I the INTERACTION of SEXISM and HETEROSEXISM in LESBIAN

THE INTERACTION OF SEXISM AND HETEROSEXISM IN LESBIAN WOMEN’S

EXPERIENCES WITH INTIMATE PARTNER VIOLENCE AND SUBSEQUENT

POSTRAUMATIC REACTIONS

A Dissertation

Presented to

The Graduate Faculty at the University of Akron

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Taylor L. Ceroni

August, 2019

THE INTERACTION OF SEXISM AND HETEROSEXISM IN LESBIAN WOMEN’S

EXPERIENCES WITH INTIMATE PARTNER VIOLENCE AND SUBSEQUENT

POSTRAUMATIC REACTIONS

Taylor L. Ceroni

Dissertation

Approved: Accepted:

______Advisor Department Chair Dr. Dawn M. Johnson Dr. Paul E. Levy

______Committee Member Interim Dean of College Dr. Margo A. Gregor Dr. Linda M. Subich

______Committee Member Dean of the Graduate Dr. Ronald F. Levant School Dr. Chand Midha ______Committee Member ______Dr. Suzette L. Speight Date

______Committee Member Dr. John F. Zipp

Abstract

Experiences of oppression and experiences of multiple oppressions have long been linked to psychological distress. Newer research has been conducted looking at the traumatic effects that oppression can have on mental health including PTSD symptom development. The experience of trauma in women and its links to PTSD have also long been studied but there has been no research to date to look at the experiences of lesbian women who experience IPV and how sexism and heterosexism may affect the development of PTSD symptoms. The current study added to the existing literature by exploring the additive and interactional roles that multiple oppressions play in individual’s lives. Specifically, the present study hypothesized additive effects and interactional effects between internalized sexism, internalized heterosexism, externalized sexism, and externalized heterosexism in predicting PTSD symptom severity.

Additionally, it was predicted that a moderated moderation would exist, where the relationship between externalized oppression and PTSD symptom severity is moderated by internalized oppression with IPV severity moderating the relationship between internalized oppression and PTSD symptom severity. Participants were 209 lesbian women. Hierarchical regression analysis found support for externalized sexism as a unique predictor for PTSD symptom severity. Implications are discussed.

Keywords: sexism, heterosexism, intimate partner violence, PTSD

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DEDICATION

I dedicate this work to all sexual minority women. It is my hope that one day we can all love equally and find solidarity in our shared fight for liberation.

ACKNOWLEDGEMENTS

First and foremost, I wish to express my gratitude to Dr. Dawn Johnson, my graduate advisor and mentor. I can’t imagine that I would have been able to accomplish all of this without your endless support, wisdom, and guidance. Thank you, Dawn. My committee members, Drs Margo Gregor, Ronald Levant, Suzette Speight, and John Zipp,

I am thankful for all the ways that you helped me to advance my thinking about this study.

I would like to recognize the unequivocal support of my cohort members,

Kathleen Alto, Maria Pappa, Sarah Sanders, and Rebecca Schlesinger. I am so grateful that you were all a part of this journey. Additionally, I would like to express my gratitude to my internship supervisors at the Southeast Louisiana Veterans Health Care system, Drs

Julie Arseneau, Laurel Franklin, Michelle Hamilton, Amanda Raines, and Karen Slaton, your support and confidence in me has been invaluable to me completing this project.

Thank you for giving me a home in New Orleans.

To my internship cohort member, Chelsea Ennis, I wish to express my heartfelt appreciation for all of your support and friendship. Thank you for always knowing when to push me and when to distract me. To my longtime friend, Ashlee Fielding, there’s nothing I could accomplish without you, including this. Lastly, to my parents, thank you for always telling me that I could be anything I wanted, including a doctor one day.

TABLE OF CONTENTS

Page LIST OF TABLES………………………………………………………………………iv

LIST OF FIGURES……………………………………………………………………....x

CHAPTER

I. INTRODUCTION……………………………………………………………...1

II. A REVIEW OF THE LITERATURE…………………………………………20

Oppression as Trauma…………………………………………………………20

Sex-related Trauma, Sexism as Trauma, and Posttraumatic Reactions……..…28

Heterosexism, Heterosexism as Trauma, and Posttraumatic Reactions……….37

Intimate Partner Violence……………………………………………………...51

Theorizing Multiple Oppressions……………………………………………...53

Research Aims and Hypotheses..……………………………………………....72

III. RESEARCH METHODS……..………………………………………………..77

Participants……………………………………………………………………...77

Measures…………………………………………………………………...... 79

Procedures……………………………………………………………………....96

Analytic Plan…………………………………………………………..………..97

IV. RESULTS……………………………………………………………………..105

Data Screening and Missing Data…………………………………………….105

Descriptive Statistics………………………………………………………….107

Hypothesis 1…………………………………………………………………..108

Hypothesis 2…………………………………………………………………..109

Hypothesis 3…………………………………………………………………..109

Hypothesis 4…………………………………………………………………..110

Hypothesis 5…………………………………………………………………..111

Hypothesis 6…………………………………………………………………..111

V. DISCUSSION…………………………………………………………………113

Hypothesis 1…………………………………………………………………..114

Hypothesis 2…………………………………………………………………..120

Hypothesis 3…………………………………………………………………..125

Hypothesis 4…………………………………………………………………..128

Hypothesis 5…………………………………………………………………..129

Hypothesis 6…………………………………………………………………..129

Clinical Implications…………………………………………………………..131

Implications for Counseling Psychology……………………………………...134

Strengths, Limitations and Future. Directions………………………………...136

Conclusions…………………………………………………………………...144

REFERENCES………………………………………………………………………....146

APPENDICES………………………………………………………………………….208

APPENDIX A. DEMOGRAPHIC QUESTIONNAIRE……………………………...208

APPENDIX B. PTSD CHECKLIST FOR THE DSM-5……………………………...209

APPENDIX C. THE SEVERITY OF VIOLENCE AGAINST WOMEN SCALE..…211

APPENDIX D. SCHEDULE OF SEXIST EVENTS….……………………………...213

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APPENDIX E. THE HETEROSEXIST HARASSMENT, DISCRIMINATION, AND

REJECTION SCALE………………………………………………………………….216

APPENDIX F. LESBIAN INTERNALIZED HOMOPHOBIA SCALE….………….218

APPENDIX G. THE INTERNALIZED MISOGYNY SCALE…………………...….221

APPENDIX H. INFORMED CONSENT…………………………………………….223

APPENDIX I. INSTITUTIONAL REVIEW BOARD APPROVAL FOR HUMAN

SUBJECTS RESEARCH……………………………………………………………..224

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LIST OF TABLES Table Page

1. Conceptual Interactions of Predictors…………………………………………195

2. Demographics……………………………...………………...……………...... 196

3. Correlations Amongst Main Variables……….……..……….……………...... 198

4. Descriptive Statistics for Main Variables……………………….………...…...199

5. Hierarchical Regressions – Hypothesis 1………………….……………...…...200

6. Hierarchical Regressions – Hypothesis 2…………………….……………...... 201

7. Hierarchical Regressions – Hypothesis 3……………………….……………..202

8. Hierarchical Regressions – Hypothesis 4………………….…………………..203

9. Moderated Moderators – Hypothesis 5……………….……………………….204

10. Moderated Moderators – Hypothesis 6……….…………….…………………205

LIST OF FIGURES Figure Page

1. Conceptual Model – Moderated Moderation of Sexism………………………206

2. Conceptual Model – Moderated Moderation of Heterosexism………………..207

Chapter I

INTRODUCTION

Oppression is a pervasive and insidious daily occurrence for many individuals with minority statuses. Oppression has been defined in multiple ways over time with the common theme that there is a dominant group and a non-dominant group, with the dominant group keeping needed resources away from the non-dominant group (Bartky,

1990; Mar’i, 1988; Sidanius, 1993; Young, 1990). Bartky (1990) in particular, viewed oppression as not just the dominant group retaining control politically and economically but also psychologically. Bartky (1990) purported that oppression is not purely political or purely psychological but that the political and psychological nature of oppression are inherently linked. Oppression is inherently a state as well as a process of domination by a majority group but also, the insidious psychological control of subjugation of a marginalized group, who believe that they are less than the majority group, deserving of less resources, and ultimately deserving of the oppression they are experiencing (Bartky,

1990; Prilleltensky & Gonick, 1996). Thus, oppression can be defined as “a state of asymmetric power relations characterized by domination, subordination, and resistance, where the dominating persons or groups exercise their power by restricting access to material resources and by implanting in the subordinated persons or groups fear or self-

deprecating views about themselves” (Prilleltensky & Gonick, 1996, pp. 129-130). The current study aimed to better understand the additive and interactional perspectives in the experiences of sexism and heterosexism in lesbian women.

Research on oppression has shown the links between the experience of oppression and negative mental health consequences, including but not limited to posttraumatic stress disorder (PTSD; Balsam, 2003; Bryant-Davis & Ocampo, 2005; Carter, 2007;

Carter, Forsyth, Mazzula, & Williams, 2005; Neisen, 1993; Root,1992; Sanchez-Hucles,

1998; Szymanski & Balsam, 2011) and argue for a change in the American Psychiatric

Associations Diagnostic and Statistical Manual of Mental Disorders (2013; DSM-5) in the diagnostic criteria for PTSD to include experiences of oppression. Less is known about how the traumatic experience of oppression, multiple oppressions, and other traumatic incidents in women’s lives influence the development of subsequent PTSD symptoms. The purpose of the current research was to investigate the impact of multiple oppressions and interpersonal trauma on lesbian women’s PTSD symptoms.

Systems of Oppression

Oppression in our society is systemic and is embedded into the structural levels that influence the experience of minority individuals in a variety of ways. Young (1990) describes oppression as structural in nature and minority groups experience oppression as a normalized every day experience with causal underpinnings “embedded in unquestioned norms, habits and symbols, in the assumptions underlying institutional rules and the collective consequences for following those rules” (p. 41). With this type of structural embedment, oppression is normalized and becomes a necessary part of how society functions which not only creates acceptance of oppression but also makes the

mechanisms largely invisible, justifying and legitimizing its existence (Hardiman,

Jackson, & Griffin, 2007).

Oppression being structural and embedded into every level of societal experience creates a hierarchy of dominant and subordinate groups (Bell, 1997; 2007). The social hierarchy provides dominant groups with advantages and privilege over necessary resources and power. The system of oppression functions when the hierarchy is continually exercised by all individuals and the majority group continues to maintain power creating social inequity (Fanon, 1963; Freire, 1970; Prilleltensky & Gonick, 1996;

Young, 1990). Further, socialization is an important aspect of individuals enacting their given roles within the system of oppression. Socialization is a process where individuals learn values, rules, and roles that allow them to live in society. These roles may be social and personal, teaching individuals the norms and expectations of them as a member of the majority group or minority group (Fanon, 1967, Harro, 2010, Memmi, 1965). The process of socialization leads minority individuals to believe that their oppression is not only normal but also acceptable furthering the system of oppression (Harro, 2010).

Another mechanism of oppression is internalized oppression, which is an intrapersonal level of oppression that is theorized to be a state as well as a process

(Freire, 1970; Pheterson, 1986; Prilleltensky & Gonick, 1996; Pyke, 2010). Internalized oppression can be defined as “the incorporation and acceptance by individuals within an oppressed group of the prejudices against them within the dominant society. Internalized oppression is likely to consist of self-hatred, self-concealment, fear of violence and feelings of inferiority, resignation, isolation, powerlessness, and gratefulness for being allowed to survive.” (Pheterson 1986; p.146). Pheterson (1986; p. 146) further defines

internalize oppression as “the mechanism within an oppressive system for perpetuating domination not only by external control but also by building subservience into the minds of the oppressed groups.” Incorporating, accepting, and building subservience shows that internalized oppression is a process that it is a necessary and purposeful part of the system of oppression maintaining the social hierarchy. The state of internalized oppression is the consequence of self-hatred, self-concealment, fear of violence, inferiority, resignation, isolation, powerlessness, and gratefulness for being allowed to survive. Limiting resources and power of minority groups and the acceptance that this is normal leads to the state of internalized oppression (Pharr, 1996, 1997; Pheterson, 1986;).

Brown (1986) discussed internalized homophobia as lesbian, gay, and bisexual

(LGB) individuals believing they are inferior because they are continuously subjected to messages of their deviance and denied power and privileges that are rewarded to heterosexual individuals. Perez (2005) discusses how this may lead LGB individuals to want to be seen as heterosexual, which is a term called “passing”. Appearing as heterosexual may make LGB individuals feel safer in social interactions but can further self-hatred as they are not being their authentic selves (David & Derthick, 2014). The action of trying to pass in heterosexual society may also isolate LGB individuals from not only their family, friends, coworkers, but also from interacting with their LGB community, ultimately rejecting their true selves and their culture which can have lasting psychological effects (David & Derthick, 2014; Hill, 2009; Perez, 2005). Nadal and

Medoza (2014) argue for the term “internalized heterosexism” rather than the historic

“internalized homophobia”. The term homophobia does not fully capture the discriminatory experiences of LGB individuals as the word “phobia” implies that it is an

irrational fear of LGB individuals. In contrast, the term “internalized heterosexism” better captures LGB discrimination as individuals may not have an irrational fear of LGB individuals but rather a bias towards favoring opposite-gender relationships over same- gender relationships, leading to discrimination of LGB individuals (Nadal & Modoza,

2014).

Lesbian women may experience internalized sexism or “internalized misogyny”, which is the internalization of the hatred, degradation, and devaluation of women in our society to maintain men’s power and ultimately, leading to the fear of women and traditional feminine qualities and characteristics (Burch, 1987; O’Neil, 1981; Piggot,

2004; Szymanski & Kashubeck-West, 2008; Szymanski, Gupta, Carr, & Stewart, 2009;

Worrel & Remer, 2003). Consequently, men and women devalue women, which is a construct called “horizontal oppression” (Piggot, 2004; Saakvitne & Pearlman, 1993;

Szymanski et al., 2009). Horizontal oppression may result from internalized misogyny and internalized heterosexism interacting in lesbian women relationships which may lead to enacting oppressive acts and violence, such as IPV (Hines, 2014; Pepper & Sand,

2015). Experiences of oppression and internalized oppression also have lasting psychological consequences and may be traumatic.

Oppression as Trauma

The psychological experience of oppression and internalization of oppression led researchers to look at the impact of oppression as traumatic. Root (1992) coined the term insidious trauma as a way to define the consequences of ongoing daily experiences of political and psychological oppression in minority individuals. Viewing oppression as traumatic has led many researchers and theorists to explore oppression as a form of

trauma that could lead to posttraumatic symptoms and posttraumatic stress disorder

(PTSD; Balsam, 2003; Bryant-Davis & Ocampo, 2005; Carter, 2007; Carter, Forsyth,

Mazzula, & Williams, 2005; Neisen, 1993; Root,1992; Sanchez-Hucles, 1998;

Szymanski & Balsam, 2011). These researchers argue that experiences of oppression should be included in the Diagnostic and Statistical manual of Mental Disorders (DSM) as part of Criterion A for posttraumatic stress disorder. Criterion A in the DSM defines what can be included as a trauma.

There is much research to suggest that experiences of oppression are related to negative psychological consequences in individuals and may be perceived as traumatic

(Anderson, 2013; Bandermann & Szymanski, 2014; Cheng & Mallinckrodt, 2015; Díaz,

Ayala, Bein, Henne & Marin, 2001; Pascoe & Richman, 2009; Pieterse, Todd, Neville,

Carter, 2012; Suarez & Gadalla, 2010; Velez, Moradi, & DeBlaere, 2015). Anderson

(2013) investigated psychological and physical stress resulting from racism in racial and ethnic minorities. The researchers found that African American individuals were more likely to experience both emotional and physical stress compared to other racial and ethnic groups. Diaz, et al. (2001) explored the relationship among racism, poverty, and homophobia in Latino gay and bisexual identifying men. They found higher rates of psychological distress, suicidal ideation, anxiety and depression in Latino gay and bisexual identifying men who also had high rates of poverty and discrimination in employment. Velez, et al. (2015) investigated the impact of multiple oppressions on mental health specifically in sexual minority Latino/a individuals. They found that internalized and externalized racism and heterosexism, which are the acts of racist and heterosexist discrimination, lead to higher rates of psychological distress; whereas solely

internalized racism and heterosexism lead to lower rates of life satisfaction and self- esteem.

Negative Consequences of Sexism and Heterosexism

Everyday Sexism

Much research has been done to show the negative physical health and mental health outcomes of sexism on women (Klonoff & Landrine, 1995; Koss, Bailey, Yan,

Herrera, & Lichter, 2003; Krieger, 1990; Landrine et al., 1995; Moradi & Subich, 2002).

Sexism’s effects on women’s experiences have long been researched and many different subtypes of sexism have been identified, such as everyday, ambivalent, covert, and neosexism (Benokraitis & Feagin's, 1995; Glick & Fiske, 1996; Swim & Cohen, 1997;

Swim, Hyers, Cohen, & Ferguson, 2001; Tougas, Brown, Beaton, & Joly, 1995).

Swim, Hyers, Cohen, and Hyers (1998) coined the term “everyday sexism” while exploring the psychological impact of everyday incidents of sexism in women. Furthering the research that examined the insidious nature of racism, everyday sexism also looks at the externalized and internalized nature of the oppression of sexism (Bartky, 1990; Lott,

1995; Swim, Cohen, Hyers, 1998). Swim, et al. (2001) discussed how much of the research has focused on retrospective surveys of women’s everyday experiences which accounts for the blatant forms of discrimination and harassment that women experience daily but can miss out on the subtler forms of discrimination, such as sexist jokes or objectification. The researchers also discussed how much of the research might be missing out on everyday sexist acts because women may experience an additive effect of experiences and it’s difficult to discern each incident or which one affected them the most. In Swim et al.’s (2001) study the researchers conducted three daily diary studies

with women and men. The results showed that women experienced approximately one to two experiences of sexist acts that affected them each week. The majority of the experiences were in the areas of traditional gender role stereotyping, demeaning and degrading comments, and sexual objectification. Approximately 75% of women reported anger and distress over the sexist incidents. They were also more likely to have effects on their psychological well-being, increased discomfort and anxiety, higher rates of depression, and lower self-esteem.

