binge eating episodes over the past 28 days. It is possible that these individuals binged more than once each day; thus, 28 binge episodes would not have been an accurate estimate for what they meant by “every day.” Our results may have been different had those participants used a numerical value. An interview-based method would allow the interviewer the chance to gather more information and to explain questions that a participant misunderstood. For example, an interviewer could have asked for further clarification about what “every day” meant.

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There are benefits to using computer-based assessments over interviews. For example, participants may be more willing to share sensitive information and less likely to respond in a way that is considered socially appropriate when using a computer than when directly speaking with an interviewer, particularly when their responses are completely anonymous, as they were in our study. For example, it might be more difficult for a lesbian woman to share that she dislikes other lesbian women with an interviewer than on an anonymous computer questionnaire because she might worry that the interviewer would judge her negatively.

Another limitation to our measure of the frequency of binge eating episodes is that participants’ memory for the past month may not be accurate, as it could be subject to forgetting. Their memory for the frequency of binge eating episodes over a shorter period of time, such as the past week or over a typical week, may have been more accurate.

The fact that our sample came from the community rather than being a college sample and ranged from 19 to 69 years of age suggests that our results are better able to be generalized to the overall population. However, our sample primarily identified as

Caucasian, and we do not know where participants were from. Thus, caution should be used when generalizing our results to different ethnic groups or different areas of the world.

There is the possibility of selection bias in our sample given that our sample was nonrandom and was primarily recruited through LGB organizations. Individuals who are less comfortable sharing their sexual orientation or who experience higher levels of internalized homophobia may be less likely to participate in research or to be members of

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the LGB organizations we recruited from than those who are out about their sexual orientation or those who experience lower internalized homophobia. Thus, important information about these individuals may be missing from our study. There was variablility in the degree of connection that our participants had to the LGB community; thus, some participants may have been recruited by word-of-mouth.

There was no way of knowing how many people viewed our solicitation for participation. Thus, the response rate for participation could not be calculated. As a result, we do not know what motivated our participants to respond to our study or how they differed from people who did not respond or did not receive the solicitation.

Recommendations for Future Research

Results from our study corroborate previous findings that depression and shame are associated with both binge eating and internalized homophobia. To our knowledge, this is the first study that has found a significant relationship between internalized homophobia, shame, and binge eating in lesbian and bisexual women. Given the limited research on the relationship between internalized homophobia, shame, and binge eating, replication of our results is needed.

The finding that higher levels of internalized homophobia were associated with higher levels of binge eating suggests that internalized homophobia may play a significant role in disordered eating in the lesbian and bisexual population. Further evidence for the significance of internalized homophobia as a correlate of disordered eating has been found in previous research. For example, internalized homophobia has been found to correlate positively with factors associated with disordered eating (e.g., body shame and self-objectification; Haines et al., 2008). Thus, further investigation into

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the role that internalized homophobia plays in the range of eating disorder symptomology

(e.g., overconcern about weight, restriction of food intake) is recommended.

Although distress tolerance did not moderate the relationship between shame and binge eating in the mediation models, it is possible that distress tolerance has an effect on the relationship between internalized homophobia and shame in the mediation models.

Specifically, individuals who are better able to tolerate distress may be less likely to experience shame resulting from internalized homophobia. Although it was beyond the scope of the current study, future analyses of our data could investigate whether this effect is present.

As mentioned above, our method of measuring the frequency of binge eating had some limitations. Future studies should better specify to participants that they provide an exact number of binge eating episodes or use an interview method to assess the frequency of binge eating episodes. Additionally, asking about their binge eating in an average week may have allowed for more accurate recall. Using an ecological model of assessment and having participants record their binge eating episodes right after they occur would also likely have provided more accurate results.

Conclusions

Perhaps the most important findings from our study are the associations of shame and internalized homophobia with binge eating. Our results suggest that shame resulting from internalized homophobia plays a prominent role in the occurrence of binge eating for lesbian and bisexual women. It is hard to avoid the stigma in society that suggests that homosexuality and bisexuality are unnatural, shameful, and something that can be changed. Thus, sexual minority individuals are left to figure out what to do with these

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heterosexist messages and how to navigate in a society that does not accept an aspect of their identity. This may be even more difficult for bisexual women, who may experience stigmatization about their bisexual identity from both the heterosexual and homosexual communities. Some lesbian and bisexual women may binge eat in an effort to escape the shame that results from their internalization of society’s homophobic and biphobic views.

There is good news. Becoming more knowledgeable about the resources available in the sexual minority community and interacting with other lesbian and bisexual women are associated with lower levels of shame and binge eating. Receiving social support from the sexual minority community may provide opportunities to dispute heterosexist views and develop a positive lesbian or bisexual identity.

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Wallis D. J., & Hetherington, M. M. (2009). Emotions and eating: Self-reported and experimentally induced changes in food intake under stress. Appetite, 52, 355– 362. doi:10.1016/j.appet.2008.11.007 Weber, G. N. (2008). Using to numb the pain: Substance use and abuse among lesbian, gay, and bisexual individuals. Journal of Mental Health Counseling, 30, 31-48. Retrieved from EBSCOhost. Weber-Gilmore, G., Rose, S., & Rubinstein, R. (2011). The impact of internalized homophobia on outness for lesbian, gay, and bisexual individuals. The Professional Counselor: Research and Practice, 1, 163-175. Retrieved from EBSCOhost. Wells, G. B., & Hansen, N. D. (2003). Lesbian shame. Journal of Homosexuality, 45, 93- 110. doi: 10.1300/Jo82v45n01_05 White, B. A., & Turner, K. (2014). Anger rumination and effortful control: Mediation effects on reactive but not proactive aggression. Personality and Individual Differences, 56, 186-189. doi:10.1016/j.paid.2013.08.012 Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T., & Larimer, M. (2007). Difficulties regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect? Eating Behaviors, 8, 162-169. doi:10.1016/j.eatbeh.2006.04.001 Wichstrom, L. (2006). Sexual orientation as a risk factor for bulimic symptoms. International Journal of Eating Disorders, 39, 448-453. doi 10.1002/eat Wichstrom, L., & Hegna, K. (2003). Sexual orientation and suicide attempt: A longitudinal study of the general Norwegian adolescent population. Journal of Abnormal Psychology, 112, 144-151. doi: 10.1037/0021-843X.112.1.144 Wild, B., Quenter, A., Friedrich, H., Schild, S., Herzog, W., & Zipfel, S. (2006). A course of treatment of binge eating disorder: A time series approach. European Eating Disorders Review, 14, 79-87. doi:10.1002/erv.673 Wilfley, D. E., Bishop, M. E., Wilson, G. T., & Agras, W. S. (2007). Classification of eating disorders: Towards DSM-V. International Journal of Eating Disorders, 40, S123–S129. doi:10.1002/eat.20436 Williamson, I. (1999). Why are gay men a high risk group for eating disturbance? European Eating Disorders Review, 7, 1-4. doi:10.1002/(SICI)1099- 0968(199903)7:1<1::AID-ERV275>3.0.CO;2-U Williamson, I., & Hartley, P. (1998). British research into the increased vulnerability of young gay men to eating disturbance and body dissatisfaction. European Eating Disorders Review, 6, 160-170. doi: 10.1002/(SICI)1099- 0968(199809)6:3<160::AID-ERV252>3.0.CO;2-H

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Williamson, I., & Spence, K. (2001). Towards an understanding of risk factors for eating disturbance amongst gay men. Health Education, 101, 217-227. doi: 10.1108/EUM0000000005645. Wilson, G. T., & Sysko, R. (2009). Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: Diagnostic considerations. International Journal of Eating Disorders, 42, 603–610. doi:10.1002/eat.20726 Worthington, R. L., & Reynolds, A. L. (2009). Within-group differences in sexual orientation and identity. Journal of Counseling Psychology, 56, 44-55. doi: 10.1037/a0013498 Zietsch, B. P., Verweij, K. H., Heath, A. C., Madden, P. F., Martin, N. G., Nelson, E. C., & Lynskey, M. T. (2012). Do shared etiological factors contribute to the relationship between sexual orientation and depression? Psychological Medicine, 42(3), 521-532. doi:10.1017/S0033291711001577

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Appendix A

Expanded Literature Review

This section is an expansion of the topics covered in my dissertation. First, the diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge eating disorder will be reviewed and comparisons between these eating disorders will be discussed. Then, factors that may play a causal role in binge eating will be discussed. Such factors include negative affect, shame, difficulties with emotion regulation, society’s thin ideal for women’s bodies, and body dissatisfaction. Finally, the role that these causal factors, as well as causal factors more specific to lesbian and bisexual women (e.g., minority stress), may play in the occurrence of binge eating in lesbian and bisexual women will be explored.

Eating disorder diagnoses and prevalence rates

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders

(DSM-5) describes someone with anorexia nervosa (AN) as (1) restricting energy intake to the point that one’s body weight is significantly low given one’s age, sex, developmental trajectory, and physical health, (2) having an “intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight” (p. 171), and (3) having a skewed perception of one’s body shape or size, overvaluing body weight or shape in one’s self-evaluation, or denying that one’s weight is dangerously low. Further, there are two subtypes of AN: one that involves only restricting food intake for at least 3 months (restricting type) and one that involves binge eating and purging behaviors for at least 3 months (binge- eating/purging type; Desk reference to the diagnostic criteria from DSM-5™, 2013).

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Prevalence rates of AN in the general population are around .9% for women and .3% for men (Hudson, Hiripi, Pope, & Kessler, 2007).

According to the DSM-5, bulimia nervosa (BN) involves recurrent binge eating and inappropriate compensatory behaviors (e.g., vomiting, excessive exercise, fasting) aimed at avoiding weight gain, as well as overvaluation of weight and shape in one’s self- evaluation. The DSM-5 defines binge eating episodes as “eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances”

(p.172). There is “a sense of lack of control over eating during the episode (e.g., feeling that one cannot stop eating or control what or how much one is eating)” (p. 72). These episodes of binge eating and compensatory must not occur during an episode of AN

(Desk reference to the diagnostic criteria from DSM-5™, 2013). The twice per week criteria for the frequency of binge episodes and compensatory behaviors in the DSM-IV-

TR (American Psychiatric Association [APA], 2000), was changed to once per week in the DSM-5. Prevalence rates for BN in the general population, based on the diagnostic criteria from the DSM-IV-TR, are 1.5% for women and .5% for men (Hudson et al.,

2007). In a sample of adolescent girls, lifetime prevalence of BN (based on the DSM-5 criteria) by the age of 20 years was 2.6% (Stice, Marti, & Rohde, 2013).

Binge eating disorder (BED) is similar to BN in that both disorders involve the occurrence of binge episodes; however, individuals with BED do not regularly engage in inappropriate compensatory behaviors to avoid weight gain from their binge episodes, and overvaluation of weight and shape is not included in the diagnostic criteria (although research suggests that overvaluation of weight and shape may be a relevant indicator of

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the severity of BED in individuals meeting criteria for the disorder; Grilo et al., 2008). In addition to recurrent binge eating episodes, the DSM-5 requires that three or more of the following features be associated with the binge eating episode: “eating much more rapidly than usual, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or very guilty afterward” (p. 174). The binge eating must also be associated with marked distress in the individual. On average, the binge eating must occur at least once per week for 3 months.

Finally, the binge eating cannot only occur during episodes of AN or BN (Desk reference to the diagnostic criteria from DSM-5™, 2013). In a non-clinical sample of people ages

18 years and older, the prevalence of BED was around 3.6% in women and 2.1% in men

(Hudson, Coit, Lalonde, & Pope, 2012). The lifetime prevalence of BED by the age of 20 years in a sample of adolescent girls was 3.0% (Stice, Marti, & Rohde, 2013).

Differences between the eating disorder diagnoses (AN, BN, and BED)

Overall, BED is more common than AN and BN, has a later age of onset, longer duration, and occurs in a more diverse population, with more ethnic minority groups meeting criteria for BED and less of a gender difference (Hudson et al., 2007).

Individuals with BED are more likely to be obese and experience weight fluctuations than individuals with AN or BN (Santonastaso, Ferrara, & Favaro, 1999; Striegel-Moore

& Franko, 2003; Striegel-Moore et al., 2001; Sullivan, 2001; Vervaet, van Heeringen, &

Audenaert, 2004), whereas AN is associated with being underweight (Hudson et al.,

2007).

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There are also differences in eating behavior for individuals with different eating disorder diagnoses. Individuals with AN report high levels of disinhibition of eating, restrained eating, and concern about eating, individuals with BN experience high dietary restriction and disinhibition of eating, and individuals with BED experience high disinhibition levels coupled with low dietary restriction (i.e., chaotic eating along with little dietary restraint), and report lower disinhibition and restraint than AN and BN

(Ardovini, Caputo, Todisco, & Grave, 1999; Crow, Agras, Halmi, Mitchell, & Kraemer,

2002; Santonastaso, Ferrara, & Favaro, 1999; Vervaet, van Heeringen, & Audenaert,

2004). The finding that individuals with BED report less restrained eating may be due to low persistence (i.e., being unable to continue to restrain eating when faced with temptation; Vervaet et al., 2004). The disorders do not differ in frequency of binge eating and impulsivity (Santonastaso, Ferrara, & Favaro, 1999). Both individuals with BED and individuals with BN experience psychological distress before and after binge eating; however, the hedonic effect of food intake during a binge episode appears to be stronger for individuals with BED, as they are more likely to report having enjoyed food while they ate, more likely to feel relaxed after binge eating, and less likely to experience discomfort or anxiety after binge eating than individuals with BN (Mitchell et al., 1999).