Landrine, Klonoff, Gibbs, Manning, and Lund (1995) also found that women who experience more everyday sexist events have higher rates of psychological distress even when taking into account other stressful life events. Klonoff, Landrine, and Campbell

(2000) had similar results, finding that women who experience more lifetime sexist events have increased anxiety, depression, and somatization. Berg (2006) explored everyday sexism and PTSD in heterosexual women and found that the majority of women (77%) reported having serious issues in their romantic relationships and also experienced high rates of emotional and verbal abuse by their romantic partners (56.7%).

Women also faced high rates of discrimination and sexual harassment at their workplace

(45.9%) and 27% of women reported having a serious mental illness in their lifetimes (ie, panic attacks, eating disorders, suicidal ideation, depression, and hospitalizations). Berg

(2006) found that there was a strong relationship between experiences of everyday sexism and PTSD, with the most predictive variable of the relationship being recent sexist degradation, which includes sexual harassment, sexist name calling, sexist jokes, and feelings of anger about sexism. Berg (2006) argues that not only are these experiences of everyday sexism traumatic in their own right, but that there is a

cumulative effect of experiences of trauma and experiences of everyday sexism that may lead to higher rates of posttraumatic symptoms and PTSD. It is important to note that in this sample, 90% were heterosexual-identifying women and the majority of studies on everyday sexism and internalized sexism have had mainly heterosexual samples.

Heterosexism

The research indicates that sexual minority individuals more likely to experience heterosexist events, such as harassment, violence, discrimination and prejudice but that these experiences are closely related to negative health and psychological distress, including posttraumatic symptoms and PTSD (Herek et al., 1999; Lewis, Derlega,

Berndt, Morris, & Rose, 2001; Mays & Cochran, 2001; Waldo, 1999). Heterosexism affects LGB individuals in many areas of their lives, such as individual, educational, occupational, familial, social, institutional, political, cultural, and religious settings

(Herek, 1995).

Heterosexism can occur in daily areas of lives that are legally protected for other minorities, such as employment and housing. Employment and housing discrimination still take place for other minorities, but legal protection may lead to increased feelings of protection and legitimacy, and less internalization of the discrimination (Herek, 2009).

Mays and Cochran (2001) found that over 50% of LGB individuals reported at least one daily experience of discrimination based on their LGB identity. Herek (2009) found that

10% of participants reported an incident of employment or housing discrimination while approximately half reported verbal harassment. As stated above, there has been a small amount of research that has linked these experiences to PTSD (Herek et al., 1999;

Szymanski & Balsam, 2011). Szymanski and Chung (2003) specifically found that

lesbian women who experienced internalized heterosexism also experienced negative mental health outcomes, such as psychological distress, depression, less social support, and greater demoralization. Bandermann and Szymanski (2014) explored coping mediators between heterosexist oppression and PTSD symptom development in lesbian, gay, and bisexual individuals. Results of the study indicated that heterosexist hate crime victimization and heterosexist discrimination had direct and unique links to PTSD symptom severity. Additionally, Szymanski and Balsam (2011) explored heterosexism’s links to PTSD symptoms by building on the previously discussed study by looking at hate crime victimization and heterosexist discrimination’s links to PTSD symptoms. Results indicated that heterosexist discrimination and hate crime victimization were both positive predictors of PTSD symptoms for lesbian women. Consistent with the sexism literature, the experience of internalized heterosexism (internalizing one’s oppression) leads to greater rates of psychological distress, psychological morbidity, and PTSD.

There have been many approaches for researching experiences of multiple oppressions, such as sexism and heterosexism but few have explored how multiple oppressions affect lesbian women’s experiences with sexist and heterosexist discrimination (external oppression) and internalized sexism and heterosexism.

Theoretical Frameworks of Multiple Oppressions

There have been many differing approaches in the study of oppression. The research on heterosexism and other types of oppression have primarily focused on two theoretical frameworks: Minority stress theory (Meyer, 1995; Meyer, 2003) and

Multicultural-feminist theories (Moradi & Subich, 2002b; Moradi & Subich, 2003).

Further, the research includes three approaches: additive, interactional (multiplicative),

and intersectional. The additive perspective describes multiple oppressions in terms of accumulating together with each form of oppression having unique links to negative mental health consequences (Moradi & Subich, 2003). The interactional approach suggests that multiple forms of oppression aren’t simply additive but that they are multiplicative where one form of oppression can increase the link between another form of oppression and negative mental health consequences (Moane, 1999; Mullaly, 2002;

Young, 1990). The intersectional perspective views oppression as not just additive or interactional which focus on solely oppressed identities, rather all of the identities someone experiences (which may be dominant or subordinate) intersect so that it is not the experience of being in one social group but a synthesis of all identities on how individuals understand and experience their oppression (Collins, 2000).

There is support for all three types of approaches to understanding multiple oppressions; current research on the experiences of heterosexism and sexism focus mainly on the additive and interactional approaches (Ragins, Cornwell, & Miller, 2003;

Szymanski, 2005; Szymanski, 2008; Szymanski, 2009; Szymanski, Kashubeck-West,

Meyer, 2008; Szymanski, 2012; Velez, Moradi & DeBlaere, 2015. Szymanski and

Henrichs-Beck (2014) and Velez, Moradi, and DeBlaere (2015) describe both the additive and interactional approaches as they relate to multiple experiences of external and internal oppression. There is support for the additive approach within the literature on both Minority stress theory (Meyers, 2003) and Multicultural-feminist theory (Szymanski and Henrichs-Beck, 2014). Both theories posit that there is an additive effect of different types of external and internalized oppressions that lead to increased negative mental health outcomes for minority individuals. In the additive perspective, each form of

oppression would have unique and direct links between the experience of external oppression and internalized oppression and they combine additively leading to negative mental health consequences. For example, heterosexist discrimination and internalized heterosexism combine and lead to psychological distress and sexist discrimination and internalized sexism combine and lead to psychological distress.

The interactional approach, or multiplicative approach, is also recognized by both minority stress theory and multicultural feminist theory though how the two theories view the interactions differs. In the minority stress theory (Meyer, 2003) external oppression

(i.e. discrimination experiences) and internalized oppression of the same type of oppression will interact and lead to poor health outcomes. For example, sexist experiences would interact with internalized sexism predicting for higher PTSD symptom severity. Minority stress theory posits that this interaction occurs because not only does internalized oppression predispose minority individuals for self-blame, it also may increase the harmful effects of discrimination experiences.

In the multicultural-feminist theory (Moradi & Subich, 2002b; Moradi & Subich,

2003; Szymanski, Kashubeck-West, & Meyer, 2008; Velex, Moradi, & DeBlaere, 2015) there are two different types of interactions recognized. The multicultural-feminist theory also suggests that externalized oppression and internalized oppression lead to negative mental health outcomes but this theory suggests that it’s because of the combining

(sexism and heterosexism) of multiple oppressions that affect people’s experiences. The first form of interactional multiplicative perspective is similar to the additive perspective in that external and internalized oppression both affect mental health but these perspectives see them as additive in one form; where each form of oppression is unique

in its links to mental health. For example, internalized sexism and internalized heterosexism combine and lead to negative mental health consequences. The second form of interactional multiplicative perspective suggests that above and beyond unique relationships, that one form of oppressed identity interacts and increases negative mental health outcomes in the other oppressed identity. For example, externalized sexism and internalized heterosexism interact and one increases psychological distress with the other.

Szymanski (2005) found a significant interaction of heterosexism and sexism in lesbian women who had experienced a hate crime which led to psychological distress.

Intersectional models of multiple oppression posits that there is a synthesis of identity and oppression which creates a new and unique experience based on this synthesis for minority individuals (gendered heterosexism). The new and unique experiences that are created from the synthesis can have a negative impact on mental health (Cole 2009; Collins 1991; Szymanski and Moffitt 2012). Much of the research has focused on the experiences of external and internal gendered racism among African

American women (King 2003; Klevens 2008; Thomas, Witherspoon, & Speight, 2004;

2008; Woods et al. 2008). To date, there has been limited qualitative research on the intersectional approach for lesbian women and a lack of quality measures to assess these constructs fully for the lesbian population. Friedman and Leaper (2010) explored the construct of gendered heterosexism in sexual minority women, as well as, experiences of sexism and heterosexism as predictors of social identity and collective action in college.

The researchers tested gendered heterosexism with a measure that they created for their study, which has only been utilized one other time in their follow-up study (Friedman &

Ayres, 2013). Lesbian women had higher levels of heterosexist discrimination than

bisexual women, and after controlling for sexism, heterosexism, and their interaction, gendered heterosexism uniquely predicted social identity and commitment to collective action. The gendered heterosexism scale the authors created has not been utilized in a study exploring mental health outcomes in sexual minority women.

The current study utilized the additive and interactional framework when exploring heterosexism and sexism in lesbian women because of the evidenced support for this framework (Szymanski, 2005; Szymanski & Balsam, 2011; Szymanski & Gupta,

2009; Szymanski & Henrichs-Beck, 2014; Szymanski & Meyer, 2008; Thoma &

Huebner, 2013; Velez, Moradi, & DeBlaere, 2014). There has been no study to date that has looked at lesbian women’s experiences with internalized sexism, internalized heterosexism, external sexism, and external heterosexism and subsequent PTSD symptoms. There has also been no study to date that has looked at these constructs as it relates to interpersonal trauma in lesbian women, even though lesbian women experience high rates of interpersonal trauma while also experiencing high rates of sexism and heterosexism, not to mention the potential horizontal oppression (Piggot, 2004; Saakvitne

& Pearlman, 1993; Szymanski et al., 2009) which may lead to increased experiences of violence in intimate partner relationships. All of these experiences may interact and increase posttraumatic symptoms.

Interpersonal Trauma

Trauma is a common experience in women’s lives in our society, as approximately five out of every 10 women will experience a traumatic event in their lifetime (National Center for PTSD, 2014). Women also experience specific types of traumatic events more frequently than men, such as sexual harassment, sexual assault,

physical assault, and intimate partner violence (Berg, 2006). Further, women who experience these types of traumatic events are more likely to experience psychological distress and physical health consequences, such as posttraumatic stress disorder

(Campbell, Jones, Dienemann, Schollenberger, O’Campo, & Wynne, 2002; Pico-

Alfonso, Garcia-Linares, Celda-Navarro, Blasco-Ros, Echeburua, & Martinez, 2006).

Historically, literature has suggested that women experience disproportionately higher rates of sex-related traumatic events due to sexism in our society (Herman, 1992; Russo,

1995; Szymanski, 2009, Holmes, Facemire, & DaFonseca, 2016). Lesbian women who experience sexism and heterosexism have also been found to experience higher rates of interpersonal trauma, including intimate partner violence (IPV; NISVS; 2010). Further, emerging literature is focusing on how experiences of oppression can lead to posttraumatic reactions and may affect trauma-related symptoms (Herman, 1992; Bryant-

Davis, & Ocampo, 2005). However, there is little research on how interpersonal trauma may impact lesbian women’s experience of oppression and subsequent PTSD symptoms.

Lesbian women experience higher rates of interpersonal violence than their heterosexual counterparts, including high rates of intimate partner violence (IPV). The

National Intimate Partner and Sexual Violence Survey (NIPSVS; 2010) reports that

46.4% of lesbian women report sexual violence in their lifetimes. In intimate partner relationships, sexual abuse has been reported by up to 50% of lesbian women (Waldner-

Haugrad & Gratch, 1997) and approximately 90% of lesbian women have reported at least one incident of psychological abuse by a romantic partner (Burke & Follinstad,

1999). A more recent study (Simpson & Helfrich, 2005), showed a prevalence rate of 41-

68% of lesbian women reporting IPV. There has been much research to show the link

between experiences of IPV and PTSD in women (Campbell, 2002; Kemp, Rawlings, &

Green, 1991). For lesbian women, the experience of sexism and heterosexism along with the high rates of IPV may all affect their development of subsequent PTSD symptoms.

IPV is a pervasive issue in women’s lives which may lead to negative mental health consequences and be impacted by experiences of sexism. However, less is known about how experiences of sexism impact lesbian women in general, and specifically impacts lesbian women who have experienced IPV. The most prevalent mental health consequence for women who have experienced intimate partner violence is PTSD

(Kemp, Rawlings, & Green, 1991; Pico-Alfonso et al., 2006). Approximately 64% of women who have experienced IPV meet diagnostic criteria for PTSD (Jones, Hughes, &

Unterstaller, 2001). Lesbian women experiencing higher rates of IPV, PTSD, and the traumatic nature of the experience of multiple oppressions may impact the relationship between oppression and PTSD symptoms. Lesbian women have unique and important considerations when it comes to their experiences of oppression and IPV experiences.

Same-gender violence has long been ignored and the fear that lesbian women may feel due to a heterosexist climate, lack of resources, fears of reporting, lack of consistent legal definitions across states, and variability in arrest practices may lead women to not report

(Duke & Davidson, 2009). Due to heteronormative views of IPV, women are perceived as the victims of abuse and men are viewed as the perpetrators of abuse, which has historically created a culture that holds the view that women can’t be perpetrators minimizing and dismissing lesbian experiences of IPV (Hassouneh & Glass, 2008; Van

Natta, 2005). The oppressive experiences that lesbian women experience, as well as, the oppressive views of IPV may impact their development of PTSD symptoms.

To date, no research has specifically investigated how lesbian women’s experience of sexism, heterosexism, and IPV may impact PTSD symptoms. The current study sought to explore the way the experience of the multiple oppressions (sexism and heterosexism) affect lesbian women’s development of PTSD and what role IPV plays in that relationship. A greater understanding of how multiple oppressions and trauma affect lesbian women’s lives is salient to the tenets of counseling psychology.

Importance to Field of Counseling Psychology

Counseling psychology has been committed to recognizing environmental and situational influences and how they shape experiences and issues of diversity and social justice, which as a mission has emphasized the importance of multiculturalism (Munley,

Duncan, McDonnell, & Sauer, 2004). Vera and Speight (2003) argued that counseling psychology should be committed to social justice. The multicultural and social justice emphasis of counseling psychology also includes better understanding of the lived experiences of lesbian women. Vera and Speight (2003) state

social justice is at the heart of multiculturalism in that the existence of

institutionalized racism, sexism, and homophobia is what accounts for the

inequitable experiences of people of color, women, gay, lesbian, and bisexual

people (among others) in the United States. Moreover, discrimination and

prejudice are intimately connected to quality-of-life issues for these groups of

people (p. 254).

It is important for counseling psychologist’s research not only to be grounded in multiculturalism but also to be committed to social justice, not only to better understand marginalized groups but also to conduct research that could lead to the promotion of

social justice action (Vera & Speight, 2003). This tenet of counseling psychology is particularly relevant in this study since it is exploring multiple oppressions in a group of individuals who have rarely been researched and historically have unequal access to resources (Roth, 1985). This study sought to help to understand the effects of interpersonal trauma on women but also, the traumatic nature of the experiences of oppression. To date there have been no studies that have explored internalized heterosexism and everyday sexism in lesbian women’s experiences with IPV and their subsequent posttraumatic reactions. The current study sought to fill the gap in the research that has historically ignored lesbian women’s experiences with IPV, PTSD symptoms, and sexism and heterosexism.

The current study seeks to address limitations of previous studies which explored sexual minority individual’s issues by utilizing research done retrospectively and through convenience sampling. This study aimed to explore important constructs, such as experiences of sexism and heterosexism in a population that has been historically overlooked. The current study also explored the theoretical frameworks of additive, minority stress, and multicultural-feminist to better understand how internalized sexism, external sexism, internalized heterosexism, and external heterosexism interact in lesbian women’s daily lives. Utilizing Velez, Moradi, and DeBlaere’s (2014) model, this study expanded the existing research multiple oppressions and its links to PTSD symptoms.

The current study focused on the additive and interactional models of multiple oppressions when exploring heterosexism and sexism.

The current study also sought to expand the research on IPV in women’s lives, specifically in lesbian women’s lives and how it may impact women’s experiences with

sexism and heterosexism. This study sought to help better understand the role of IPV and

PTSD symptoms in a context of women experiencing multiple oppressions. Further, the study sought to fill a gap in the IPV literature for a population of women with historically low access to necessary resources, high stigma, and discrimination.

CHAPTER II

REVIEW OF THE LITERATURE

The purpose of the first chapter was to give an overview of the issues concerning interpersonal trauma and multiple oppressions in lesbian women’s lives and the development of posttraumatic stress disorder (PTSD). It specifically highlighted the limitations in previous research and the lack of research on the experiences of sexism and heterosexism in lesbian women who experience interpersonal trauma and the development of subsequent PTSD symptoms. The current chapter critically evaluates the literature on oppression, multiple oppressions, sexism and heterosexism as trauma, sexism and heterosexism’s links to psychological distress and PTSD, and the additive and interactional models of how external and internalized oppression may affect lesbian women may lead to PTSD, and what role the most frequent type of interpersonal trauma in lesbian women (i.e., intimate partner violence (IPV)) may play in these relationships.

Oppression as Trauma

Oppression

Generally, oppression is the social inequality that exists due to one group exercising power over another (Fanon, 1963; Freire, 1970). Oppression has been described as a state or a process. Viewing oppression as a state, suggests that there is a

dominant group and a non-dominant group, with the dominant group keeping needed resources away from the non-dominant group (Bartky, 1990; Sidanius, 1993; Young,

1990). The state of oppression therefore is an outcome of the domination of the dominant group over the non-dominant group (Pilleltensky & Gonick, 1996). Mar’i (1988) stated

"Oppression involves institutionalized collective and individual modes of behavior through which one group attempts to dominate and control another in order to secure political, economic, and/or social-psychological advantage" (p. 6). The definition that

Mar’I (1988) describes defines oppression as a process. This not only includes a psychological and political component but requires adoption of these ideologies in oppressed individuals to maintain and perpetuate the system of oppression (Fanon, 1967;

Freire, 1970; Memmi, 1965).

Fanon (1967) describes the system of colonialism and the psychological effects of the colonized. When the colonized group’s culture is destroyed creating feelings of inferiority about one’s culture. Memmi (1965) also described the process of psychological control through the destruction of one’s culture during colonization as an integral part of perpetuating the oppression of a subordinate group while maintaining the dominant group’s power and domination. Both Fanon (1967) and Memmi (1965) are describing the reluctant acceptance and ultimately internalization of oppression through the process of colonization but also through socialization in oppressed individuals. Freire

(1970) and Miller (1986) suggest that through the process of oppression both subordinate groups and dominant groups are affected by the experience of oppression, with both groups accepting their given roles and perpetuating the system through socialization.

Inherently, oppression contains psychological processes.

Historical and contemporary definitions of oppression include psychological factors of oppression as part of the process. In particular, Bartky (1990) viewed oppression as not just the dominant group trying to retain control politically and economically but also psychologically. The concept that oppression is inherently a state as well as a process of not only, domination by a majority group but also the insidious psychological control of making a marginalized group believe that they are less than the majority group, deserving of less resources, and ultimately deserving of the oppression they are experiencing (Bartky, 1990; Prilleltensky & Gonick, 1996). Thus, oppression can be defined as “a state of asymmetric power relations characterized by domination, subordination, and resistance, where the dominating persons or groups exercise their power by restricting access to material resources and by implanting in the subordinated persons or groups fear or self-deprecating views about themselves” (Prilleltensky &

Gonick, 1996, pp. 129-130). Further, Root (1992) discussed how the psychological and political oppression of marginalized groups (ie., women, racial and ethnic minorities, sexual minorities, gender minorities, and disabled individuals) can lead to something the author suggested was insidious trauma. Insidious trauma is the continuous everyday incidents of discrimination that minority groups endure.

Hardiman, Jackson, and Griffin (2007) describes three levels of oppression: (a) personal or individual (b) institutional or structural, and (c) societal or cultural. Each of these different levels of oppression are unique but together creates a system of oppression where prejudice, discrimination, justification of oppression, and the legitimization of oppression are apparent in all facets of society. The individual level of oppression includes the thoughts, attitudes, and behaviors that express prejudice and discrimination.

Institutional levels of oppression are the laws and policies that influence and perpetuate oppression while also legitimizing prejudice and discrimination against minority groups.

Finally, cultural levels of oppression are implicit and explicit values and norms that not only influence discrimination and prejudice but also provide a justification for why they exist (Hardiman et al., 2007). For lesbian and gay individuals, this level of oppression may be rooted in religious beliefs and doctrines that justify discrimination, prejudice, and influence institutional methods of discriminating against them (Feldblum, 2006). All of these levels of oppression intertwine and maintain the system of oppression, whereas one level requires the other levels to operate. This system creates a social hierarchy with rules for how each group should act in society, with some groups being rewarded privileges in power, status, and resources while other groups have little to no power, status, or access of resources (Johnson, 2001; Moane, 1999; Mullaly, 2002). These findings continue to suggest that oppression is a process with psychological consequences.

Young (1990) discusses five ways that groups are oppressed: (a) exploitation, or the inequality of compensation through social processes that maintains class differentials,

(b) marginalization, or the process of making a group have a low standard in society or limiting them to the “margins” of society, (c) powerlessness, which is the maintaining of dominant power so that subordinate groups have limited opportunities for advancement,

(d) culture of silence, which is a type of powerlessness where individuals in marginalized groups do not discuss their oppression, and (e) cultural imperialism, or making the dominant group’s culture the norm in society which may lead to internalized oppression.

Young’s (1990) conditions for oppression can be seen as it relates to race, gender, sexual

orientation, or ability status. Another construct of oppression that minority individuals experience is internalized oppression.

Internalized Oppression

Experiences of oppression lead to considerable distress in individual’s lives and minority individuals can also experience internalized oppression, where individuals begin to view themselves as undeserving and unimportant (Prilleltensky & Gonick, 1996).

Internalized oppression is a powerful part of the system of oppression as it is an effect of oppression as well as being necessary for the maintenance of oppression (Hardiman &

Jackson, 1997; Moane, 1999; Mullaly, 2002; Pharr, 1996, 1997). Internalized oppression is experienced by subordinate groups as well as dominant groups and can be experienced simultaneously in an individual’s multiple identities in social groups (ie., race, gender, sexual orientation, ability, class, religion). Internalized oppression can also be viewed as a state, process, and/or action (Collins, 2000; Pharr, 1996, 1997; Pheterson, 1986; Moane,

1999). The state of internalized oppression can be the psychological or spiritual thoughts, feelings, and characteristics associated with the subordinate group (Collins, 2000;

Pheterson, 1986; Phar, 1996, 1997). The process of internalized oppression is the perpetuation and maintenance of these internalized beliefs through the socialization and the adoption of them (Pheterson, 1986; Phar, 1996, 1997). Internalized oppression as an action is the everyday behaviors that subordinate groups learn and perform as part of the system (Collins, 2000; Sherover-Marcuse, 1994). Internalized oppression as a state, process, and action can occur independently or together, co-occurring in the daily lives of subordinate groups as well as in the maintenance of oppression (Hardiman & Jackson,

1997).

This study will utilize the definition of internalized oppression as a process as well as a psychological state. Brown (1986) defines internalized oppression as “as the process by which a member of an oppressed or stigmatized group internalizes into her or his core identity and self-concept all or part of the negative stereotypes and expectations held by the culture at larger regarding that group.” (Brown, 1986, p. 100). The internalization of oppression occurs through socialization (Harro, 2010), intergenerational transmission and the adoption of the dominant groups beliefs in subordinate groups of the oppressive system (Fanon, 1967; Freire, 1970; Memmi, 1965).

The experience of internalized oppression may be the most harmful part of the system of oppression. Speight (2007) discusses the harmfulness of internalized racism, arguing that this negative consequence of oppression may actually lead to the most damage to an individual’s well-being. Speight (2007) also points out that as everyday experiences of racism become more subtle and covert. The subtle and covert nature of everyday experiences of racism have assisted in normalizing oppression as part of everyday life making the internalization of the dominant groups values easily transmitted and maintained. This is particularly harmful as the normalization of dominant values leads to the destruction of subordinate groups culture suggesting that the dominant group is normal, and the subordinate group is abnormal or inferior (Hardiman & Jackson, 1997;

Speight, 2007). Speight (2007) further discusses that although experiences of discrimination and harassment may assist the internalization of oppression, an individual doesn’t necessarily have to experience an incident of discrimination or harassment to know that they are viewed as inferior and to internalize that message. This phenomenon makes not only experiences of oppression incredibly harmful but also the internalization

of oppression harmful, as well. This has lead researchers to look at oppression as a traumatic experience, one that can potentially lead to PTSD symptoms.

Oppression as Trauma

The negative effects of oppression have long been researched (Adams, 1990;

Bloom, 1997; Klonoff & Landrine, 1995; Moradi & Subich, 2002; Pascoe & Richman,

2009, Velez, Moradi, DeBlaere, 2015) and there is literature to suggest that experiences of oppression lead to negative health and mental health consequences in minority groups.

Some trauma researchers have suggested that the negative effects of experiences of oppression should be considered as traumatic (Root, 1992, Vivero & Jenkins, 1999).

Further, Carter (2007) discussed how these experiences of race-related trauma lead to negative mental health consequences including traumatic stress. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) defines PTSD as the exposure, witnessing, or learning of a traumatic event that threatens ones’ life, serious injury, or physical integrity. After exposure to a traumatic event, PTSD is characterized by the development of posttraumatic symptoms in four different clusters: (a) intrusion,

(b) avoidance, (c) negative alterations in cognitions and mood, and (d) alterations in arousal and reactivity. Carter (2007) discussed how people of color are more likely to have higher rates of PTSD and experience more severe symptoms of PTSD than White individuals. The author also discusses that people of color experience higher rates of violence, which puts them at higher risk for developing posttraumatic symptoms and

PTSD. This discussion suggests that racism may play a part in the development of PTSD and influence the severity of the symptoms.

Further research in this area has illustrated that racism in its subtle, blatant, internalized and insidious forms is traumatic and that there is a link between experiencing oppression and the development of PTSD symptoms (Franklin, Boyd-Franklin, & Kelly,

2006; Helms, Nicolas, Green, 2010). This has led some scholars to call for a change in how the DSM defines trauma in a PTSD diagnosis, specifically in criterion A (definition of trauma) to include oppression-based trauma as part of that definition (Holmes,

Facemire, DaFonseca, 2016; Kira, 2001, 2010; Root, 1992; Carlson, 1997; Bryant-Davis

& Ocampo, 2005; Carter, 2007).

Kira (1997, 2001) offers a taxonomy of trauma that includes experiences of trauma that are not in the traditional definition of a criteria A trauma in the DSM-5 (

APA, 2013), including (a) attachment trauma (divorce, abandonment, parental death, loss of significant others), (b) autonomy/identity/individuation (feelings of inadequacy, alienation, incompetence), (c) interdependence or disconnectedness (moving from schools, moving states, loss of lengthy relationships), (d) achievement/self-actualization

(loss of employment, loss of money, loss of health), (e) survival trauma (war, witnessing death, attempted suicide, homicide), (f) factitious trauma (secondary trauma), (g) indirect or vicarious trauma (genocide), (h) one step transmission of trauma (clinicians, fire fighters, police), (h) generational family trauma transmission (family violence, incest), (i) historical trauma (slavery, Holocaust), and (j) multigenerational transmission of structural violence (poverty). Kira (2010) argues that marginalized groups can experience posttraumatic stress but also suggests that one group may not experience oppression the same way as other groups. However, Gilfus (1999) suggests that expanding criteria A to include oppressive experiences stops the victim-blaming that exists and actually

externalizes experiences of oppression as not part of the individual’s doing but the larger society. Giflus (1999) furthers that this inclusion would lead to actually addressing the issue of racism, sexism, heterosexism, and other oppressive experiences rather than pathologizing the individual.

Even though there has been research to show oppression is traumatic and has links to PTSD symptoms, there has been no change in regard to oppression in the current definition of a traumatic event in the most current edition of the DSM; the DSM-V (APA,

2013). The research on oppression as trauma and its link to posttraumatic reactions has historically been discussed when examining race-related trauma. However, there is a gap in the literature when considering the traumatic nature of sexism.

Sex-related Trauma, Sexism as Trauma, and Posttraumatic Reactions

Given the high rates of personal violence women experience, there is an extant amount of literature illustrating the negative effects on the psychological health for female survivors of trauma (Campbell, 2000; Johnson, Zlotnick, & Perez, 2008; Kemp,

Rawlings, & Green, 1991; Pico-Alfonso et al., 2006). However, less is known about women’s experiences with sexism and the development of PTSD symptoms. It could also be argued that sexism, like racism, can be viewed as traumatic.

There are many different types of sexism described in the literature, Swim et al.

(1995) described old-fashioned sexism which is the belief in traditional gender stereotypes that hold the notion that women are less capable than men. The adherence of these traditional gender role beliefs leads to the differential treatment of women compared to men. Benokraitis (1997) also described old-fashioned sexism as blatant sex discrimination which is the unconcealed and deliberate mistreatment of women based on

the belief that women are unequal. Blatant sex discrimination includes overt and purposeful sexist actions, including: sexist language, harassment, and physical violence.

This can also include overt mistreatment in all areas of a woman’s life, such as employment, education, politics, religion, and the family. Old-fashioned sexism is less accepted in our society than modern forms of sexism (Swim et al., 1995) with some researchers believing that the modern forms of sexism have replaced old-fashioned sexism because of an increase in feminist attitudes as well as, a societal belief that blatant sexism is morally wrong and unacceptable (Morrison, Morrison, Pope, & Zumbo, 1998;

Swim & Cohen, 1997; Twenge, 1997).

Benokraitis and Feagin (1995) coined the term “modern sexism”, in an attempt to describe the different types of overt and covert sexism that women experience. Modern sexism is conceptualized as being comprised of four different types of sexist discrimination: everyday (Benokraitis and Feagin's, 1995), ambivalent (Glick & Fiske,

1996), covert (Tougas, Brown, Beaton, & Joly, 1995), and neosexism (Swim & Cohen,

1997; Swim, Hyers, Cohen, & Ferguson, 2001). Glick and Fiske (1996) conceptualized ambivalent sexism as having two different constructs: benevolent sexism and hostile sexism. Benevolent sexism is the concept that stereotypical beliefs about gender roles that view women as less competent and weaker than men can be covert and seem positive in nature. For example, the traditional belief that men are physically stronger than women may lead a man to believe that he needs to help women in physical tasks. At a societal level, this seemingly positive behavior can lead to women being discriminated against when seeking jobs that may require them to do highly physical tasks, such as: military careers, police and fire department careers. Conversely, hostile sexism is the concept that

traditional views about gender roles leads to prejudicial beliefs about women and mistrust. Unlike benevolent sexism, hostile sexist acts are overt and blatant, ie., degradation, sexual harassment, rape, physical violence. Glick and Fiske (1996) view these constructs as independent yet related as both constructs lead to prejudicial attitudes towards women.

Tougas, Brown, Beaton, and Joly (1995) and Becker and Swim (2011) define neosexism as the belief that discrimination against women doesn’t exist and the resentment towards any equality movements. Neosexism is another subtle form of sexism that leads to continued discrimination against women. Covert sexism is also conceptualized as a subtle form of sexism and focuses on the act of engaging in discriminatory and deleterious treatment of women but doing so in a hidden fashion. For example, individuals may outwardly state that they support gender equality but behave in ways that hinder and sabotage women (Benokraitis & Feagin, 1995; Swim & Cohen,

1997). Covert sexism can be particularly insidious as individuals may outwardly support gender equality while intentionally engaging in sexist behaviors to make women fail.

Swim, Hyers, Cohen, and Ferguson (2001) conceptualized everyday sexism as the mundane everyday experiences of sexism that women encounter. Everyday sexism is another form of subtle sexism and Swim et al. (2001) note that it is also likely that the numerous incidents of sexism that women experience in a day may go unnoticed because the acts can be ambiguous in nature and women may have trouble with identifying them as sexist. These everyday experiences of sexism may have a cumulative effect on women and lead to distress (Swim et al., 2001). Gender microaggressions which can be defined as the intentional or unintentional common daily verbal, behavioral, or environmental

incidents that women experience which include derogatory and sometimes hostile insults.

Microaggressions tend to be unconscious to the individual committing them as they don’t necessarily know that they are doing something that is harming to another individual

(Capodilupo, et al., 2010; Nadal, Rivera, & Corpus, 2010; Nadal, 2011). Dovidio and

Gaertner (1998) and Twenge (1997) describe that oppression is becoming more subtle and covert and have become a daily experience in the lives of marginalized groups, including women and sexual minorities.

Even though there are many different terms for the experience of sexism, the more modern forms tend to focus on the perception of the discriminatory experience. The term “perceived discrimination” has debated as of recently, with some researchers finding the term offensive and likening it to the color-blind approach in the race literature. The term “perceived” conveys that discrimination might not actually be occurring or that the individual might be unrealistic with the idea that they are experiencing discrimination, when actually it is just simply discrimination and is a realistic ever-occurring experience

(Neville, Awad, Flores, 2013; Banks, 2014). However, some argue that the literature on perceived discrimination research is attempting to highlight the everyday incidents of discrimination that minority population’s experience and the subsequent distress that it causes.

The small base of literature on the intersection of sexism, trauma, and PTSD symptoms focuses on the perceived type of sexism termed “everyday sexism”. Klonoff and Landrine’s (1995) groundbreaking work on sexist discrimination, explored the concept of subtle everyday experiences of sexism and its effects on women. The researchers described sexual harassment, sexist name-calling, and systemic

discrimination, and how these daily experiences in women’s lives lead to psychological distress above and beyond regular life stress. The researchers also introduced the concept of chronic sexist discrimination and noted that the impact of having regular lifetime experiences of sexist discrimination may have different consequences in comparison to women who experience acute forms of discrimination.

Building on this research, Landrine and Klonoff’s (1997) subsequent study examined experiences of everyday sexism and results indicated that of the 652 women and of those women, 99% had experienced at least one sexist experience in their lifetime.

Swim, Hyers, Cohen, and Ferguson (2001) furthered this research by coining the term

“everyday sexism” and highlighting these everyday sexist events as harmful when accumulated over time. The researchers asked a sample of 40 women to keep diaries of their daily experiences of sexist events for two weeks. Results indicated that the women in their sample reported a mean of 2.05 sexist experiences a week with a range from zero to nine sexist experiences. The most common sexist experience reported was in the category of "traditional gender role prejudice and stereotyping", which comprised of incidents such as comments about stereotypical female traits, roles that are appropriate and not appropriate for women, and incidents of double standards for women. The findings suggest that women are experiencing these subtle types of sexist acts at high rates in their daily lives, but they are also experiencing such high rates of blatant overt sexism, that the everyday subtle sexist events may be going unnoticed by women, even though results still show they are leading to distress. The current study will utilize everyday sexism as the accumulated experiences of sexist experiences that lead to greater distress.

The role of internalized sexism has also been explored and this byproduct of oppression has been found to have a negative impact on women's psychological health.