Diagnostically, BED differs from BN in that individuals with BED do not regularly engage in compensatory behaviors (APA, 2013). Indeed, research has shown that individuals with BN report significantly more episodes of compensatory behaviors than individuals with BED, who usually do not report engaging in any compensatory behaviors (Sullivan, 2001). Individuals with BN are significantly more likely to have a history of AN than individuals with BED, who typically do not show a history of AN

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(Santonastaso, Ferrara, & Favaro, 1999; Sullivan, 2001). Although individuals with BN tend to report a higher drive for thinness than individuals with BED, they do not differ in levels of shape and weight concerns, even when controlling for BMI (Latner & Clyne,

2008). Dieting plays a more prominent role in the onset of BN than BED, with most individuals with BN reporting the onset of dieting occurring before the onset of the disorder whereas individuals with BED show a more equal probability of binge eating versus dieting occurring before the onset of the disorder (Santonastaso, Ferrara, &

Favaro, 1999).

Causal models for disordered eating

Negative affect. Research has consistently indicated a link between negative affect and binge eating. In a series of prospective studies of adolescent girls, Stice and colleagues found negative affect, depressive symptoms, emotional eating (i.e., the tendency to eat in response to emotions), and low self-esteem to predict the onset of and future increases in binge eating and compensatory behaviors (e.g., Presnell, Stice, Seidel,

& Madeley, 2009; Stice, 2001; Stice & Agras, 1998; Stice, Killen, Hayward, & Taylor,

1998; Stice, Presnell, & Spangler, 2002). Further, research has found that bulimic symptoms predict future depressive symptoms (Presnell, Stice, Seidel, & Madeley, 2009;

Stice & Bearman, 2001), although this result has not been consistently found (Spoor et al., 2006). Bulimic symptoms may result in feelings of shame and guilt, and increased rumination about one’s inability to control food intake, which may result in depressive symptoms (Presnell et al., 2009).

In addition to depressive symptoms, stress also appears to predict binge eating.

Pendleton et al. (2001) investigated the effect of negative stress on treatment outcome in

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a sample of obese patients with BED by comparing the experience of negative stress to the frequency of binge eating at pre-treatment, post-treatment, and 6-month follow-up.

Pendleton et al. (2001) found that patients who experienced high levels of negative stress reported a frequency of binge eating three times greater than that experienced by those who reported low levels of negative stress. Negative stress also predicted treatment outcome by increasing the amount of time it took individuals to reduce the frequency of binge eating.

Stice, Presnell, & Spangler (2002) did not find support for anxiety or anger precipitating the onset of binge eating. The authors suggested that the sympathetic arousal occurring during episodes of anxiety and anger may have suppressed eating.

Alternatively, anxiety may have a more remote effect on binge eating. For example, a single-subject time-series study of an individual undergoing treatment for BED found anxiety on one day to predict the likelihood of binge eating on the next day, whereas depression predicted eating behavior on the same day (Wild et al., 2006).

Ecological Momentary Assessment (EMA) studies have found that individuals with binge eating disorder (BED) report negative affect both preceding and following binge eating, and they report the greatest impairment in mood following binge eating.

Further, these studies have found that hunger and negative affect are significantly greater immediately before binge eating than prior to regular eating (Hilbert &Tuschen-Caffier,

2007; Stein et al., 2007).

Overall, binge eating episodes do not appear to alleviate negative affect since mood remains poor afterward; however, they may temporarily improve mood while binge eating is occurring. For example, Deaver, Miltenberger, Smyth, Meidinger, and Crosby

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(2003) found that binge eaters experienced an increase in pleasantness during binge eating followed by a decrease in pleasantness after the binge episode. The increase in pleasantness during binge eating suggests that the binge provided relief from negative mood; however, the relief was temporary since pleasantness decreased after the binge

(Deaver et al., 2003). To sum up, it appears that binge eating is an ineffective method used to reduce negative mood, although it might temporarily increase feelings of pleasantness.

Emotion regulation. The finding that bulimic symptoms do not predict decreases in negative affect could be explained by a third variable. One possibility is that the negative affect-binge eating relationship is due to emotion regulation difficulties, which are often found to be present in individuals with eating disorders (e.g., Bydlowski et al.,

2005; Sim & Zeman, 2005). In line with some of the naturalistic studies on the relationship between binge eating and mood, binge eaters may be prone towards using ineffective strategies to cope with emotions, particularly using binge eating as a maladaptive coping strategy to temporarily reduce or avoid negative emotions.

Compensatory behaviors (e.g., vomiting, fasting, or excessive exercise) may then be used to reduce anxiety caused by a fear of gaining weight from a binge episode (Heatherton &

Baumeister, 1991).

The presence of emotion regulation difficulties and the use of ineffective emotion regulation strategies (e.g., emotion-oriented coping, distraction and avoidance coping, substance use, ruminative thinking) are associated with binge eating, purging, and emotional eating (i.e., the tendency to eat in response to emotions; Bydlowski et al.,

2005; Fassino, Piero, Gramaglia, & Abbate-Daga, 2004; Heatherton & Baumeister, 1991;

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Kubiak, Vogele, Siering, Schiel, & Weber, 2008; Schwarze, Oliver, & Handal, 2003;

Whiteside et al., 2007). Self-report studies have consistently found that individuals who have the tendency to eat in response to emotions (emotional eaters) are more likely to binge eat than those who do not eat in response to emotions, who tend to eat normally or less when experiencing negative affect (Eldredge & Agras, 1996; Masheb & Grilo, 2006;

Ricca et al., 2009; Wallis & Hetherington, 2009). Of note, however, Wallis and

Hetherington (2009) found that some non-emotional eaters reported overeating after a stress induction, which suggests that there may be other factors influencing whether individuals overeat in response to stress (Wallis & Hetherington, 2009).

One other factor that may contribute to eating in response to emotions is alexithymia, or having difficulty with identifying and making sense of emotions.

Alexithymia has been found to contribute to the association between negative affect and binge eating (Whiteside et al., 2007). Alexithymia may make it difficult to choose an effective emotion regulation strategy, thus the more pervasive and longer-lasting negative mood states experienced by binge eaters may be due to not knowing how to improve their mood (Whiteside et al., 2007). Alexithymia has been found to predict emotional eating in individuals with BED, suggesting that, when experiencing a negative mood state, they are not able to make sense of what they are feeling and use eating as a means to deal with the discomfort caused by the negative mood (Pinaquy, Chabrol, Simon, Louvet, & Barbe,

2003).

In addition to alexithymia, poor interoceptive awareness (i.e., the inability to distinguish internal cues, such as confusing appetite or hunger cues with feelings of emotion) has been found to play a role in disordered eating. For example, Davis and

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Jamieson (2005) found binge eaters who experienced reduced negative affect and increased positive affect after binge eating reported lower levels of interoceptive awareness than individuals who did not experience a change in mood after binge eating.