Szymanski, Gupta, Carr, and Stewart (2009) explored internalized sexism, self- objectification, and the acceptance of traditional gender roles. With a sample of 274 heterosexual women and found that women who experience more reported sexist events also experienced higher levels of psychological distress. Interestingly, the researchers also found that internalized misogyny, a type of internalized sexism that describes the mistrust and dislike of other women based on an internalized belief that men are the superior gender, was a greater predictor of psychological distress in women. However, when sexist events and internalized misogyny were analyzed together, sexist events became the greater predictor of psychological distress over internalized misogyny. These results indicate that sexist events may lead to increased psychological distress in women and also internalized sexism intensifies the psychological distress women experience.

Additionally, these findings suggest that Speight’s (2007) argument discussed in the previous section about internalized racism in racial minorities may also be true for other marginalized populations, such as women. The comparison can be made between

Szymanski et al.’s (2009) results and Speight’s (2007) argument, since the findings indicate that women’s beliefs that they are less valuable than men actually lead them to experience sexist events in a more distressing way, which may be because they have internalized the sexism they experience and believe the sexist values of the oppressor.

Extending this mechanism, experiencing the distress of internalized sexism may influence and worsen women’s posttraumatic reactions when they experience a more overt traumatic event as well (ie. IPV or sexual assault). These types of overt sexist

experiences may affect women’s experiences with trauma and lead to the development of

PTSD symptoms.

Sexism and PTSD

In considering the link between sexism and PTSD, Berg (2006) explored everyday sexism and its effects on PTSD symptoms in 382 women. Berg was influenced by the work of Vivero and Jenkins (1999), who argued that discrimination based on sex and other marginalized identities effects self-esteem and well-being. Further, they argued that “discrimination trauma” be added to the PTSD diagnostic definition of criterion A in the DSM. Berg (2006) asserts that women generally report higher levels of PTSD than men and more severe symptomatology, even when factors such as, the number of traumatic events is controlled for. The researcher was primarily interested in exploring whether women who experience greater numbers of everyday sexist events experience higher levels of traumatic symptoms. Berg (2006) utilized a sample of 382 women who completed a measure of sexist events, a stress checklist based on gender, and a PTSD measurement. She found that 100% of women in her sample had experienced a sexist incident in the past year and within their lifetime. More than a third of the women also reported having been abused verbally, emotionally, or physically, sexually molested, sexually assaulted, or had been in abusive relationships with men. Results also showed that there was a relationship between everyday sexism and PTSD, and that recent sexist degradation (sexual harassment and disrespect) was the most predictive variable for developing PTSD symptoms. The results of this study suggest that sexism both affects women's posttraumatic reactions and their experience with trauma. It could also be argued that the everyday sexist event of sexist degradation may lead to posttraumatic

symptoms and PTSD, as well. Future research should seek to further explore the relationship between the everyday sexist act of sexist degradation and the development of posttraumatic symptoms.

Reisner et al.’s (2016) study of 452 transgender individuals and gender nonconforming women explored the transgender individuals’ experiences with discrimination, reasons attributed to discrimination, childhood trauma, intimate partner violence, depression, and PTSD symptom development. Reisner et al. (2016) utilized an everyday discrimination scale and then asked participants to identify the reason they attributed to each incident of discrimination experienced. Results indicated higher rates of

PTSD than the general population, experiences with IPV and childhood trauma even though when controlling for these experiences the high rates of PTSD still existed, indicating that regardless of trauma history, the experience of discrimination was still associated with PTSD. The results of this study suggest the importance of looking at experiences of oppressed identities including gender when looking at the impact on the development of PTSD symptoms. Reisner et al. (2016) also argues that because IPV rates are higher in LGBT women that research should be conducted further exploring the impact of IPV in the experience of oppression, as LGBT individuals experience IPV at higher rates and likely experience it due to discrimination related to their identity.

Balsam and Szymanski (2005) and Szymanski and Stewart (2010) discuss the importance of exploring intersecting identities when examining sexism’s effects on women. The intersection of identities is important to note as the researchers discuss how the more numerous the oppressed identities, the greater the experiences of discrimination and posttraumatic distress. Further, the intersection of these identities can lead to unique

forms of discrimination, which in turn may have increased negative psychological effects

(Szymanski, 2005). The researchers explored the concept of insidious trauma on lesbian women and their experiences of sexism and heterosexism, as well as their subsequent posttraumatic symptoms. The researchers explored this by utilizing two types of events: a traumatic event that would meet criterion A for a PTSD diagnosis (ie. heterosexist hate crime victimization) and also sexist and heterosexist discrimination (which does not meet the criterion A definition of trauma), and they examined the subsequent PTSD symptoms.

Results of both studies indicated that the experience of sexist and heterosexist discrimination both predicted for PTSD symptoms in lesbian women regardless of whether they experienced a hate crime or not (Szymanski, 2005; Szymanski & Stewart,

2010).

These findings suggest that sexism and heterosexism were as traumatic as experiencing a criterion A trauma (ie. hate crime victimization) and both lead to the development of PTSD symptoms. This supports the notion that criterion A of the DSM should be modified to include oppressive experiences as a traumatic event. It also suggests that sexist experiences may lead to an increase in PTSD symptomology in women regardless of experience of external oppression, especially women with intersecting minority identities, such as lesbian women. Since sexist external oppression can also include experiences like IPV, rape, and sexual assault, the findings would suggest that the experience of heterosexist external oppression (hate crime victimization) and having multiple identities that are oppressed may have a serious effect on women’s psychological health. These relationships should continue to be explored in future studies. The literature on sexism and its effects on trauma, sexism as a form of trauma,

and sexism’s effects on subsequent posttraumatic reactions suggest that sexism as a form of oppression does impact women’s experiences with trauma and posttraumatic reactions.

Heterosexism, Heterosexism as Trauma, and Posttraumatic Reactions

Heterosexism as trauma.

Another form of oppression that can lead to emotional distress and traumatic symptomatology in lesbian women is heterosexism (Otis & Skinner, 1996). Neisen

(1993) defined heterosexism as the continuous traumatic exposure to discrimination and prejudice in the lives of lesbian, gay, and bisexual (LGB) individual’s that influences their psychological well-being. Balsam (2003) explored heterosexism in lesbian and bisexual identifying women and how they experience what the author coined “cultural trauma” based on the traumatic nature of identity development and experiences of homophobia as a sexual minority. There may be a gendered element to heterosexist experiences and psychological trauma for women specifically, as men report more traumatic experiences than women overall but women experience higher rates of violence based on their gender and are also disproportionately more likely to develop PTSD and

PTSD symptoms during their lives (Norris, Foster, & Weishhar, 2002).

Cochran (2001) argues that utilizing the insidious trauma framework discussed in prior sections is also relevant for understanding the experiences and psychological well- being of LGB individuals. The author also reports a large disparity in mental health symptoms and disorders when compared to heterosexual individuals. There is much research that has been conducted that has found a relationship between LGB individual’s experiences with heterosexism, harassment, and violence leading to psychological distress, adverse health-related outcomes, and job-related consequences (Herek et al.,

1999; Lewis, Derlega, Berndt, Morris, & Rose, 2002; Mays & Cochran, 2001; Waldo,

1999).

Meyer (1995) explored the stigmatization of LGB identifying individuals and their experiences with oppressive events, coining the term heterosexism. Herek (1995) discusses the impact of heterosexism in LGB individuals’ experience of daily life.

Heterosexism may occur across many domains, including: educational, occupational, familial, social, and religion. An individual’s experience of heterosexism can vary from discrimination to harassment and violence. Mays and Cochran (2001) explored a sample of 73 LGB identifying individuals and 2,844 heterosexual identifying individuals surveying all participants on their daily and lifetime experiences with discrimination. The researchers also assessed for participant’s current and one-year prevalence for psychological distress, depression, anxiety, substance dependence, and overall rating of mental health. LGB identifying individuals reported higher rates of daily and lifetime discrimination. Approximately 73% of LGB individuals reported an incident of discrimination compared to 65% of heterosexual individuals. Furthermore, 42% of LGB individuals attributed their experiences of discrimination to their sexual orientation in contrast to 98% of heterosexual individuals believing their discrimination was not based on their sexual orientation. The researchers also found that perceived discrimination experiences were positively related to psychological distress, quality of life, and psychiatric morbidity. When the researchers controlled for the difference in discrimination experiences, psychiatric morbidity and sexual orientation were related.

The results of this study suggest that perceived heterosexism and experiences of

discrimination may lead to higher rates of psychological distress, and higher rates of psychiatric morbidity in LGB individuals.

Exploring prevalence of hate crimes and more severe forms of violence against

LGB individuals is not a new topic of research in the last few decades. The National

Institute of Mental Health in 1989 held an expert panel addressing that prevalence data for antigay violence should be a top priority for research and urged researchers to help collect data to assist the National Coalition of Anti-Violence Programs in the United

States (Herek & Berill, 1990; Harlow, 2005). In the past, data from the Federal Bureau of

Investigation had been used and did show that sexual stigma historically leads to criminal acts on LGB individuals, but they had only utilized convenience samples and failed to show how widespread LGB victimization is (Herek & Sims, 2007). Berill (1992) explored data from 1977 and 1991 including 24 studies, and found that all but one of these studies used a convenience sample of LGB individuals. The author argues that this is unique to heterosexist oppression as compared to other forms of oppression. The researcher found that 9% of the sample reported an aggravated assault with a weapon which they reported being due to their sexual orientation and 17% of respondents reported physical assault without a weapon due to their sexual orientation. Of the respondents, 44% reported threats of violence, 33% reported being chased or followed,

25% had objects thrown in their direction, 13% reported being spit on, and 80% reported being verbally harassed. Of the 24 studies, the majority did not separate data by their sexual orientation or gender (Berill, 1992).

Some research has been conducted focusing on LGB individuals as it relates to their age to explore the rates and pervasiveness of external heterosexism across the

lifetime in LGB individuals. Huebner, Rebchook, and Kegeles (2004) found in a sample of 1,248 gay and bisexual men aged 18-27 years that 5% reported experiencing physical violence against them in the last 6 months due to their sexual orientation. Pilkington and

D’Augelli (1995) explored a sample of 194 LGB individuals aged 15-21 years and found that 9% reported at least one aggravated assault with a weapon, 18% had experienced assault, 22% had been sexually assaulted, and 44% had been threatened with violence.

All of the respondents reported their victimizations being due to their sexual orientation.

D’Augelli and Grossman (2001) explored older LGB adults in their study of lifetime occurrence of hate crimes. There sample was 416 LGB individuals over the age of 59 years in the United States. The sample included 16% of individuals that reported being physically attacked in their lifetime, 7% had been sexually assaulted, and 29% had been threatened with violence. Szymasnki (2009) examined the relationship between heterosexist events and psychological distress in gay and bisexual identifying men. The sample included 210 gay and bisexual identifying men and the results indicated that men experienced at least one incident of rejection, harassment, or discrimination in the last year of their lives. Interestingly, rejection about gay and bisexual men was the highest with 52% reporting anti-gay remarks from family members, 34% reporting being rejected by family due to their sexual orientation, and 49% being treated unfairly by their family members. Experiences of heterosexism was related to psychological distress in gay and bisexual men. Further, self-esteem moderated the relationship between heterosexist events and psychological distress with low self-esteem being associated with increased risk of psychological distress.

Herek (2009) summarized many of these studies and argued that the way the data were reported was problematic in their categorizations of crimes and time frames, and because the majority of the studies utilized convenience samples, it becomes impossible to get an accurate prevalence rating of victimization against LGB individuals in the

United States. The author addressed the gap in the literature by not only looking at prevalence data for violence against the LGB population but also looking at their experiences with internalized stigma. The author conceptualizes these widespread experiences of violence in the LGB community as a result of sexual stigma, which is another term for heterosexism. Herek (2004, 2007, 2009) defines sexual stigma as the negative view by society for individuals who seem non-heterosexual due to their beliefs, identities, behaviors, relationships, or community. Sexual stigma leads to the belief system that homosexuality is lesser than heterosexuality and therefore manifests as discrimination at the individual and institutional levels, as well as leading to violent crimes against LGB individuals (Herek, 2009; Herek, Chopp, & Strohl, 2007). Herek

(2009) also explored a form of internalized stigma, which the author named felt stigma.

Stemming from the work by Scrambler & Hopkins (1986) felt stigma is an internalized response to the fear or threat of enacted stigma. The awareness of the threat of enacted stigma may lead LGB individuals to feel a subjective sense of threat which may cause them to act in protective ways to combat potential enacted stigma. For example, LGB individuals may hide their sexual orientation from others. This seemingly protective act can lead to many negative consequences, including feelings of shame, lack of normal social interaction, and potentially not obtaining necessary social support (Herek, 2007;

Herek, 2009).

Herek’s (2009) utilized a sample of 662 gay, lesbian, and bisexual identifying individuals in the United States and looked at eight types of enacted sigma in the areas of criminal victimization, harassment and threats, and discrimination (employment). The author assessed for felt stigma by asking three statements: (a) “Most people where I live think less of a person who is gay.” (b) “Most employers where I live will hire openly gay people if they are qualified for the job.” (c) “Most people where I live would not want someone who is openly gay to take care of their children.” The term “gay”, “lesbian”, or

“bisexual” were substituted in the questions based on how the participant initially responded. Results indicated that approximately 20% of LGB individuals had experienced a criminal victimization based on their sexual orientation. When factoring in attempted criminal victimization the percent increases to 25%. Half of the sample reported harassment (verbal abuse) and this was the most widespread experience of LGB individuals in the sample. Also, one out of every 10 in the sample reported housing or employment discrimination based on their sexual orientation. Gay men reported the highest rates of physical and property victimization with approximately 38% experiencing physical crimes, property crimes, or both types of criminal victimization.

Lesbian women were more likely than bisexual identifying men and women to experience criminal victimization and harassment. Results of the felt stigma data suggest that approximately 55% of the sample indicated some degree of felt stigma. Felt stigma was overall significantly higher in individuals who had experienced criminal victimization and employment discrimination in their lifetime. This data suggests that some individuals may attribute violent acts to their sexual orientation and more subtle acts (verbal abuse) as less about their sexual orientation because it is more ambiguous

(Herek, 2009). Given the retrospective self-report nature of the study no causal relationship can be determined. Although this study was groundbreaking in its exploration of the prevalence of LGB violence and internalized stigma, there are limitations to the study further than just its statistical analysis. Methodologically, the construct of felt stigma may have many more nuances than beliefs and feelings that you are inferior to heterosexual individuals because of your sexual orientation. For instance, the construct of felt stigma may also include expectations of rejection, hiding and concealing, and negative coping strategies (Meyer, 2007).

Results of these studies demonstrate the insidious nature of heterosexism and its effects on LGB identifying individuals ranging from the more subtle forms of verbal abuse, rejection, and harassment to the more blatant forms of physical assault, sexual assault, and aggravated assault. LGB individuals are not just at risk for hate crimes based on their sexual orientation but they are also more likely than heterosexual individuals to experience other forms of traumas in their lifetimes, such as childhood sexual, physical, and psychological abuse (Balsam, Rothblum, & Beauchaine, 2005; Corliss, Cochran, &

Mays, 2002; Hughes, Johnson, & Wilsnack, 2001). The prevalence for LGB individuals to experience sexual, physical, and psychological abuse in their families, as well as, rejection from their family members based on their sexual orientation (Szymanski, 2009) indicates that LGB individuals are at a higher risk for being targets of abuse in their childhood and adolescent by their family based on their sexual orientation.

Further, Herek et al (1999) explored the experiences of LGB-related hate crimes and the adverse mental health consequences of this blatant form of heterosexism.

Historically, LGB discrimination and prejudice has been accepted in our society and is

impacted by laws that are implemented in many states that make discrimination against sexual minorities legal and acceptable. The author discusses that when a LGB individual experiences a hate crime they may feel as if it was their fault or they deserve it based on the knowledge that their discrimination is not only legal but acceptable. Depending on where they are in their identity development, the individual may internalize these beliefs and ultimately have psychological distress based on their sexual orientation (Garnets et al., 1990). Much of LGB identity development is done through external sources and interactions, with many LGB individuals receiving negative messages from their family, community, and peers at an early age without learning effective coping skills for these experiences. Consequently, when an LGB individual experiences blatant heterosexist acts, ie hate crimes, they may be more likely to internalize the experience and believe it was just, which may lead to increased psychological distress and trauma-related symptoms (Herek et al, 1999).

Herek et al. (1999) looked at 1170 women and 1089 men who identified as LGB living in California. Approximately 1/4 of the men and 1/5 of the women had experienced an LGB hate crime at least once in their lifetime and approximately 2/5 of men and more than half of the women had experienced a crime that was not due to their sexual orientation, such as burglary and theft. In this study, men were more likely than women to experience an LGB hate crime but were less likely to experience a general crime against them, ie sexual assault. Moreover, individuals who had experienced a hate crime based on their sexual orientation within the past five years were more likely to have experienced increased anger, anxiety, depression, and posttraumatic stress compared

to individuals who had experienced non-LGB related crimes and individuals that had no experiences with crimes.

Szymanski and Chung (2003) explored the construct of internalized heterosexism in their study on internalized heterosexism for lesbian woman. This was in response to previous criticism of the definition of homophobia since it is not an irrational fear of lesbian individuals. The authors stated “lesbianism is a real threat to heteropatriarchal values and structures” and thus heterosexism is a better conceptualization of the oppression lesbian women experience (Kitzinger, 1996). The authors discuss the construct of internalized heterosexism broadly as LGB individuals internalizing society’s negative beliefs, values, attitudes, and assumptions about homosexuality (Szymanski &

Chung, 2003). Internalized heterosexism is believed to be something that all LGB individuals will experience in their lifetime and is viewed as a necessary developmental experience as a result of living their daily lives in a heterosexist society and experiencing heterosexist discrimination (Shidlo, 1994).

Previous research on internalized heterosexism in LGB individuals finds that transcending these internalized beliefs and growing a positive internalized identity about their LGB identity is the main construct in identity formation (Cass, 1979; Coleman,

1982; Lewis, 1984). However, until LGB individuals are able to overcome internalized heterosexism it is considered to be a great stressor in their lives and daily experiences

(Shidlo, 1994; Szymanski & Chung, 2003). Literature has found the concept of internalized heterosexism in lesbian and bisexual identifying women to be linked to depression, general distress, demoralization, alcoholism, low self-esteem, loneliness, and decreased social support (Radonsky & Borders, 1996; Herek et al., 1997; DiPlacido,

1998; McGregor et al., 2001; Szymanski et al., 2001). McGregor et al. (2001) studied the construct of internalized sexism in lesbian women who were being treated for early detected breast cancer and found that increased internalized heterosexism was related to increased psychological distress. However, the authors recognize the limitation of co- occurring experiences that can lead to psychological distress, such as cancer. None of these studies have specifically looked at factors associated with internalized heterosexism and internalized sexism in lesbian women.

Szymanski and Chung (2003) were the first authors to specifically look at factors associated with internalized heterosexism in lesbian women solely. One of the factors theorized in previous literature but never explored was the relationship between internalized heterosexism and feminist identification, attitudes about feminism, access to resources for coping, and involvement in the feminist community. The sample included

210 lesbian women and the authors found that internalized heterosexism was related to feminist constructs and suggests that lesbian women who also identify with feminist values have less internalized heterosexism and also were found to have more access to coping resources. The authors also argue that feminism is a resource for coping for lesbian women to cope with and combat oppression they experience. The findings are also consistent with previous research that suggests that sexism and heterosexism are linked and intersect to form a unique form of oppression for bisexual and lesbian women

(Herek, 1994).

There have only been three studies to date that explored heterosexism and internalized heterosexism’s effects on psychological health. Rotosky and Riggle’s (2002) study explored external and internalized heterosexism in lesbian and gay identifying

individuals in the work place. The researchers found that if an individual had less internalized heterosexism and the job site they worked at had a nondiscrimination policy in place, they were more likely to be more satisfied at their job and also more likely to publically identify themselves as lesbian or gay. Meyer’s (1995) study which focused on gay men and their experiences of discrimination and violence, internalized heterosexism, and perceived stigma, which were all found to be related to greater psychological distress. This study showed that internalized heterosexism moderates the relationship between experiencing external heterosexism (discrimination and violence) and psychological distress in gay men.

There has been only one study to date specifically looking at psychological distress from heterosexist events and internalized heterosexism in lesbian women.

Szymanski (2005) looked at the relationship between heterosexism and internalized heterosexism in 143 lesbian women that had experienced perceived heterosexist harassment, rejection, and discrimination, and their subsequent psychological distress.

The researcher found that lesbian women who had experienced a recent perceived act of externalized heterosexism had higher rates of psychological distress. Inconsistent with previous literature (Meyers, 1995) on gay men, they did not find that internalized heterosexism moderated the relationship between externalized heterosexism and psychological distress. These findings suggest that unlike the literature on gay men, lesbian women experience negative mental health consequences due to external heterosexism regardless of having internalized heterosexist beliefs (Szymanski & Chung,

2003). It is difficult to conclude whether there are gender differences from both of these findings about internalized heterosexism, as the authors used different measures on all of

their variables. There has been no research to date to further look at these constructs in lesbian women. Another important construct when exploring heterosexism as trauma is its links to posttraumatic stress disorder.

Heterosexism and PTSD.

From the previous literature discussed, it is clear that heterosexism and internalized heterosexism can be traumatic for LGB individuals and lead to psychological distress. Unlike the literature on sexism’s links to posttraumatic stress disorder (PTSD), even less is known about heterosexism and posttraumatic reactions. Many of the studies on LGB individuals’ psychological distress have focused on increased prevalence of heterosexist violence and mental health as compared to heterosexual individuals

(Cochran, 2001; Meyer, 2003). Mays and Cochran (2001) explored this link between higher rates of heterosexist events and psychological distress in LGB individuals. The researchers compared LGB experiences of daily incidents of discrimination with heterosexual identifying individuals and found that more than three thirds of LGB individuals experienced an incident of discrimination that they perceived was due to their sexual orientation. The researchers also found that 41.8% of LGB individuals indicated that they had any psychiatric disorder in the past year compared to 16.8% of heterosexual individuals. The rates for indicating that they had current high psychological distress for

LGB individuals was 26.8% compared to 16.8% of heterosexual-identifying individuals.

Previous literature has also demonstrated that experiences of LGB hate crimes has led to increased psychological distress in the areas of depression, anxiety, suicidal ideation, and self-esteem (Herek, Gillis, & Cogan, 1999; Otis & Skinner, 1996;

Szymanski, 2005; Waldo et al., 1998). Research has also been found to suggest that

experiences of heterosexism are related to psychological distress in racially and ethnically diverse samples of LGB individuals (Szymanski, 2006; Szymanki & Meyer,

2008; Szymanski, 2009; Sung, 2010) even though no research has been conducted to solely look at the intersection of racism and heterosexism in LGB individual’s experiences with traumatic heterosexist events and their posttraumatic reactions.

There have been three studies conducted that have explored PTSD symptoms in

LGB individuals and externalized heterosexism. Herek et al. (1999) which was discussed in the previous section found that LGB individuals who had experienced a hate crime based on their sexual orientation within the last 3-5 years had greater PTSD symptoms than LGB individuals who had not experienced a hate crime. D’Augelli, Grossman, and

Starks (2006) examined LGB individuals experiences with victimization based on their sexual orientation, current mental health, trauma symptoms, and PTSD. Their sample included 528 LGB youth (15-19 years) and they were assessed three times over the course of two-years on victimization and mental health symptoms. Approximately 80% reported verbal abuse, 14% reported physical assault, and 9% reported sexual assault because of their LGB identity. The participants reported verbal abuse beginning at the age of 11 years for males and 14 years for females that they related to being perceived as

LGB. The participants also reported that nearly all of their perpetrators were male and males were more likely to report victimization than females. The authors theorize that because they were also exploring “gender atypical behavior” in childhood, that the higher rates in males could be based on society’s acceptance of female nontraditional behavior in youth (tomboy) compared to male nontraditional behavior (D’Augelli, Grossman, &

Starks, 2006). These findings highlight the importance of looking at sexism as it interacts

with heterosexism in LGB individuals. D’Augelli, Grossman, and Starks (2006) also found that 9% of LGB youth met criteria for PTSD and it was related to both physical and verbal violence. Females were significantly more likely to have a PTSD diagnosis than males.

Szymanski and Balsam (2011) is the only study to explore experiences of heterosexism and PTSD symptoms specifically in lesbian women. There is a large literature base that shows that lesbian women experience higher rates of trauma in their lifetimes than heterosexual women, including childhood abuse and abuse in adulthood

(Balsam, Rothblum, & Beauchaine, 2005; Corliss, Cochran, & Mays, 2002; Hughes,

Johnson, & Wilsnack, 2001; Moracco, Runyan, Bowling, & Earp, 2007; Tjaden,

Thoeness, & Allison, 1999). Lesbian-women are also experiencing a wide range of traumatic events based on their lesbian identity or perceived lesbian-identity, as well.

Herek, Gillis, and Cogan (1999) found that 19% of lesbian women reported an incident of lifetime physical assault based on their identity. Herek (2009) that was outlined in the previous section found that 12.5% of lesbian women had experienced a physical assault in their lifetime and 54% had been verbally abused or verbally harassed. With the evidence that lesbian women experience higher rates of traumatic events in their lifetimes, higher rates of violence, and the fact that women in general experience higher rates of PTSD, it is shocking that only one study to date has been done to look at these constructs in lesbian women.

Szymanski and Balsam (2011) had a sample of 247 lesbian women that had experienced either a heterosexist-based hate crime or general heterosexist discrimination

(harassment, rejection) and their subsequent PTSD symptoms. The authors explored both

of these types of experiences because a hate crime would meet criteria A for PTSD where heterosexist discrimination would not, arguing that the PTSD diagnosis should include experiences of oppression as traumatic. Both types of heterosexist acts were found to both be predictors of PTSD symptoms in lesbian women. These findings suggest that experiences of heterosexism in general lead to PTSD symptomatology in lesbian women.

Szymanski and Balsam’s (2011) findings also suggest that experiences of oppression are experienced as traumatic and can lead to negative mental health consequences, including PTSD. This adds to a growing literature base (Alessi, Meyer, &

Martin, 2011; Gold, Marx, Soler-Baillo, & Sloan, 2005; Holmes, Facemire, DaFonseca,

2016; Long et al., 2008; Weathers & Keane, 2007) that suggests that Criteria A be adapted to include experiences of discrimination as traumatic and that they can lead to the development of PTSD. Szymanski and Balsam (2011) also found that self-esteem only partially mediated and did not moderate the relationship between heterosexist discrimination and PTSD symptoms. This finding suggests that regardless of how a lesbian woman feels about herself, heterosexist experiences still cause negative mental health consequences.

Intimate Partner Violence

Another form of trauma that lesbian women are likely to experience is intimate partner violence (IPV). Previous literature suggested that LGB experiences with IPV were as common as heterosexual partner violence, and some suggest that IPV rates are even higher in sexual minority women (Farley, 1996; Renzetti, 1992). Similarly to heterosexual women who experience IPV, lesbian women are just as likely to hide the violence they experience (Lobel, 1986). Historically, people have not recognized same

gender relationships because intimate partner violence has mostly been portrayed as male violence against women. LGB relationships have exclusively been viewed as having less apparent power differentials as there is no male and female dynamic and therefore people have viewed this as a mutual behavior which has led to the belief that the victim has a part in their abuse (Farley, 1996; Renzetti, 1992). The majority of the research on intimate partner violence in same gender relationships has mostly been done on gay identifying men. Island and Letellier (1991) approximated that around 500,000 gay men are victims of intimate partner violence. There is less known about the prevalence of abuse in lesbian relationships and reports vary widely.

The reports of intimate partner violence in same gender relationships are likely low due to internalized heterosexism, stigma, fear, and a shortage of services for lesbian women (Renzetti, 1996). Renzetti (1996) discusses the fears associated with lesbian women utilizing shelter services. Lesbian women report a fear of rejection from shelters and shelter residents, and a fear that a same gender perpetrator could gain access to them in the shelter system. Research also suggests that protection orders fail in general for victims of intimate partner violence with evidence suggesting that the majority of intimate partner violence perpetrators offend again within two years of having a protective order on them, 29% have been found to offend with severe violence in their subsequent acts (US Department of Justice, 1998). Many states legal systems do not give the same protection to individuals in same gender relationships (DaLuz, 1994; Fray-

Witzer, 1999; Lundy & Leventhal, 1999; NCAVP 1997) and within states that do have protections, it’s likely that law enforcement agents and judges will not enforce them

equally to same gender victims as they do with heterosexual partnered victims (Lundy &

Leventhal, 1999).

These findings highlight the importance of examining lesbian women’s experiences with heterosexism and sexism, trauma especially intimate partner violence, and subsequent posttraumatic reactions and PTSD. Research has focused on exploring multiple oppressions either in an additive framework or in an interactional framework.

Relevant research will be discussed.

Theorizing Multiple Oppressions

As outlined above the psychological stress that occurs for being a member of a minority group has long been researched, especially for racial and ethnic minorities

(Allport, 1954; Crocker & Major, 1989). There are three primary approaches to investigating the impact of multiple oppressions: additive, interactional (i.e. multiplicative), and intersectional. The additive perspective suggests that each form of oppression will accumulate (or add together) with each unique form of oppression leading to negative mental health consequences (Moradi & Subich, 2003). The interactional, or multiplicative perspective purports that multiple forms of oppression are multiplicative, in that each experience of oppression does not add together but rather interacts and multiplies the experience of oppression, so that it’s just not the experience of sexism plus heterosexism but also plus sexism multiplied by heterosexism (Moane,

1999; Mullaly, 2002; Young, 1990). Intersectional theory suggests that individuals are a part of multiple social groups, including dominant and subordinate membership and that they can therefore experience privilege and disadvantages simultaneously based on different identities. Therefore, one membership does not define an individual’s

experience of oppression but the intertwining nature of all oppressed and privileged identities (Collins, 2000).

Wong, Liu, and Klann (2017) provided three research paradigms for utilizing intersectional theory when conducting social science research: (a) the intergroup paradigm, (b) the interconstruct paradigm, and (c) the intersectional uniqueness paradigm. Levant and Wong (2017) described the intergroup paradigm as including group comparisons of multiple social identities in quantitative research. The authors describe the interconstruct paradigm as research that explores relationships in constructs that are based on multiple social idenitities. Additionally, the researchers define the intersectional uniqueness paradigm which assumes that multiple social identities are inherently linked which creates intertwined experiences based on these social identities.

Levant and Wong (2017) note that though these three paradigms are broad they can be applied to all social science research on intersectionality theory.

Current research in sexism and heterosexism has focused on the additive and interactional perspective though much research has begun to focus solely on the interactional perspective (Ragins, Cornwell, & Miller, 2003; Szymanski, 2005;

Szymanski, 2008; Szymanski, 2009; Szymanski, 2012; Szymanski & Henrichs-Beck

(2014) Szymanski, Kashubeck-West, & Meyer, 2008; Velez, Moradi & DeBlaere, 2015).

Interactional theory is still primarily used in the study of sexism and heterosexism because gender is seen as the primary force in the oppression of sexual minority individuals (Herek, 1994; Pharr, 1988; Szymanski & Owens, 2009). Szymanski and

Owens (2009) state “heterosexism acts as a weapon of sexism by enforcing rigid gender roles and compulsory heterosexuality”. In one study looking at intersectionality in

college-aged sexual minority women’s experiences with discrimination and their relationships with identity and collective action, Friedman and Campbell (2010) found that there were significant interactions between sexual orientation identity and feminist and LGBQ activism, however when including gender identity, they found no significance. This finding indicates that gender identity is more complex and may differ in lesbian and bisexual women. Results also indicated lesbian women reported higher rates of heterosexist discrimination and had higher scores in their gender identity measure. Friedman and Campbell (2010) discuss their findings suggest a difference in sexual minority identity and gender identity in lesbian women compared to bisexual women and that future research should be done to understand sexual minority women’s identities with their gender and sexual orientation. Comparing lesbian women to bisexual women and to heterosexual women continues to be an issue in the research base and these results also show the importance of studying lesbian women separately and exploring the interaction of experiences of gender and sexual orientation. Also, the results of this study were primarily correlational, so future research should also to continue to explore the intersectionality of lesbian women’s experiences.

Pharr (1988) also argues that combatting heterosexism must include traditional gender roles because inherently sexism is the driving force. Pharr (1988), Szymanski and

Owens (2009), and Szymanski and Carr (1988) all argue that gender is the root of heterosexism and without challenging traditional gender roles we maintain both forms of oppression. Research (Ragins, Cornwell, & Miller, 2003; Szymanski, 2005; Szymanski,

2008; Szymanski, 2009; Szymanski, 2012; Szymanski & Henrichs-Beck, 2014;

Szymanski, Kashubeck-West, & Meyer, 2008; Velez, Moradi & DeBlaere, 2015)

suggests that the interaction between sexism and heterosexism in lesbian women’s experiences may be of more salient to this population in comparison to other identities because of the gender component, whereas lesbian women may be able to experience discrimination or internalize negative messages about themselves based on being a woman or about being a sexual minority, not necessarily solely on being a lesbian.

However, there are criticisms of the additive and interactional models since research (Crenshaw, 1989; King, 2003; Lewis & Neville, 2015; Buchanan, 2005;

Thomas, Witherspoon, & Speight, 2008; Cole, 2009) on other identities, especially in the literature on racism which currently focus on an intersectional approach. Research investigating African American women’s experiences with oppression utilizing an additive and interactional model (Moradi & Subich, 2003; Szymanski & Stewart, 2010) found significant results that sexism and racism lead to increased psychological distress but neither found interaction effects. The interaction perspective when exploring internal and external oppression has had support and criticisms (Feinstein, Goldfried, & Davila,

2012; Meyer, 1995; Rostosky, Riggle, Horne, & Miller, 2009; Szymanski & Ikizler,

2013; Szymanski & Stewart, 2010; Szymanski & Sung, 2010; Velez, Moradi, &

DeBlaere, 2015). Moradi & Grzanka (2017) discuss the importance of intersectionality in the field of counseling psychology as it reflects on the values of the field. It is important to note, that there is also support for exploring interactional theory not only in the sexism and heterosexism literature but also in the racism and heterosexism literature (Szymanski

& Meyer, 2008; Szymanski & Gupta, 2009; Thoma & Huebner, 2013) as well as support for exploring causal paths in external and internalized oppression with mental health outcomes (Hatzenbuehler, 2009; Velez, Moradi, & DeBlaere, 2015). Grzanka, Santos, &

Moradi (2017) discuss the importance of intersectionality research in the field of counseling psychology to include activism and coalition building, as well as addressing the limitations of the measures currently available that may not be capturing intersectionality. Additionally, the authors discuss the importance of interdisciplinarity in counseling psychology’s research on intersectionality and that researchers should actively challenge the oppressive institutions they research. There has been research (Bauer, 2014;

Bowleg, 2008; Cole, 2008; Grzanka & Frantell, 2017; Hancock, 2007; Luna, 2016;

Mallinckrodt, Miles, & Levy, 2014; Syed, 2010) that have attempted to utilize these approaches individually, however the authors suggest that counseling psychologists strive to conduct research that includes all of these suggestions. Szymanski and Henrichs-Bech

(2013) noted that the lack of quality measures to assess intersectionality for lesbian women and the lack of empirical research exploring these constructs for sexual minority women in general has prevented researchers from being able to explore this perspective fully.