Also, interoceptive awareness has been found to mediate the relationship between negative mood and emotional eating in women with eating disorders (Van Strien, Engels, van Leeuwe, & Snoek, 2005). This means that negative mood results in emotional eating, at least in part, due to an inability to distinguish the emotional experience from sensations of hunger and satiety.

Distress tolerance. Emotional distress tolerance is another factor associated with emotion regulation difficulties that has been linked to bulimic behaviors. Emotional distress tolerance involves one’s perception of “negative emotional experiences in terms of his or her (1) appraisals of the negativity and/or threat value of negative emotions, (2) beliefs regarding his or her coping ability in a given negative emotional situation, and (3) resulting willingness to experience negative emotions” (Clen, Mennin, & Fresco, 2011, p.152). Low distress tolerance, or finding negative affect to be aversive, unbearable, difficult to tolerate, and difficult to cope with (i.e., distress intolerance), can lead individuals to avoid directly and effectively coping with negative affect (Anestis, Fink,

Smith, Selby, & Joiner, 2011). Distress tolerance has been found to be associated with disorders involving impulsivity, undercontrol of behavior, and emotional dysregulation

(e.g., borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders; Lynch & Mizon, 2011). Lynch and Mizon (2011), using a behavioral conceptualization of distress tolerance, suggested that behaviors associated with intolerance of distress (e.g., self-injury, binge eating) are temporarily reinforced

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through the reduction of aversive tension, regardless of later consequences of that behavior. This model is in line with Heatherton and Baumeister’s (1991) escape model of disordered eating behaviors; an individual with low distress tolerance may binge eat to escape the discomfort caused by negative affective states (Anestis et al., 2011).

Individuals with low distress tolerance may be more likely to become overwhelmed by less severe experiences of negative affect (i.e., more sensitive to emotional stimuli) than individuals with moderate or high distress tolerance (Lynch & Mizon, 2011); thus they may more frequently become overwhelmed by experiences of negative affect. These individuals may then attempt to use coping strategies that could quickly reduce aversive emotional states (e.g., binge eating; Anestis et al., 2011).

Although both individuals with BN and BED report higher negative affect before and after binge eating episodes than regular eating, individuals with BED have been found to report less negative affect before binge eating (Hilbert &Tuschen-Caffier, 2007).

This may indicate that individuals with BED have lower distress tolerance than individuals with BN, finding even moderate levels of negative affect unbearable, and are more likely to binge eat in response to a wider range of negative affective experiences and intensities (Anestis et al., 2011).

Shame. Shame involves an evaluation of one’s entire self as being bad or flawed, and it may manifest as shame about specific aspects of the self (e.g., shame about one’s body weight or shape; Sanftner, Barlow, Marschall, & Tangney, 1995). Research has found that shame and shame-proneness are associated with disordered eating, including bulimic symptoms, and difficulties with impulse regulation in samples of presumably heterosexual women (Sanftner et al., 1995; Sanftner & Crowther, 1998; Gee & Troop,

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2003; Troop, Allan, Serpeli, & Treasure, 2008). For example, women who binge eat report greater fluctuations in and higher levels of shame than women who do not binge eat (Sanftner & Crowther, 1998). However, some research has found that shame associated with eating and body-related shame are more closely associated with the severity of disordered eating attitudes than is a more global conceptualization of shame- proneness (Burney & Irwin, 2000). These mixed findings suggest that women may differ with regards to the type of shame that relates to binge eating episodes, or that different types of shame relate to different symptoms of disordered eating (e.g., shame about body appearance may relate more to overconcern about body weight and shape, shame about eating may relate more to purge symptoms, and a global sense of shame may relate more to binge eating; Burney & Irwin, 2000).

The thin ideal and body dissatisfaction. In Western society an ideal involving thinness for women’s bodies exists, and the female body is sexually objectified (i.e., the female body being viewed and evaluated as a sexual object). Body dissatisfaction resulting from exposure to the thin ideal body shape for women and from sexual objectification of the female body has been suggested as a causal factor for disordered eating (e.g., binge eating, purging, and dietary restraint; Stice, 2001). Exposure to these cultural factors may lead women to tie some of their self-worth to their physical appearance, to evaluate their physical attractiveness based on the thin ideal, and to monitor their body and appearance in terms of the thin ideal (i.e., self-objectificaton;

Fredrickson & Roberts, 1997; Noll & Fredrickson, 1998). Failure to meet the thin ideal may lead women to feel dissatisfied with their bodies which may lead to psychological distress and eating disorder symptoms.

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Some researchers have suggested that, rather than general negative affect (e.g., depressive symptoms) leading to binge eating, negative affect resulting from dissatisfaction with and negative self-evaluation regarding one’s weight and shape may lead to binge eating (Pratt, Telch, Labouvie, Wilson, & Agras, 2001; Stice & Agras,

1998). Additionally, it has been suggested that body dissatisfaction could result in dietary restriction as a means to improve body shape and weight (Stice & Agras, 1998). In particular, Stice and Agras (1998) suggested a dual-pathway model of bulimic pathology where internalization of the cultural ideal for a thin body and pressure to be thin from family, peers, and the media lead to body dissatisfaction that results in two possible pathways to binge eating: dietary restraint or negative affect. They suggested that dietary restraint might bring about binge eating from the caloric deprivation brought on by dieting or from disinhibited eating resulting from breaking strict dietary rules.

Alternatively, binge eating could result from negative affect because, as discussed previously, it can provide distraction from or comfort for negative mood states. Finally, binge eating could result from both dieting and negative affect (Stice, 2001).

In a longitudinal investigation of a sample of adolescent girls, Stice (2001) found prospective evidence for most of the relationships in the dual pathway model. Pressure to be thin and internalization of the thin ideal predicted subsequent body dissatisfaction, and body dissatisfaction predicted subsequent dietary restraint and negative affect, both of which predicted binge eating. There was a marginally significant relationship between initial dieting and negative affect, which may be due to variability in whether binge eating vs. dieting behavior develops first. Evidence also suggested that internalization of the thin ideal and pressure to be thin could each result in dieting without initially leading

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to body dissatisfaction. For most of the sample, changes in dietary restraint occurred along with changes in negative affect. This suggests that both negative affect and dietary restraint were involved in binge eating, perhaps due to negative affect moderating the relationship between dietary restraint and binge eating (Stice, 2001).