The current study will focus on interactional theory because of the support for utilizing this approach in lesbian women when exploring sexism and heterosexism, as well as results found in much of the research that heterosexism is a tool to further sexism creating an interaction between the two (Pharr, 1988; Szymanski & Carr, 2008;

Szymanski & Owens, 2009). However, future research should explore the unique interactions of the multiple oppressions of lesbian women and their experiences with psychological well-being.

The research on multiple oppressions including heterosexism has focused on two theories: Minority stress theory (Brooks, 1981; Meyer, 1995; 2003) and Multicultural-

feminist theory (Cole, 2009; Moradi & Subich, 2002b; Moradi & Subich, 2003), which have incorporated additive, interactional, and intersectional approaches. Though the two theories conceptualize additive similarly, they have distinct differences in how they conceptualize the interactional approach.

Multicultural and Feminist Theories

The interaction of multiple oppressions literature stems from the Multicultural and

Feminist theories (Cole, 2009; Moradi & Subich, 2002b; Moradi & Subich, 2003). For example, Cole (2009) discusses the concept of intersectionality in psychology research focusing on feminist and critical race theories. Historically, researchers have focused on one identity in order to simplify models or by excluding them by controlling for other identities that their participants identify as (Betancourt & Lopez, 1993). Cole (2009) argues that the majority of individuals identify in more than one category of social identities and that these multiple identities may interact and intersect with one another in many ways. Cole (2009) explains the history of intersectionality and places its roots beginning with a group of African American Feminists called the Combahee River

Collective and their manifesto in 1977 and 1995. The authors were expressing their inability to distinguish their race from their gender from their class because “they are most often experienced simultaneously” (p.234). Intersectionality has long been a part of political, liberation, and civil rights movements while more recently becoming a part of academic research and feminist studies (Cole, 2009; McCall, 2005; Risman, 2004).

However, research on sexism and heterosexism differs from the argument that

Cole (2009) was making in that it is argued that gender and sexual orientation are not experienced simultaneously but rather because of strict gender roles that are experienced

by being a woman and by being a sexual minority, lesbian women may be able to experience discrimination or internalization of oppression for both identity statuses separately at times as well as together (Pharr, 1988; Szymanski & Carr, 2008; Szymanski

& Owens, 2009). This is a unique experience for lesbian women compared to other minority individuals where both identities may be more salient at any given time.

Multicultural and feminist research has primarily looked at the interaction between sexism and heterosexism rather than the interaction of a combination of identities simultaneously.

Multicultural-Feminist theories have primarily been utilized in the study of sexism solely and as one of the forms of multiple oppressions. However, the theory began with an additive approach to looking at multiple oppressions and then led to an interactional perspective. The additive approach to looking at multiple oppressions suggests that having multiple experiences of internalized oppression and multiple experiences of externalized oppression add together to affect mental health, and that it is the additive nature of having more forms of oppression that ultimately leads to negative mental health consequences (Meyer, 1995; Szymanski, 2006). Gilbert (1992) spoke to counseling psychologists directly arguing that counseling psychologists should have an understanding of how sexism affects every area of a woman’s life. There is much research to show the negative effects that sexism has on women in all domains; ie occupational discrimination, rape and sexual assault, abuse, and other forms of sexist discrimination (Fitzgerald, 1993; Koss, 1993; Koss, Heise, & Russo, 1994; Browne,

1993, Carden, 1994; Landrine & Klonoff, 1997). Landrine et al. (1995) and Klonoff and

Landrine (1995) conceptualized sexist events as distal and proximal predictors of mental

health outcomes. In this model, distal predictors are sexist events that a woman has experienced throughout her lifetime, whereas proximal predictors are sexist events that a woman has experienced recently (past year). In Landrine et al. (1995) the authors found that experiences of sexism were related to their psychological symptoms above and beyond their daily life stressors. These types of perceived lifetime and recent sexist events can be viewed as external oppression.

The multicultural-feminist research on racism and sexism in African American women (Beal, 1970; Jeffries and Ransford, 1980; Ladner, 1971) began also with an additive approach to the multiple oppressions of racism and sexism. For example, Beal’s

(1970) suggested that racism and sexism have direct effects on African American women independently but that the combination (additive) of the multiple oppressions are what impact African American women’s lives. Even with the support for the additive approach to exploring multiple oppressions, multicultural-feminist researchers began to theorize that it is not just the added effect of internalized and externalized oppressions that were affecting mental health in minority individuals but an interaction effect between types of oppression. There was a shift in the research to suggest that there is something unique about the experience of internalized oppression versus the experience of externalized oppression. So, researchers started to explore the interaction of types of oppression that worsen experiences of other types of oppression. For example, the internalization of sexism may worsen the link between internalized heterosexism and psychological distress, or the experience of sexist externalized oppression (discrimination) may worsen the link between experiences of heterosexist externalized oppression (discrimination) and psychological distress. Much like the additive perspective, interactional theory is looking

at the accumulation of forms of oppression but also how they interact and affect the other form of oppression and mental health consequences (Velez, DeBlaere, & Moradi, 2015).

Landrine, Klonoff, Alcarez, et al. (1995) applied an interactional conceptualization of sexism and racism when they suggested that racism may intensify the impact of sexism and vice versa. However, Moradi & Subich (2003) were the first to explore the additive and interactive links of sexism and racism with psychological distress in African American women. Results indicate that sexism and racism separately, and also a higher number of perceived racist or sexist events all related to higher levels of psychological distress in African American women but when explored additively, only sexist events were a unique predictor of psychological distress and the researchers found no interaction effect between racist and sexist experiences. The researchers suggest that this may be due to the measures they used as participants may have fused their racist and sexist experiences and that women may feel there is no distinction in these identities. The authors argue that future research should look at more subtle forms of oppression rather than solely overt to better capture intersectionality. However, this research did suggest that there may be something unique about types of oppression and how women perceive their experiences of sexism and racism since the results indicated significance with sexism and racism separately.

Feminist theory has also historically focused on sexism as a root of the high rate of IPV in women (Figes, 1970; Millett, 1970). MacKinnon (1987) argued that the pervasiveness of violence against women by men makes the oppression of sexism the most widespread form of oppression globally. Simpson and Helfrich (2014) stated that feminist theory and radical feminism has helped to recognize “a global epidemic of

culturally sanctioned violence against women” (p.443). Historically, the theory has not helped to understand the high levels of intimate partner violence within same-gender relationships (Renzetti, 1998; Ristock, 2003; Simpson & Helfrich, 2014). Carvalho, et al.

(2011) argues that because of minority stressors that are unique to lesbian women may affect the impact of IPV, such as: conflict due to the relationship being out publically, threats to “out” partners to family and employers, lack of social support, absence of a lack of resources, fear of discrimination in the legal system and in shelters, and fear of discrimination in accessing services (Ristock, 2005; Murray et al., 2007; Kulkin et al.

2007).

Balsam’s (2001) reported that 60% of women in the study stayed in the abusive relationship because of a lack of resources and the majority did not go to a shelter. Within

Meyer’s (2003) minority stress model this would include experiences of internalized heterosexism and internalized sexism, which have been found to be related to negative mental health outcomes including PTSD (Hatzenbuehler, 2009; Meyer, 2003; Franklin,

Boyd-Franklin, & Kelly, 2006; Carter, 2007; Helms, Nicolas, Green, 2010). The results

(Reisner et al., 2016) discussed earlier in transgender individual’s experiences with oppression, IPV, and PTSD also suggests that we don’t understand the impact of IPV on

LGBT individual’s experiences with trauma and the trauma of oppression and future

PTSD symptom development. There is no study to date that explores the experiences of internalized and externalized oppression on lesbian women’s development of PTSD symptoms and the impact that experiencing IPV has on that relationship. The other theory primarily utilized in the study of sexism and heterosexism is minority stress theory

(Brooks, 1981; Meyer, 1995, 2003).

Minority Stress Theory

Minority stress theory suggests that individuals in stigmatized minority groups experience excessively high rates of stress and negative life events due to the discrimination and prejudice that they experience as a minority individual (Brooks, 1981;

Meyer, 1995, 2003). Meyer (2003) suggests that minority stress is socially-based and chronic, meaning that there is an additive effect to other life stressors that an individual may experience. Minority stress is created from societal institutions and processes not the individual. As it pertains to lesbian women, Brook’s (1981) book reviewing minority stress in lesbian women and defined the construct as a psychological stressor that minority individuals experience solely from being aware of their minority status. Meyer’s

(1995) study was the first to look at minority stress as a construct for gay –identifying men and argued that like other minority groups, gay individuals also experience chronic stress due to discrimination. Historically, the theory of minority stress has its roots in social and psychological orientations and theorizes that there is a conflict that is experienced by individuals in a minority group based on society’s dominant values and the minority group’s values conflicting resulting in difficulties socially for minority group individuals because they possess less social power (Mirowsky & Ross 1989;

Pearlin 1989; Meyer, 1995). Some researchers have argued that the experience of such a conflict for individuals is at the root of all stress that minority individuals experience in society, with some research suggesting that it leads to feelings of alienation and isolation

(Durkheim 1951; Lazarus & Fokman, 1984; Merton, 1968; Moss 1973; Thoits, 1999).

Minority stress theory suggests that the experiences of externalized oppression

(discrimination) leads to the internalization of that oppression in minority individuals

which may ultimately lead to psychological distress. This theory suggests that internalized oppression is the concept that is affecting the link between experiences of external oppression and psychological distress, but little is known about these effects on lesbian women.

Brook’s (1981) groundbreaking work on lesbian individuals and minority stress described that LGB identifying individuals live in an “ascribed inferior status” (p.78).

Meyer’s (1995) study provided this framework when looking at internalized homophobia as the amount a gay-identifying individual internalizes and believes the negative attitude society has for gay people. For LGB identifying individuals, the internalization of these negative attitudes can begin when they start exploring and questioning their sexual identity or when they begin to label themselves (Meyer, 1995). The exploration and labeling as LGB often takes place before an individual “comes out” or publicly informs friends, family, etc of their identity status (Thoits, 1985; Thoits, 1999). The research suggests that this may be the time LGB individuals start internalizing the negative societal views about themselves and the process of chronic minority stress begins

(Brooks, 1981; Stein & Cohen, 1984; Meyer, 1995; Meyer, 2003). However, an LGB individual does not need to self-identify or self-disclose as LGB to experience stigmatization (Brooks, 1981). Another example of how internalized oppression may affect psychological well-being is Meyer’s (1995) study which utilized the framework of minority stress including three conceptualizations: internalized heterosexism, perceived stigma, and experiences of externalized heterosexism (discrimination and violence).

Results indicated that gay men had high rates of minority stress in all three conceptualizations and all three were independently significant. Additionally, all three

conceptualizations were overall and independently related to negative mental health outcomes: psychological distress during the past year, demoralization, guilt, sexual problems, suicide, and AIDS-related traumatic stress (distress related to the effects of the

AIDS epidemic). Results suggest that the greater the internalization of the experience of heterosexism with the experience of externalized heterosexism (discrimination and violence) led to worse mental health consequences. This suggests that lesbian women may also experience high rates of internalized heterosexism which may lead to increased mental health consequences.

Meyer’s (2003) follow-up work provided an updated framework of the researcher’s previous work extending the research on internalized oppression by exploring two new conceptualizations of stressors: distal and proximal minority stress.

Stemming from Lazarus and Folkman’s (1984, p. 321) definition of social structures:

Distal concepts whose effects on an individual depend on how they are

manifested in the immediate context of thought, feeling, and action—the proximal

social experiences of a person’s life.

Meyer (2003) proposes that these stressors are on a continuum from distal to proximal.

Distal stressors are the overt discriminatory events that LGB individuals experience that do not need an individual’s perception of them. For example, violence, hate crimes, and harassment base on sexual identity. Distal stressors can also exist at the institutional, procedural, and structural levels; such as, legislation that exists or is enacted to target

LGB individual’s legal rights or ability to gain safe employment, housing, education, and marriage (Rostosky et al., 2010). Meyer (2003) proposes distal stressors as a type of external oppression. Proximal stressors are the subjective stress intra-personally based on

an LGB individual’s experiences and self-identity. Proximal stressors can lead to internalized oppression and can manifest itself in expectations of rejection (based on

LGB identity), concealment (hiding LGB identity out of fear of being harmed), or internalized stigma (internalized homophobia). There are many terms to describe the experience of internalized oppression for LGB individuals: internalized homophobia

(Meyer, 1995; 2003), internalized heterosexism (Szymanski, Kashubeck, & Meyer,

2008), and internalized homonegativity (Mohr & Kendra, 2011). Even though, all of these terms are attempting to explain the experience of internalized oppression in LGB individuals, the concept of internalized homophobia in Meyer’s (2003) study is more accurately represented by the construct of internalized homonegativity. Internalized homonegativity refers to the demoralization constructs of feeling one’s self as negative, deserving of derogatory treatment, and denigration of character based on the internalization of heterosexist values and expectations regarding their LGB identity

(2011). So, even though Meyer (2003) is including parts of the construct of internalized heterosexism, the proposed construct focuses more on the self-blaming attributes of internalized heterosexism.

Distal and proximal minority stressors are viewed to be chronic and negatively associated with LGB identifying individual’s well-being and mental health outcomes

(Meyer, 2003). Meyer, (2003) also gives a framework of understanding how multiple oppressions affect each other and how external and internal oppressions together affect

LGB individual’s mental health. This framework conceptualizes heterosexist discrimination (external oppression) and internalized heterosexism (self-blaming attributions) will interact with mental health both individually and combined. Other

research has been conducted exploring internalized oppression as a mediator for a causal link with external oppression and mental health outcomes (Hatzenbuehler, 2009).

Meyer’s (2003) and Hatzenbuehler’s (2009) research continues to support the idea that internalized oppression is the concept that is worsening the link between experiences of externalized oppression and negative mental health consequences. However, it has not been consistent since there have been other research that has not found this link

(Szymanski & Ikizler, 2013; Szymanski & Stewart, 2010; Szymanski & Sung, 2010).

There has been more support for the interaction rather than mediation, especially in the racism and heterosexism literature (Szymanski & Gupta, 2009; Szymanski & Meyer,

2008; Thoma & Huebner, 2013), which supports the notion of exploring interactional theory in lesbian women. Since there is support for both multicultural-feminist theory and minority stress theory when exploring LGB individual’s mental health outcomes, the current study will explore both theories and a combination of the two when looking at the interaction between sexism and heterosexism in lesbian women’s subsequent PTSD symptoms.

Integrating Interactional Theories

Both minority stress theory and multicultural-feminist agree that external and internalized oppressions affect individuals in minority groups and their mental health, which includes lesbian women’s experiences with heterosexism and sexism. The distinction between minority stress theory and multicultural-feminist theory is that minority stress theory would conceptualize the negative mental health outcomes as coming from the internalization of one identity affecting the link between experiences of externalized discrimination of the same identity and psychological distress; such as

higher internalization of sexism may interact and affect the link between greater perceived incidents of externalized sexism and posttraumatic symptoms. Multicultural- feminist theory conceptualizes that one form of oppression interacts and affects the link of the other form of oppression and psychological distress. For example, the greater internalization of sexism may interact and affect the link of the internalization of heterosexism and posttraumatic symptoms (Velez, Moradi, & DeBlaere, 2015).

There is also research (Binning, Unzueta, Huo, & Molina, 2009; Jackson, Yoo,

Harrington, & Guevarra, 2012; Roccas & Brewer, 2002; Shih, Young, & Bucher, 2013) to suggest that a combination of multicularal-feminist and minority stress theory may be a better approach as interactions may be complex due to resilience and protective factors.

For example, if an individual experiences little internalized oppression for one minority identity it may be protective when they experience external discrimination for another minority identity, and there may be little to no mental health outcomes. As the above research and mixed results suggest, the way individuals experience oppression and identity development is extremely complex and some individuals may use an identity that they view as less marginalized to cope with the experiences of the discrimination of the other identity. The research on this “buffering effect” should be considered when exploring a potential combination of minority stress and feminist-multicultural frameworks.

Support for additive and interactive links in sexual minority samples is definitely mixed and the majority of the research has focused on racism and heterosexism. No study to date has compared additive and interactive links with sexism and heterosexism in lesbian women who experience trauma, and specifically looking at their posttraumatic

reactions as an outcome. Szymanski’s (2005) study on heterosexism and sexism as correlates of psychological distress in women found support for an interaction of the identities, as the experience of heterosexist victimization in lesbian women strengthened the link between sexist discrimination and psychological distress.

Velez, Moradi, and DeBlaere (2014) explored multiple oppressions and the mental health of sexual minority Latina/o individuals. The study sampled 173 sexual minority Latina/o individuals and investigated the additive and interactive relationships between heterosexism and racism, specifically looking at external oppression as racist discrimination and heterosexist discrimination, and internalized oppression, as internalized racism and internalized heterosexism, with outcomes of psychological distress, lower life satisfaction, and lower self-esteem. The study results showed that there was an additive effect of racist discrimination, heterosexist discrimination, and internalized heterosexism but not internalized racism with psychological distress.

However, internalized racism and internalized heterosexism both had relationships with lower life satisfaction and lower self-esteem. This suggests that the additive framework is supported somewhat but mainly when looking at internalized oppressions links to well- being. The interaction framework results that looked at both minority stress and multicultural-feminist theories found support for an interaction between racist discrimination and heterosexist discrimination and both internalized oppressions; internalized racism and internalized heterosexism. These findings suggest that the multicultural-feminist framework of looking at how one type of oppression affects the other form of oppression was better supported for psychological distress than the minority stress model which found that the heterosexist discrimination and internalized heterosexism interaction were

all non-significant with psychological distress. However, when looking at self-esteem, they all accounted for unique variance. This would suggest that an integrative framework of both the minority stress model and the multicultural-feminist model, or what the authors call “synthesized” would be better explored when looking at multiple oppressions.

Interestingly, the findings on internalized racism and self-esteem showed that even when perceived racist discrimination was low, Latina/o individuals with either low or high internalized heterosexism all had similar levels of self-esteem (Velez, Moradi, &

DeBlaere, 2014). Further, when there was high racist discrimination, the individuals with lower internalized heterosexism had higher self-esteem compared to those with high internalized heterosexism. When looking at the same concept in heterosexist discrimination and internalized racism, self-esteem stayed the same for individuals who had low or high internalized racism when perceived heterosexist discrimination was low

(Velez, Moradi, & DeBlaere, 2014. However, when there was high perceived heterosexist discrimination, self-esteem was higher in those with low internalized racism. These findings suggest that internalized racism did in fact interact with heterosexist discrimination by increasing low self-esteem when individuals experienced high rates of perceived heterosexist discrimination. Whereas, the interaction of racist discrimination and internalized heterosexism suggest an increase in self-esteem for individuals who experience high perceived racist discrimination and low internalized heterosexism. These findings show the complexity of these interactions but do support the above-mentioned literature that some individuals with low internalized oppression protect their self-esteem even when faced with high rates of discrimination on other identities (Velez, Moradi, &

DeBlare, 2014). This finding also supports the previous literature that high internalized oppression is linked to low self-esteem in sexual minorities (Meyer, 1995; Meyer, 2003).

Overall, this research supports additive and interactive forms of frameworks when looking at multiple oppressions and highlights the importance for future research on other identities to better understand how experiences of oppression and internalized oppression work together in minority individuals and their experiences with mental health.

The present study furthers the research of Szymanski (2005; 2014) and Velez,

Moradi, & DeBlare (2014) by exploring additive and interactive frameworks with sexism and heterosexism in lesbian individual’s experiences of trauma and their subsequent posttraumatic reactions.

Current Study

There have been no studies to date to look at the interaction of heterosexism and sexism and the role that intimate partner violence (IPV) plays in the link between internalized oppression and PTSD symptoms for lesbian women.

The consideration of oppression as a form of trauma is an important topic in counseling psychology. Multiculturalism and social justice are core principles in our field and understanding the experiences of oppression is part of that principle (Prilliltensky &

Nelson, 2002; Vera & Speight, 2003). There has been much literature on the experiences of racial and ethnic minorities’ experiences of oppression and subsequent mental and physical health consequences. However, there is a lack of research on the traumatic impact of sexist experiences on women and how those experiences can impact women’s experiences of interpersonal trauma and posttraumatic reactions. There is also a gap in the literature considering lesbian women’s multiple minority statuses and the impact of

the multiple forms of oppression that these individuals experience. All of these constructs are important to the field of counseling psychology and should continue to be explored and examined. While there is only a small amount, the literature reviewed here suggests that sexism and heterosexism do have an impact on women’s posttraumatic reactions, and additionally shows that the experiences of sexism and heterosexism leading to PTSD symptoms may be impacted by increased internalized sexism and internalized heterosexism, with high levels of intimate partner violence impacting the development of

PTSD symptoms. Taken together these studies illustrate that sexism and heterosexism may lead to more severe experiences with PTSD symptoms and the development of

PTSD symptoms generally.

Research Aims and Hypotheses

The current study aimed to fill the gaps in the literature for lesbian women, their experiences with IPV, and their daily experiences living with multiple oppressions.

Generally, this study sought to better understand the links between the experience of oppression and PTSD. The study also aimed to better understand additive, minority stress, and multicultural-feminist theory’s frameworks in sexual minority women’s experiences with external and internalized sexism and heterosexism. This study tested predictions of minority stress, multicultural-feminist frameworks, and a combination of the two theories of external and internalized sexism and heterosexism in lesbian women and the links to PTSD symptoms. The study also utilized the model that Velez, Moradi,

& DeBlare (2014) tested in their study with Latina/o sexual minority individuals. The present study also explored the role that experiences of IPV plays in the relationship

between experiences of oppression and PTSD symptoms. The research questions and hypotheses of the current study are:

Research Question 1: Is there an additive effect of external sexism (sexist discrimination experiences), external heterosexism (heterosexist discrimination experiences), internalized sexism, and internalized heterosexism on lesbian women’s symptoms of

PTSD?

• H1: I predicted that perceived sexist discrimination, heterosexist discrimination,

internalized sexism, and internalized heterosexism will each be uniquely related

to higher PTSD symptom severity in lesbian women.

Research Question 2: Does internalized oppression strengthen the relationship between experiences of externalized oppression and PTSD symptom severity in lesbian women?

• H2: Minority stress theory proposes that internalized oppression will interact with

externalized oppression (sexist discrimination experiences/heterosexist

discrimination experiences) for sexism and heterosexism. Hence, internalized

sexism will interact with sexist experiences and internalized heterosexism will

interact with heterosexist experiences increasing the link between external

oppression and negative mental health consequences (Velez, Moradi, & DeBlaere,

2015). Therefore, I predicted that sexist discrimination would interact with

internalized sexism and that heterosexist discrimination would interact with

internalized heterosexism, with internalized oppression of each type of oppression

increasing the strengthen the relationship between external oppression and PTSD

symptom severity in lesbian women.

Research Question 3: Does oppression of one type (sexism external/internal) increase the link of the other type (heterosexism external/internal) and PTSD symptom severity in lesbian women?

• H3: Multicultural-feminist theory proposes that externalized oppressions (sexist

discrimination experiences and heterosexist discrimination experiences) interact

and internalized oppressions (internalized sexism and internalized heterosexism)

interact. Therefore, sexist discrimination interacts with heterosexist

discrimination, and internalized sexism interacts with internalized heterosexism,

increasing the link between external oppression experiences and internalized

oppression with negative mental health consequences (Velex, Moradi, &

DeBlaere, 2015). Consequently, I predicted that sexist discrimination would

interact with heterosexist discrimination and that internalized sexism interacts

with internalized heterosexism beyond that accounted for by their unique links,

with each form of oppression increasing the relationship of the other form of

oppression and PTSD symptom severity in lesbian women.

Research Question 4: Does one form of externalized oppression strengthen the relationship between the other form of internalized oppression and PTSD symptom severity in lesbian women?

• H4: In an attempt to combine minority stress theory and multicultural-feminist

theory, we hypothesize that one form of externalized oppression (sexist

discrimination experiences/heterosexist discrimination experiences) will interact

with the other form of internalized oppression (internalized

heterosexism/internalized sexism). That is, sexist discrimination will interact with

internalized heterosexism and heterosexist discrimination will interact with

internalized sexism, in both cases increasing the link between external oppression

of one form and internalized oppression of the other form, with negative mental

health consequences. Velez, Moradi, & DeBlaere (2015) named these types of

interactions “synthesized interactions,” where one form of oppression (ie. external

sexism) is interacting with the other form of oppression (ie. internalized

heterosexism). Thus, I predicted that heterosexist discrimination interacts with

internalized sexism and that sexist discrimination interacts with internalized

heterosexism, so that internalized oppression of one type increases the

relationship of external oppression of the other type of oppression and PTSD

symptom severity in lesbian women. I also predicted that this interaction would

account for greater variance and would have a larger effect size than the other

aforementioned interactions (See Table 1 for all conceptual interaction terms for

hierarchical regressions).

Research Question 5: How do lesbian women’s experience of IPV impact their experiences of sexism, internalized sexism, and PTSD symptoms?

• H5: I predicted that there will be a moderated moderation, where the relationship

between externalized sexism and PTSD symptom severity is moderated by

internalized sexism with severity of IPV moderating the relationship between

internalized sexism and PTSD symptom severity in lesbian women. I also

predicted a significant positive relationship between externalized sexism and

PTSD symptom severity for those who have higher internalized sexism and

greater severity of IPV.

Research Question 6: How do lesbian women’s experience of IPV impact their experiences of heterosexism, internalized heterosexism, and PTSD symptoms?

• H6: I predicted that there will be a moderated moderation, where the relationship

between externalized heterosexism and PTSD symptom severity is moderated by

internalized heterosexism with severity of IPV moderating that relationship in

lesbian women. I also predict a significant positive relationship between

externalized heterosexism and PTSD symptom severity for those who have higher

internalized heterosexism and greater severity of IPV.

CHAPTER III

METHOD

The current study hoped to extend the literature on the experiences of sexism and heterosexism in lesbian women and their subsequent posttraumatic symptoms. This study explored the additive and multiplicative models to better understand how the multiple oppressions of sexism and heterosexism combine or interact in women’s lives and their effects on mental health. The current study explored the role of experiences of intimate partner violence in lesbian women’s lives and how it affects the relationship between externalized oppression experiences, internalized oppression, and subsequent PTSD symptoms. The current chapter outlines the methods conducted in the study. I discuss the participants, measures (see appendices), procedures, and the statistical analytic plan of the study.

Participants

Data were collected from 422 women. After removing participants who did not meet minimum inclusion criteria (i.e., self-identified as a woman, over 18 years old, sexual identity criteria) and/or had too much missing data (see Chapter IV description of

Data Screening and Missing Data), 209 participants remained. The initial power analysis that was conducted indicated a minimum of 123 participants should be sampled for a

power of .80, an f2 = .15, and α = .05. Thus, it was determined that the current study was sufficiently powered for the proposed analyses. Cohen (1988) describes f2 as a medium effect size and it is utilized in regression analyses to assess the magnitude of the effect independent of the sample size. Moradi, Mohr, Worthington, and Fassinger (2009) discuss the challenges when methodologically sampling sexual minority individuals. For example, we anticipated that not every woman who is attracted to women will identify as a “lesbian” and it is important when studying sexual minority individuals to be aware of the importance of language. Taking into account the diversity of sexuality expressions, we gave participants the Kinsey Scale in the demographics (Kinsey, Pomeroy, & Martin,

1948) and utilized individuals who identify as a five (predominantly attracted to the same gender, but more than incidentally attracted to the other gender), six (predominantly attracted to the same gender, only incidentally attracted to the other gender) or seven

(exclusively attracted to the same gender) so to capture women who are mostly attracted to the same gender at the time of recruitment. Klein, Sepekoff, and Wolf (1985) discussed the importance of utilizing measures of sexual orientation that allow for sexual exploration and changes throughout the lifetime and on a continuum.

The sample ranged in age 18 to 56 (M=28.46, SD=8.67). The majority of the sample identified as White (78%), exclusively attracted to the same gender (65.1%), and lesbian (87.6%). The majority of the sample identified as exclusively attracted to the same gender (65.1%), 27.8% identified as predominantly attracted to the same gender, only incidentally attracted to the other gender, and 72.5% identified as predominantly attracted to the same gender, only incidentally attracted to the other gender. Additionally, the majority of participants (46.9%) identified their socioeconomic status (SES) as, “my

family has no problem buying the things we need and sometimes we also buy special things.” Please see Table 2 for demographic characteristics of the sample.

Measures

Demographic Questionnaire. A brief demographics questionnaire (see Appendix

A) was given and participants responded to five questions that assess their age, gender, race, ethnicity, socioeconomic status, and sexual orientation.

PTSD Symptom Severity

Posttraumatic Stress Disorder Checklist for the DSM-5 (PCL-5; Blevins,

Weathers, Davis, Witte, & Domino, 2015). The PCL-5 (See Appendix B) is a self- report measure developed to assess the twenty symptoms of PTSD in the Diagnostic and

Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013).

This scale was utilized in the current study to measure symptoms of PTSD in participants. Sample items of the PCL-5 include, “In the past month, how much were you bothered by: Repeated, disturbing, and unwanted memories of the stressful experience?” and “In the past month, how much were you bothered by: Feeling very upset when something reminded you of the stressful experience?” (Blevins, Weathers,

Davis, Witte, & Domino, 2015). The scale consists of 20 items rated on a 5-point Likert scale 0 (not at all) to 4 (extremely). Participants are prompted to answer all items for how much they have been bothered by each symptom in the past month. A participant’s score is derived by summing all items for an overall PTSD symptom score, which can range from 0-80. A higher score indicates higher PTSD symptoms. A total score for PTSD symptoms in the last month was utilized in the present study as was outlined by Blevins,

Weathers, Davis, Witte, & Domino (2015). There is no empirical support that we are

aware of for the use of total scores for the PCL-5 (i.e., through confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure, although total scores are what are most often used in research (Dardis, Dichter, & Iverson, 2018; Dardis, Amoroso, & Iverson, 2017; Iverson,

Dardis, & Pogoda, 2017; Ovrebo, et.al., 2018; Straub, McConnell, & Messman-Moore,

2018).

Blevins, Weathers, Davis, Witte, and Domino (2015) conducted two studies to test the psychometric properties of the PCL-5. The first study utilized a sample of 278 college students who had experienced incidents of self-reported trauma. The sample included 197 females (70.9%) and 81 males (29.1%) aged 18-54 years. The majority of the sample identified as Caucasian (81.30%) and African American (11.5%). The PCL-5 scores indicated strong internal consistency (α=.94), which was comparable to other measures of PTSD symptoms, including the PTSD Checklist (PCL), the Posttraumatic

Diagnostic Scale (PDS), and the Detailed Assessment of Posttraumatic Stress Scale

(DAPS). PCL-5 test-retest reliability was explored in a subset of 53 participants who were given the initial battery during study two if they volunteered, retest interval was approximately a week (M=6.14 days). Total scores showed strong test-retest reliability

(r=.82, 95% CI [.71, .89), as did the total scores for the other measures of PTSD symptoms respectively rs = .85, 95% CI [.75, .91], .80, 95% CI [.68, .88], and .91, 95%

CI [.85, .95].

Convergent validity was explored with the PCL-5 and other PTSD measures and strong correlations were found between the Posttraumatic Stress Disorder Checklist

(PCL; Herman, Huska, & Keane, 1993; Weathers, Litz, Herman, Huska, & Keane, 1993;

Weathers, 2008), r = .85, p < .01, Posttraumatic Stress Diagnostic Scale (PDS; Foa,

1995), r = .85, p < .01, and Detailed Assessment of Posttraumatic Stress (DAPS; Briere,

2001), ), r = .84, p < .01.Discriminant validity was assessed with related constructs and unrelated constructs. Depression, a related construct was found to have a correlation of r

= .60; 36% overlapping variance and Mania, an unrelated construct had a correlation of r

= .31; 10% overlapping variance, indicating good discriminant validity. Predicted correlations and λ values were used to calculate construct validity effect sizes. The PCL-

5 had large effect sizes specifying a strong similarity between predicted and observed correlations (ralerting-CV = .90, rcontrast-CV = .92).

A common factors model was estimated though confirmatory factor analysis for the four-factor model of PTSD symptoms in the DSM-5 (Re-experiencing; Avoidance;

Negative Alterations in Cognitions and Mood; Hyperarousal), which had questionable fit, particularly with CFI and TLI: χ2(164) = 455.83, p < .001, standardized root mean square residual (SRMR) = .07, root mean squared error of approximation (RMSEA) =

.08, comparative fit index (CFI) = .86, and Tucker-Lewis index (TLI) = .84. Analyses showed good fit for the items of the PCL-5 with the 4-factor model and superior fit for the six-factor model (Liu et al., 2014; reexperiencing, avoidance, negative alterations in cognitions and mood, anhedonia, anxious arousal, and dysphoric arousal factors) and seven factor (Armour et al., 2015; reexperiencing, avoidance, negative affect, anhedonia, externalizing behavior, anxious arousal, and dysphoric arousal factors) models, χ2 (164)

= 318.37, p < .001, SRMR = .05, RMSEA = .06, CFI = .92, and TLI = .90, and 7-factor,

χ2 (164) = 291.32, p < .001, SRMR = .05, RMSEA = .06, CFI = .93, and TLI = .91,

models. The 6 and 7 factor models had a significantly better fit than the DSM-5 4-factor model.

Blevins, Weathers, Davis, Witte, and Domino (2015) second study had a sample of 558 college students that reported a traumatic incident from the same university as the first study. The sample included 419 females (75.2%) and 138 males (24.8%). The majority of the participants identified as Caucasian (85.5%) and African American

(7.7%). In this study, analyses showed similar results to the first study, with strong reliability and validity. The PCL-5 still had high internal consistency (α=.95). Interitem correlations were ranged .25 to .77 (M=.51) which is in the recommended range.

Convergent and Discriminant validity also indicated strong correlations for the PCL-5 and DAPS (r=.94, p<.001), and the Personality Assessment Inventory (PAI; Morey,

2007) (r=.92, p<.001) and with the pattern of the correlations in Study 1. Additionally, the PCL-5 had large effect sizes specifying a strong similarity between predicted and observed correlations 5 (ralerting-CV = .94, rcontrast-CV = .81). The confirmatory factor analysis of the DSM-5 4-factor model had mostly adequate fit to the data (with the exception of TLI): χ2 (164) = 558.18, p < .001, SRMR = .05, RMSEA = .07, 90% CI

[.06, .07], CFI = .91, and TLI = .89. The 6-factor model, χ2(155) = 389.02, p < .001,

SRMR = .04, RMSEA = .05, 90% CI [.05, .06], CFI = .94, and TLI = .93, and 7-factor model, χ2(149) = 352.26, p < .001, SRMR = .04, RMSEA = .05, 90% CI [.04, .06], CFI =

.95, and TLI = .94 both had superior fit compared to the 4-factor DSM-5 model but they did not significantly differ using the scaled Chi-Square difference test, χ2 (6) = 0.91, p = n.s..