Body dissatisfaction in lesbian and bisexual women. It is not clear how influential body dissatisfaction is on the development of eating disorder symptoms in lesbian women. Theorists suggest that lesbian women may be protected from societal pressure to be thin because the lesbian subculture rejects the importance of thinness in comprising a woman’s attractiveness and self-worth (Brown, 1987 cited in Heffernan, 1994; Guille &

Chrisler, 1999). Some studies have shown that lesbian women report lower body dissatisfaction than heterosexual women (Boehmer, Bowen, & Bauer, 2007; French et al.,

1996; Herzog et al., 1992). Lesbian women may also experience less pressure to fit the thin ideal in order to attract a romantic partner than heterosexual women due to body weight and shape being less important to lesbian women when choosing a romantic partner than it is for heterosexual men (Blumstein & Schwartz, 1983 cited in Heffernan,

1994; Heffernan, 1996; Herzog et al., 1992).

Also, lesbian women may be protected from societal pressure to be thin because they are more likely to identify as being feminist and to challenge or reject gender role expectations and traditional female beauty standards as a result. Lesbian women who report greater disordered eating attitudes (e.g., body dissatisfaction, drive for thinness) and behaviors (e.g., compulsive eating, disinhibition of eating) have been found to report less feminist identity (through the greater acceptance of traditional gender roles), whereas more commitment to feminist activism has been found to relate to less disinhibited

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eating, drive for thinness, and body dissatisfaction (Guille & Chrisler, 1999; Snyder &

Hasbrouck, 1996). Although lesbian women have been found to report less internalization of the thin ideal (Sharp & Mintz, 2002) and greater adoption of feminist attitudes (Guille & Chrisler, 1999) than heterosexual women, they do not differ on their awareness of the thin ideal (Sharp & Mintz, 2002), and lesbian women have been found to not take as critical of a feminist stance on cultural attitudes about weight and appearance (i.e., the thin ideal) as they do for traditional attitudes about women’s rights and gender roles (Heffernan, 1999).

Furthermore, some studies have found lesbian and heterosexual women to report similar amounts of body dissatisfaction (Beren, Hayden, Wilfley, & Grilo, 1996; Moore

& Keel, 2003; Stout, 2001; Wagenbach, 2003) and body esteem (Striegel-Moore, Tucker,

& Hsu, 1990), and bisexual and mostly heterosexual women appear to report similar levels of body dissatisfaction as exclusively heterosexual women (Polimeni, Austin, &

Kavanagh, 2009). For both heterosexual and lesbian women, self-objectification (i.e., greater body surveillance) has been found to relate to greater body shame due to the perception that one’s body does not meet the cultural thin ideal female body, which has been found to predict symptoms of disordered eating (Haines et al. 2008; Kozee & Tylka,

2006; Noll & Fredrickson, 1998). Also, lesbian and heterosexual women have been found to report similar amounts of weight and shape concerns (Heffernan, 1996; Sharp &

Mintz, 2002; Strong et al., 2000), with lesbians who reported greater internalization of the thin ideal experiencing more weight and shape concerns than those with less internalization of the ideal (Heffernan, 1996). Although both lesbian and heterosexual women report feeling less satisfaction with their bodies when they are a heavier weight

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than they would prefer, lesbian women’s dissatisfaction appears to begin at a heavier weight than it does for heterosexual women (Wagenbach, 2003), consistent with lesbian women being found to report a higher ideal weight than heterosexual women (Herzog et al., 1992).

Although it is possible that lesbian women are at a reduced risk for internalizing the societal thin ideal due to the more flexible standards of beauty that tend to be found in the lesbian community, these findings suggest that lesbian women are not immune to the societal thin ideal (Owens, Hughes, & Owens-Nicholson, 2003; Sharp & Mintz, 2002;

Strong et al., 2000). Lesbian and bisexual women probably do not get involved in the lesbian community or develop feminist ideals until later in their lives (e.g., after coming out about their sexual orientation). Thus, early on in life, they are exposed to the same thin cultural ideal as heterosexual women and likely internalize it to some degree. The internalization of this ideal may conflict with the feminist values of the lesbian subculture and cause dissonance and distress (Pitman, 1999).

Minority stress as a unique factor involved in disordered eating and distress in lesbian and bisexual women

As mentioned, the experience of negative stress, particularly associated with daily hassles, predicts binge eating. For lesbian and bisexual women, chronic stress due to stigma, discrimination, and victimization connected to being a sexual minority (i.e., sexual minority stress) may lead to psychological disturbances (e.g., low self-esteem, stress, lack of social support) and further risk of engaging in disordered eating behaviors

(Brown, 1987). Although societal attitudes toward sexual minorities have improved over time, lesbian and bisexual women live in a society where heterosexuality is the norm and

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where prejudice and discrimination towards and rejection of sexual minority groups remain prevalent (Huebner, Rebchook, & Kegeles, 2004 cited in Kelleher, 2009). GLB individuals report more experiences of discrimination than heterosexual individuals, and this discrimination, in part, accounts for the greater prevalence rates of psychological disturbances found in some GLB individuals compared to heterosexual individuals (Mays

& Cochran, 2001).

Minority stress occurs when members from a minority group experience discord between the expectations of society in general and their individual characteristics. For example, a lesbian woman’s desire for a romantic relationship with another woman would be in conflict with society’s promotion of heterosexual romantic relationships as the norm. The conflict between the lesbian woman’s desire and society’s norm may result in feelings of distress. The minority stress hypothesis suggests that, in addition to stressors experienced by people in general, members of minority groups experience chronic stressors associated with their minority status in society, which may result in negative psychological outcomes. These societal stressors are beyond the direct control of the individual, unlike more general stressors involved in daily life, and coping with them may require additional effort (Meyer, 2003). The ability to cope with minority stress would likely influence whether members of minority groups experience distress and negative health outcomes.

Meyer (1995) conceptualized the minority stress experienced by GLB individuals into three components: internalized homophobia (IH; internalizing society’s negative views on sexual minorities, discomfort with and avoidance of one’s homosexuality), perceived stigma (expectation of rejection and discrimination due to one’s sexual

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orientation), and heterosexist experiences (actual experiences of prejudice and discrimination due to one’s sexual orientation). Research suggests that internalized homophobia is the most powerful predictor of distress out of the three components of minority stress (Meyer, 1995).

Internalized homophobia has been found to be associated with psychological distress and several negative psychological outcomes in GLB individuals (Szymanski &

Kashubeck-West, 2008). These include: depression, suicidality, demoralization, shame, conflict or confusion about one’s sexual orientation, lower levels of sexual orientation disclosure, attempts to pass as heterosexual, a lack of social support, loneliness, traditional sex role attitudes, greater alcohol use, low self-esteem, body dissatisfaction, and eating disturbances (Allen & Oleson, 1999; Haines et al., 1998; Herek et al., 1997;

Kimmel & Mahalik, 2005; Meyer, 1995; Reilly & Rudd, 2006; Szymanski & Chung,

2003; Szymanski, Chung, & Balsam, 2001; Williamson & Hartley, 1998; Williamson &

Spence, 2001). Internalized homophobia has also been found to relate to the use of ineffective coping strategies (e.g., avoidant coping; Meyer & Dean, 1998).

Since GLB individuals live in a heterosexist society that invalidates their identities, internalized homophobia has been suggested as part of the development of sexual identity. Integrating one’s sexual orientation identity into one’s sociocultural context is an import step towards developing a healthy GLB identity, as internalized homophobia is associated with a weaker GLB identity (Ross & Rosser, 1996). In particular, rejection of antigay stereotypes is needed to develop a positive GLB identity, psychological well-being, and possibly a lower risk for eating disorder symptoms

(Herzog et al., 1992; Luhtanen, 2003).

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One way to develop a positive GLB identity is through social support. The

“coming out” process is important in gaining social support because it provides a chance to disprove stigma and feel accepted regardless of sexual orientation. Receiving social support from others and acceptance of one’s sexual minority status from heterosexual friends is associated with less internalized homophobia (Szymanski & Kashubeck-West,

2008). Furthermore, greater social support in general (i.e., not specifically related to sexual orientation) is associated with greater psychological well-being in bisexual women

(Sheets & Mohr, 2009) and lesbian women (Szymanski & Kashubeck-West, 2008).

Involvement in the lesbian community and feminism may also make it easier to develop a positive lesbian identity by providing opportunities to critically evaluate societal views of sexuality, social support, and affirmation of one’s identity, which should lessen internalized homophobia (Szymanski & Chung, 2003).

Internalized homophobia and eating disorder symptoms. Internalized homophobia is not always resolved and, as mentioned, can lead to negative psychological outcomes, including eating disorder symptoms. Lesbian women with higher levels of internalized homophobia have been found to report higher levels of body shame and self- objectification, which both relate to disordered eating (Haines et al., 2008). Wagenbach

(2003) found that lesbian women in earlier stages of sexual identity development, where they identify less with being lesbian, reported greater concerns with thinness and dieting than lesbian women in later stages of sexual identity development. On the other hand, stage of sexual identity development was not found to predict body dissatisfaction or bulimic symptoms (Wagenbach, 2003). As previously mentioned, this may be due to lesbian and bisexual women not being completely protected from the influence of the

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societal ideals of thinness and attractiveness. Even if lesbian and bisexual women become more involved in the lesbian community and develop a healthy lesbian or bisexual identity, they are still exposed to the traditional ideals that convey the message that being thin and beautiful is necessary for societal acceptance; therefore they may still be at risk for disordered eating (Heffernan, 1996). These ideals may push lesbian and bisexual women to strive to meet the feminine ideals in order to gain societal acceptance and avoid being derided or rejected, perhaps to compensate for their sexual orientation not meeting societal expectations (Brown, 1987).

Greater exposure to the lesbian or bisexual community and coming out to supportive people in their lives are associated with better psychological outcomes for lesbian and bisexual women (Morris, Waldo, & Rothblum, 2001; Rosario, Hunter,

Maguen, Gwadz, & Smith, 2001). Lesbian women with a history of anorexia nervosa or bulimia nervosa have reported that disclosing their sexual orientation to other people and connecting with lesbian women who were out about their sexual orientation were important to their recovery from disordered eating (Jones & Malson, 2013). Thus, connection to the lesbian or bisexual community and the process of coming out to other people about one’s sexual orientation appear to be important factors in lesbian and bisexual women’s experience of disordered eating.

Binge eating to regulate emotions resulting from minority stress. For lesbian and bisexual women who have difficulty coping with minority stress, binge eating may function as a way to regulate negative affect resulting from minority stress, perhaps as an escape from the negative self-awareness brought about by their stigmatized status. In a qualitative study of lesbian women with a history of anorexia nervosa or bulimia nervosa,

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some participants described their eating disorder behaviors as an attempt to avoid their lesbian identity that was emerging in a world where they were expected to conform to heterosexual norms (Jones & Malson, 2013).

Emotion regulation difficulties have been found to relate to minority stress, psychological distress, and eating disorder symptoms in GLB individuals. For example,

Hatzenbuehler, McLaughlin, and Nolen-Hoeksema (2008) found that sexual minority adolescents reported greater internalizing symptoms and emotion regulation difficulties than their heterosexual peers, and emotion regulation difficulties mediated the relationship between sexual minority status and symptoms of depression and anxiety.

Lesbian women have been found to report more difficulty with recognizing emotions compared to heterosexual women, which may be due to attempts to ignore feelings that are incongruent with the heterosexual norm (e.g., attraction to other women). Lesbian women also report a greater sense of ineffectiveness and negative self-evaluation, which might reflect internalization of the stigma associated with being a sexual minority.

Further, lesbian women report binge eating for affect regulation (Heffernan, 1996).

Emotion regulation deficits have also been found to mediate the relationship of implicit prejudicial attitudes (i.e., internalized homophobia) and stigma-related stressors to psychological distress. GLB individuals who reported more negative implicit self- stigmatization and the experience of more stigma-related stressors were more likely to use problematic emotion regulation strategies, such as avoidant coping, rumination, and suppression, and experienced greater levels of psychological distress (Hatzenbuehler,

Dovidio, Nolen-Hoeksema, & Phillis, 2009; Szymanski & Owens, 2008). Also, on days where stigma-related stressors occurred, GLB individuals have reported using more

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suppression and rumination emotion regulation strategies and obtained less social support than on days when no stressor occurred. Furthermore, rumination (“uncontrollable perseverant thinking about past or present events”; Kubiak, Voegle, Siering, Schiel, &

Weber, 2008, p. 206), but not suppression of emotions, mediated the relationship between experiencing a stigma-related stressor and psychological distress. Thus, the more GLB individuals engaged in rumination following discrimination, the greater psychological distress they experienced (Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009).

Emotion regulation problems may come about as a result of attempts to conceal one’s sexual orientation, perhaps due to internalized homophobia. This is because concealment of one’s sexual orientation may (1) interfere with emotion regulation by depleting coping resources and reinforcing the concealment of one’s feelings along with the inappropriateness they relate to their sexual orientation and (2) cut off social support, which is important for developing a positive GLB identity and coping with stigma

(Pachankis, 2007; Ross and Rosser, 1996)

Shame, negative affect, minority stress, and disordered eating. Shame may result from internalization of the negative stigma associated with being a sexual minority (i.e., internalized homophobia). As mentioned earlier, binge eating and purging occur in response to negative affect and are associated with the experience of internal shame.

Shame for people with eating disorders may be associated with different parts of themselves, including their body appearance, eating behaviors, purging behaviors, or their sexual identity (Goss & Allan, 2009). Heterosexual women who binge eat and purge may do so in response to negative affect and shame resulting from not meeting the thin ideal (i.e., body shame) or from eating (Burney & Irwin, 2000); however, lesbian and

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bisexual women may experience additional negative affect and shame due to the stigma of being considered different than the norm (i.e., through heterosexism and internalized homophobia).

Internalizing heterosexist societal norms (e.g., heterosexual marriage, economic benefits of marriage only being available to heterosexual couples, and religious condemnation of homosexuality) may lead lesbian and bisexual women to see themselves as inherently flawed, resulting in feelings of shame (Pitman, 1999). Shame about being attracted to individuals of the same sex may lead to shame about one’s self and one’s body. Experiencing shame and negative affect as a result of internalized homophobia may place lesbian and bisexual women at a greater risk for binge eating and purging in response to negative affect and shame (Beren et al., 1996). This may, in part, explain why some studies show that lesbian women report less internalization of the thin ideal than heterosexual women but still report binge and purge symptoms. They may still internalize the slender ideal as being representative of femininity, heterosexuality, social acceptance, and attractiveness, and also be exposed to and internalize the prejudice against people who are overweight or obese that is prevalent in society. Disordered eating may then result as a way to “compensate” for their sexual orientation (Pitman, 1999). Bisexual women may experience even more shame associated with their sexual orientation than lesbian women as they may experience rejection from both the heterosexual and lesbian communities due to not “picking a side” (Koh & Ross, 2006; Lehavot, Balsam, &

Ibrahim-Wells, 2009).

Allen and Oleson (1999) found internalized homophobia to be positively associated with internalized shame. They suggested that shame could play a mediating

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role in the relationship between internalized homophobia and psychological distress.

Lesbian women, gay men, and bisexual women and men have been found to report greater levels of internalized shame than heterosexual men and women (Wells, 1996 cited in Wells & Hansen, 2003), and lesbian women have been found to report levels of shame that come close to being clinically significant, particularly for lesbian women who have not integrated their sexual orientation into their identity (Wells & Hansen, 2003). Shame associated with internalized homophobia may also lead to attempts at concealing one’s sexual orientation, which, as discussed previously, may result in emotion regulation difficulties due to depletion of coping resources.

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Appendix B

Sexual Orientation Questionnaire

The following two questions are asked to assess how intensely you are sexually attracted to men and women. Consider times when you had sexual fantasies, daydreams, or dreams about a man or woman, or have been sexually aroused by a man or woman. 1. During the past year, the most I was sexually attracted to a man was (choose one

answer):

a. Not at all sexually attracted

b. Slightly sexually attracted

c. Mildly sexually attracted

d. Moderately sexually attracted

e. Significantly sexually attracted

f. Very sexually attracted

g. Extremely sexually attracted

2. During the past year, the most I was sexually attracted to a woman was (choose

one answer):

a. Not at all sexually attracted

b. Slightly sexually attracted

c. Mildly sexually attracted

d. Moderately sexually attracted

e. Significantly sexually attracted

f. Very sexually attracted

g. Extremely sexually attracted

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The following question is asked to assess your sexual identity.

1. How would you describe yourself as a person?

a. Gay/lesbian

b. Bisexual

c. Heterosexual

d. Other, namely

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Appendix C

Eating Disorder Exam Questionnaire (adapted)

Read this First:

Some questions ask about (1) eating what most people would regard as an unusually large amount of food and (2) feeling a sense of having lost control while eating.

1. An unusually large amount of food is more food than you usually eat, even for a large meal, and an amount of food that most people would consider to be more than a large meal.

2. A sense of having lost control while eating might be experienced as feeling driven or compelled to eat; not being able to stop eating once you have started; not being able to keep yourself from eating large amounts of certain kinds of food in the first place; or giving up on even trying to control your eating because you know that, no matter what, you are going to overeat.

1. Over the past four weeks (28 days), have there been times when you have eaten what other people would regard as an unusually large amount of food? Yes/no

a. If yes, how many such episodes have you had over the past 4 weeks?

b. During how many of these episodes of overeating did you have a sense of having lost control?

2. Over the past four weeks (28 days) have you had episodes of eating in which you have had a sense of having lost control but have not eaten an unusually large amount of food? Yes/no

a. If yes, how many of such episodes have you had over the past 4 weeks?

3. Over the past four weeks have you made yourself sick (vomit), taken laxatives, or taken diuretics (water tablets) to counteract the effects of binge eating? Yes/no

a. If yes, on how many days out of the last 28 days have you done any of those?

4. Over the past four weeks have you not eaten for 24 hours or more to counteract the effects of binge eating? Yes/no

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a. If yes, on how many days out of the last 28 have you done this?

5. Have you vigorously exercised to counteract the effect of binge eating? Yes/no

a. If yes, on how many days out of the last 28 have you done this?

6. Have the past four weeks been representative of the past year? Yes/no

a. If no, how has the past year differed from the past four weeks?

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Appendix D

Personal Feelings Questionnaire (PFQ-2)

For each of the following listed feelings, to the left of the item number, please place a number from 0 to 4, reflecting how common the feeling is for you.

4 = you experience the feeling continuously or almost continuously 3 = you experience the feeling frequently but not continuously

2 = you experience the feeling some of the time 1 = you experience the feeling rarely

0 = you never experience the feeling

1. embarrassment 2. feeling ridiculous 3. sadness 4. self-consciousness 5. feeling humiliated 6. euphoria 7. feeling "stupid" 8. feeling "childish” 9. mild happiness 10. feeling helpless, paralyzed 11. depression

12. feelings of blushing 13. feeling laughable 14. rage 15. enjoyment

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16. feeling disgusting to others

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Appendix E Lesbian Internalized Homophobia Scale (short-form, bisexual inclusive)

Short form LIHS (Bisexual Inclusive) Please indicate your agreement or disagreement with each of the following statements by writing in the appropriate number from the scale below. There are no right or wrong answers; however, for the data to be meaningful, you must answer each statement given below as honestly as possible. Your responses are completely anonymous. Please do not leave any statement unmarked. Some statements may depict situations that you have not experienced; please imagine yourself in those situations when answering those statements.

Strongly Moderately Slightly Neutral Slightly Moderately Strongly Disagree Disagree Disagree Agree Agree Agree 1 2 3 4 5 6 7

1. I try not to give signs that I am a lesbian/bisexual woman. I am careful about the way I dress, the jewelry I wear, the places, people and events I talk about.

2. I can’t stand lesbians who are too “butch”. They make lesbians as a group look bad.

3. Attending lesbian/gay/bisexual events and organizations is important to me.

4. I hate myself for being attracted to other women.

5. I believe female homosexuality is a sin.

6. I am comfortable being an “out” lesbian/bisexual woman. I want others to know and see me as a lesbian/bisexual woman.

7. I have respect and admiration for other lesbians/bisexual women.

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8. I wouldn’t mind if my boss knew that I was a lesbian/bisexual woman.

9. If some lesbians would change and be more acceptable to the larger society, lesbians as a group would not have to deal with so much negativity and discrimination.

10. I am proud to be a lesbian/bisexual woman.

11. I am not worried about anyone finding out that I am a lesbian/bisexual woman.

12. When interacting with members of the lesbian/gay/bisexual community, I often feel different and alone, like I don’t fit in.

13. I feel bad for acting on my lesbian desires.

14. I feel comfortable talking to my heterosexual friends about my everyday home life with my female partner/lover or my everyday activities with my lesbian/bisexual friends.

15. Having lesbian/bisexual friends is important to me.

16. I am familiar with lesbian/gay/bisexual books and/or magazines.

17. Being a part of the lesbian/gay/bisexual community is important to me.

18. It is important for me to conceal the fact that I am a lesbian/bisexual from my family.

19. I feel comfortable talking about homosexuality in public.

20. I live in fear that someone will find out I am a lesbian/bisexual woman.

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21. If I could change my sexual orientation and become heterosexual, I would.

22. I do not feel the need to be on guard, lie, or hide my lesbianism/bisexuality to others.

23. I feel comfortable joining a lesbian/gay/bisexual social group, sports team, or organization.

24. When speaking of my female lover/partner to a straight person I change pronouns so that others will think I’m involved with a man rather than a woman.

25. Being a lesbian/bisexual woman makes my future look bleak and hopeless.

26. If my peers knew of my lesbianism/bisexuality, I am afraid that many would not want to be friends with me.

27. Social situations with other lesbians/bisexual women make me feel uncomfortable.

28. I wish some lesbians wouldn’t “flaunt” their lesbianism. They only do it for shock value and it doesn’t accomplish anything positive.

29. I don’t feel disappointment in myself for being a lesbian/bisexual woman.

30. I am familiar with lesbian/gay/lesbian movies and/or music.

31. I am aware of the history concerning the development of lesbian/gay/bisexual communities and/or the lesbian/gay/bisexual rights movement.

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32. I act as if my female lovers are merely friends.

33. I feel comfortable discussing my lesbianism/bisexuality with my family.

34. I could not confront a straight friend or acquaintance if she or he made a homophobic or heterosexist statement to me.

35. I am familiar with lesbian music festivals and conferences.

36. When speaking of my female lover/partner to a straight person, I often use neutral pronouns so the sex of the person is vague.

37. Lesbians are too aggressive.

38. I frequently make negative comments about other lesbians/bisexual women.

39. I am familiar with community resources for lesbians/bisexual woman (i.e., bookstores, support groups, bars, etc.).

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Appendix F The Distress Tolerance Scale

Directions: Think of times that you feel distressed or upset. Select the item from the menu that best describes your beliefs about feeling distressed or upset.

1. Strongly agree

2. Mildly agree

3. Agree and disagree equally

4. Mildly disagree

5. Strongly disagree

1. Feeling distressed or upset is unbearable to me.

2. When I feel distressed or upset, all I can think about is how bad I feel.

3. I can’t handle feeling distressed or upset.

4. My feelings of distress are so intense that they completely take over.

5. There’s nothing worse than feeling distressed or upset.

6. I can tolerate being distressed or upset as well as most people.

7. My feelings of distress or being upset are not acceptable.

8. I’ll do anything to avoid feeling distressed or upset.

9. Other people seem to be able to tolerate feeling distressed or upset better than I can.

10. Being distressed or upset is always a major ordeal for me.

11. I am ashamed of myself when I feel distressed or upset.

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12. My feelings of distress or being upset scare me.

13. I’ll do anything to stop feeling distressed or upset.

14. When I feel distressed or upset, I must do something about it immediately.

15. When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels.

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Appendix G

Depression Anxiety Stress Scale (DASS21), Depression Scale

Please read each statement and circle a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past 12 months. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time

1. I couldn’t seem to experience any positive 0 1 2 3 feeling at all.

2. I found it difficult to work up the initiative to 0 1 2 3 do things.

3. I felt that I had nothing to look forward to. 0 1 2 3

4. I felt down-hearted and blue. 0 1 2 3

5. I was unable to become enthusiastic about 0 1 2 3 anything.

6. I felt I wasn’t worth much as a person. 0 1 2 3

7. I felt that life was meaningless. 0 1 2 3

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Appendix H Outness Inventory

Use the following rating scale to indicate how open you are about your sexual orientation to the people listed below. Try to respond to all of the items, but leave items blank if they do not apply to you.

1 = person definitely does NOT know about your sexual orientation status 2 = person might know about your sexual orientation status, but it is NEVER talked about 3 = person probably knows about your sexual orientation status, but it is NEVER talked about 4 = person probably knows about your sexual orientation status, but it is RARELY talked about 5 = person definitely knows about your sexual orientation status, but it is RARELY talked about 6 = person definitely knows about your sexual orientation status, and it is SOMETIMES talked about 7 = person definitely knows about your sexual orientation status, and it is OPENLY talked about 0 = not applicable to your situation; there is no such person or group of people in your life

1. mother 1 2 3 4 5 6 7 0 2. father 1 2 3 4 5 6 7 0 3. siblings (sisters, brothers) 1 2 3 4 5 6 7 0 4. extended family/relatives 1 2 3 4 5 6 7 0 5. my new straight friends 1 2 3 4 5 6 7 0 6. my work peers 1 2 3 4 5 6 7 0 7. my work supervisor(s) 1 2 3 4 5 6 7 0 8. members of my religious community 1 2 3 4 5 6 7 0 (e.g., church, temple) 9. leaders of my religious community 1 2 3 4 5 6 7 0 (e.g., church, temple) 10. strangers, new acquaintances 1 2 3 4 5 6 7 0 11. my old heterosexual friends 1 2 3 4 5 6 7 0

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Appendix I Demographic Questionnaire

1. What is your age (in years)?

2. What is your biological sex? (Please circle one)

a. Male

b. Female

c. Transsexual

3. How do you define your gender? (Please circle one)

a. Male

b. Female

c. Transgender, female to male

d. Transgender, male to female

e. Other

4. Which of these do you identify as your race or ethnicity (circle all that apply)?

a. Hispanic/Latino/Latina

b. African American/Black

c. Native American/American Indian

d. Asian/Pacific Islander

e. Alaskan Native

f. White/Caucasian

g. Other

5. If you chose more than one race or ethnicity, specify the percentages of each.

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6. Are you currently in a romantic relationship?

7. If yes, is your partner male or female?

8. How many previous romantic relationships have you been in?

9. How many of your previous romantic relationships have been with a male versus

female partner (write the number on the respective lines below)?

Male:

Female: _

10. What is your current body weight (in pounds)?

11. What is your current height (in feet and inches)?

12. If you are currently employed, please provide a brief description of the work you

do.

13. Do you have a job that requires you to be to engage in a high level of physical

activity that requires a significant increase in the amount of food you consume?

14. Are you an athlete? If yes, please describe the sport you participate in and the

extent of training you are involved in for that sport (e.g., hours per week that you

train, intensity of the training, how often you compete).

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