Intimate Partner Violence

Severity of Violence against Women Scale (SVAW: Marshall, 1992). The

SVAW (See Appendix C) is a self-report measure of recent threats and incidents of physical violence and assault. The SVAW was utilized in the current study to measure experiences of intimate partner violence. Participants are instructed to answer how often each item occurred in the past year. There are three categories of the SVAW: (a) threats of violence, including mild violence, moderate violence, and serious violence, (b) actual violence mild, minor, and serious, and (c) sexual violence. A sample item in the threats of mild violence category include: “acted like a bully towards you.” A threats of moderate violence item includes: “threatened to destroy property.” A sample item of threats of serious violence includes: “threatened to kill you.” The actual violence mild, minor, and serious category includes items such as; “pushed or shoved you” for mild violence. Minor violence items include: “scratched you.” A moderate violence item example is: “slapped you around the face and head.” A serious violence item example is: “beat you up”. The sexual violence category includes items such as; “physically forced you to have sex”

(Marshall, 1992). The scale consists of forty-six items of threats of violence, actual violence, and sexual violence rated on a Likert scale ranging from 1 (never) to 4 (4 or more times). Scores are summed for an overall severity of violence score. Higher scores indicate greater incidents of violent events. In the present study, a total score was used for items indicated in the past year which has been typically used in research (Sansone, Chu,

& Weiderman, 2007; Schafer et al., 2012; Thomas & Weston, 2018; Wiist & McFarlane,

1998) and is the method described by Herman (1992). However, there is no empirical support that we are aware of for the use of total scores for the SVAW (i.e., through

confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure.

Items were created by Marshall (1992) to better capture the experiences of violence and their severity level. The Conflict Tactics Scale (CTS; Strauss. 1979) had been the main scale used for measuring IPV and critics of the scale argued that it was not sensitive enough and did not measure the intensity and consequence of acts of violence.

For example, “hit or tried to hit with an object.” Unlike the CTS, the SVAW allows researchers to measure perceived intent of violence by assessing for threats of violence, as well as actual incidents of violence experienced and the severity of violence.

Marshall (1992) utilized a sample of 707 college student women ranging from ages 17 to 72 (M=20.39, SD=5.76) to explore the dimensionality using exploratory factor analysis of 49 physically abusive, sexual abuse, and threats of abuse. These acts included: symbolic violence, threats of physical violence, actual violence, and sexual violence. Three items were included in the initial study that were later not included in the final SVAW. Participants rated all items on a 10-point Likert scale on how serious, aggressive, abusive, threatening, and violent each act was if done to a woman. The participants also rated how much physical, psychological, and emotional harm it would cause a woman. Marshall (1992) discussed that the intent was to have at least four factors when exploring a list of behaviors of IPV (symbolic acts, threats, physical, and sexual violence). The author discussed the desire for comprehensiveness in the scale and since there could be perceived threat levels (minor, moderate, and serious), as well as, actual violence (minor, moderate, and serious violence), the author decided to explore a 8, 9, and 10-factor solution though the 9-factor model was ultimately selected. Means were

calculated for severity scores and a 9-factor solution was found: (a) minor violence

(56.8% variance), (b) serious violence (10.1% variance), (c) threats of serious violence

(4.7% variance), (d) sexually violent acts (4.3% variance), (e) symbolic violence (1.6% of variance), (f) threats of moderate violence (1.2% of variance), (g) threats of mild violence (1% of variance), and (h) mild violence (0.8% of variance).

Alpha coefficients, mean severity scores for each dimension, and correlations were utilized to test the 9-factor model. Alphas were .92 for symbolic violence and .96 for moderate threats, mild, moderate, and serious violence. Mean severity scores were:

7.10 for symbolic violence, 5.50 for mild threats, 7.29 for moderate threats, 8.50 for serious threats, 7.65 for minor violence, 7.71 for mild violence, 8.53 for moderate violence, 9.06 for sexual violence, and 9.24 for serious violence. All 36 t-tests for differences were significant. Correlations ranged from .34 to .88. A mean correlation of

.69 was found for severity. Correlations for within dimensions rather than between were also calculated. Mean correlations ranged from .73 (sexual violence) to .90 (moderate violence) with a mean score of .80. Symbolic violence had a similar correlation with the between dimensions mean score. All other dimensions the mean correlation was higher than between dimensions. Marshall (1992) provided no fit statistics for the factor analysis in Study one of the SVAW.

Marshall (1992) conducted a second study of the SVAW to better explore whether the levels of violence found could be generalized to women outside a college sample. The second study utilized a sample of 208 women in the Dallas-Fort Worth Metroplex area who ranged in age from 19 to 75 (M=40.80, SD=13.03). Both studies occurred in the same time period, so the original 49 behaviors were also utilized in this study. Amount of

threat and violence were not included in this survey. Mean severity scores were calculated and an exploratory factor analysis using maximum likelihood extraction with oblique rotation. The 9-factor solution accounted for 80.6% of the variance in severity ratings. The symbolic violence factor (1.6% variance). The threats of mild, moderate, and serious violence factors (1%, 1.2%, and 4.7% of variance respectively). The mild, minor, moderate, and serious violence factors (0.8%, 56.8%, .7%, and 10.1% of variance respectively). Finally, the sexual violence factor (4.3% of variance). Coefficient alphas ranged from .89 (symbolic violence) to .96 (mild and serious violence).

A second order confirmatory factor analysis was also utilized, and the four violent acts were included as first order factors: (a) symbolic, (b) threats, (c) physical, and (d) sexual. Results indicated two higher order factors: (a) minor, moderate, serious, mild, and sexual violence (67.5% of variance), and (b) threats of violence, which included serious and moderate threats, symbolic violence, and mild threats (8.0% of variance). Mean severity scores were calculated and were similar to study one though minor and mild violence were reversed in study two’s sample. Mean severity scores were 7.91 for symbolic violence, 6.55 for mild threats, 8.05 for moderate threats, 8.95 for serious threats, 8.55 for mild violence, 8.98 for minor violence, 9.27 for moderate violence, 9.79 for serious violence, and 9.48 for sexual violence. When comparing the dimensions all but serious threats and mild violence differed significantly. Correlations between dimensions were similar to study 1 with a range of .60 to .74 (sexual violence to minor violence), with an overall mean of .67 which was lower than the .69 mean found in the student sample. Correlations were also calculated for each act and ranged from .61 to .85

(serious threats to mild and moderate violence) and the mean correlations of .73 in this

study is compared to .79 in the college student sample. Forty-six acts were ultimately selected for the SVAW, however Marshall (1992) provided no fit statistics for study two of the SVAW.

Sexism & Heterosexism

Schedule of Sexist Events (SSE: Klonoff & Landrine, 1995). The SSE (See

Appendix D) is a self-report measure of recent and lifetime sexist events and is utilized as a measure of everyday sexism. The SSE was utilized in the current study to measure experiences of everyday sexism. The SSE can be used to measure sexist events in that participants experience in their lifetime (SSE-Lifetime) and in the past year (SSE-

Recent). The current study will utilize the SSE-Recent. Sample items of the SSE include,

“How many times have people failed to show you the respect that you deserve because you are a woman?” and “How many times have you been called a sexist name like bitch, cunt, chick, or other names?” (Klonoff & Landrine, 1995). The scale consists of twenty items of sexist behavior and they are rated on a Likert scale ranging from 1 (the event never happened) to 6 (the event happens all of the time) for recent (past year). Scores are summed for frequency of recent sexist events. Higher scores indicate greater incidents of sexist events. The current study utilized a total score of past year sexist experiences, which is typically used in research (Klonoff, Landrine, & Campbell, 2000; Moradi &

Subich, 2002; Moradi & Subich, 2004) and was the original method described by Klonoff and Landrine (1995). However, there is no empirical support that we are aware of for the use of total scores for the SSE (i.e., through confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure.

Items were created by Klonoff and Landrine (1995) for an unpublished qualitative study investigating women’s answers to the question, “what’s the worst thing that has ever happened to or has been done to you because you are a woman?” The measure was then studied for its psychometric properties in a sample of 631 women. The majority of the sample included women who identified as Caucasian (64%) and the ages ranged from

18-73 years old. The majority of the sample was community-based (53%) and the rest of the sample were college students. Exploratory factor analysis indicated four factors for were adequate: Sexist Degradation and its Consequences, Sexist Discrimination in

Distant Relationships, Sexism in Close Relationships, and Sexist Discrimination in the

Workplace. Results indicated Chronbach’s alphas for the SSE-Recent (α =.90) and split- half reliability was (r = .83). The test-retest reliability of the SSE was conducted; however the researchers discussed how this form of reliability testing was not an adequate way to assess reliability since the participants may experience new sexist events daily. Test-retest reliability was conducted on 50 college women with the SSE-recent on the initial administration and then again 2-weeks later. The results for the test-retest reliability were r=.63 for the SSE-Recent.

Klonoff and Landrine (1995) also tested the validity of the SSE in their study, initially looking at how the SSE correlated with the Hassles-F (Kanner, Coyne, Schaeffer,

& Lazarus, 1981) and the Peri-Life Events Scale (PERI-LES) (Dohrenwend, Krasnoff,

Askenasy, & Dohrenwend, 1978). The SSE-Recent correlated with the other stressful life events measures. Landrine and Klonoff (1997) adapted the SSE to the SSE-Appraisal by including an intensity rating. Participants are prompted with the question, “How stressful was this for you?” and the item is rated on a 6-point Likert scale from 1 (Not at all

stressful ) to 6 (Extremely stressful). Psychometric properties were also tested for the new adaptation. The sample included 652 women ranging from 17 to 73 years of age. The majority of the sample was White (n=405) and Latinas (n=136), Asian/Pacific Islander

(n=45), Black (n=42), and Other Ethnic groups (n=24). Two-thirds of the sample were college students and the majority indicated that they were single (58.6%). Similarly, to their 1995 study, reliability (α =.93) and split-half reliability (r =.89) were both highly reliable. The SSE-Appraisal was found to have good validity and reliability in this sample, as well as in their 1995 study.

Heterosexist Harassment, Rejection, and Discrimination Scale (HHRDS;

Szymanski, 2006). The HHRDS (See Appendix E) is a self-report measure that was developed by Szymanski (2006) to measure everyday heterosexist events in the author’s study on heterosexist events and lesbian’s psychological distress. In the current study, the

HHRDS was used to measure experiences of externalized heterosexism. The scale was designed to be similar to the other everyday measures of oppressive events, such as the

SSE which was also utilized in the current study. The HHRDS asks participants to answer items about the frequency of incidents of heterosexist harassment, rejection, and discrimination in their lifetime and in the past year. The present study had participants answer items for the past year. Sample items of the HHRDS include, “How many times have you been verbally insulted because you are a lesbian?” and How many times have you been treated unfairly by your employer, boss, or supervisors because you are a lesbian?” (Szymanski, 2006). The scale consists of 14 items rated on a 6-point Likert scale ranging from 1 (the event has never happened to you) to 6 (the event happened almost all the time; more than 70% of the time). Mean scores are calculated and higher

scores on the HHRDS indicates greater the heterosexist experiences in the past year. The present study utilized an overall mean score of heterosexist experiences in the past year, which is typically used in research (Denton, Rostosky & Danner, 2014; Szymanski &

Ikizler, 2013; Szymanski & Meyer, 2008) and was the method used by Szymanski

(2006). However, there is no empirical support that we aware of for the use of total scores for the HHRDS (i.e., through confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure.

There are three subscales of the HHRDS (Szymanski, 2006): The Harassment and

Rejection subscale, the Workplace and School Discrimination subscale, and Other

Discrimination subscale. The Harassment and Rejection subscale explores recent perceived rejection and harassment in areas such as friends, family members, verbal rejection, physical violence or threats of physical violence, and verbal harassment. A sample item includes, “How many times have you been rejected by family members because you are a lesbian?” The Workplace and School Discrimination subscale looks at discrimination specifically in the areas of employment, the work place, and academic pursuits. A sample item includes, “How many times have you been treated unfairly by your employer, boss, or supervisors because you are a lesbian?” The Other

Discrimination subscale also looks at situation specific events of heterosexist discrimination in areas such as, interactions with strangers, service workers, and medical professionals. A sample item includes, “How many times have you been treated unfairly by strangers because you are a lesbian?” Szymanski (2006) recommends using the measure as a whole as some participants may not experience certain types of

discrimination based on certain individual circumstances, ie., not employed, not currently enrolled in academics.

Szymanski (2006) explored the psychometric properties of the HHRDS with a sample of 143 lesbian women. The sample was predominantly White (90%) and highly educated (74% had a minimum of a Bachelor’s degree). Ages ranged from 19 to 70 years old. Factor analysis indicated a good fit for the three-factor model: Harassment and

Rejection (α =.89), Workplace and School Discrimination (α =.84), and Other

Discrimination (α =.78). Overall, the measure had high internal consistency (α =.90).

Inter-scale correlations had a ,42 to .56 range. Subscales of the HHRDS found moderate correlations with each other however good internal consistency was found. Correlations had a range from .73 to .90 for the total and subscales. Construct validity was also strong with positive correlations between the HRDS and other measures of psychological symptoms.

Internalized Sexism & Internalized Heterosexism

Lesbian Internalized Homophobia Scale (LIHS; Szymanski & Chung, 2001).

The LIHS (See Appendix F) is a self-report measure developed by Szymanski and Chung

(2001) to address the need for an internalized heterosexism scale for women rather than for gay men. The researchers argue that because the existing scales were created based on theories and empirical literature about gay men, it is problematic to assume that they would be appropriate for lesbian women based on simply same sex attraction. The authors further argue that there is a difference between gay men and lesbian women culture and that the development of the LIHS fills the need of a measure that has been created and validated on sexual minority women. The LIHS total score was used in the

current study to measure internalized heterosexism. Sample items of the LIHS include, “I hate myself for being attracted to other women?” and “I live in fear that someone will find out I am a lesbian?” (Szymanski & Chung, 2001). The LIHS consists of 52 items that are rated on a 7-point Likert scale from 1 (Strongly disagree) to 7 (Strongly agree).

The LIHS includes reverse-scored items and the scores are averaged and totaled as well as averaged subscales are utilized, with higher scores indicating greater internalized heterosexism. The present study utilized an overall total score for internalized heterosexism which has been typically used in research (Amadio & Chung, 2004;

Szymanski, 2006) and was the method suggested by Szymanski & Chung (2001).

However, there is no empirical support that we are aware of for the use of total scores for the LIHS (i.e., through confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure.

There are 5 subscales of the LIHS which were derived from previous literature

(Burisch, 1984; Gartrell, 1984; Herek, 1984; Pearlman, 1987; Pharr, 1988; Sophie, 1987) on internalized oppression and grounded in theory. The items were then created based on these dimensions. The five dimensions are: Connection with the Lesbian Community,

Public Identification as a Lesbian, Personal Feelings about Being a Lesbian, Moral and

Religious Attitudes Toward Lesbianism, and Attitudes Toward Other Lesbians. The

Connection with the Lesbian Community subscale measures the connection with the larger lesbian community and how frequently the participants engage in contact with other lesbian women. A sample item includes: “When interacting with members of the lesbian community, I often feel different and alone, like I don’t fit in.” The Public

Identification as a Lesbian subscale measures how much the participants worry about

being identified as a lesbian in public as well as how much the participants want the ability to “come out”. A sample item includes: “I live in fear that someone will find out I am a lesbian.” The Personal Feelings about Being a Lesbian subscale measures the participant’s self-esteem and feelings of guilt about their identity. A sample item includes: I hate myself for being attracted to other women.” The Moral and Religious

Attitudes Toward Lesbianism subscale measures how much the participants have internalized religious messages that their lesbianism is wrong and atypical. A sample item includes: “Female homosexuality is a sin.” Finally, the Attitudes Toward Other

Lesbians subscale measures the participant’s feelings and attitudes about other lesbian women particularly in the areas of their adherence to stereotypical lesbian norms and judgments about other lesbian women’s adherence to the same norms. A sample item includes: “My feelings toward other lesbians are often negative.”

Psychometric properties were tested on a sample of 157 lesbian women ages ranging from 18 to 74 years old. The sample identified Caucasian (86%), African

American (8%), Hispanic/Latina (3%), Asian American/Pacific Islander (1%),

Multiracial (2%), and Other (1%). The five subscales indicated strong internal reliabilities: Connection with 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).

Interscore correlations ranged from .60 to .87. The authors also measured the test-retest reliability of the LIHS in a two-week period and total scores indicated a Chronbach’s alpha of α =.93. The subscales Chronbach’s alphas were as follows: Connection with the

Lesbian Community (α =.91), Public Identification as a Lesbian (α =.93), Personal

Feelings about Being a Lesbian (α =.88), Moral and Religious Attitudes Toward

Lesbianism (α =.75), and Attitudes Toward Other Lesbians (α =.87). To explore content validity the authors used five expert raters who indicated support (Szymanski & Chung,

2001b). Construct validity was also supported when correlations were explored between the LIHS and measures of depression, self-esteem, social support, loneliness, passing for straight, LGB group membership, and sexual orientation conflict (Szymanski & Chung,

2001; Szymanski, Chung, & Balsam, 2001). Subsequent studies have translated the scale into the Italian language and also modified it for use with other sexual minority women, ie bisexual women (Balsam & Szymanski, 2005; Montano, 2000; Rowan, 2004).

The LIHS measure unique aspects of internalized heterosexism but research has also suggested that the five dimensions that the LIHS measures have not been cohesively included in other internalized heterosexism measures and have been created for gay men

(Szymanski & Chung, 2001). Szymanski & Chung (2001) argue that these dimensions are a combined experience in lesbian women’s lives and important constructs to be measured together when assessing for internalized heterosexism in women. The LIHS is currently the only published scale for internalized heterosexism in lesbian women.

Szymanski & Chung (2001) found a total scale alpha of .94 for the LIHS. Further,

Szymanski & Chung (2001) found correlations between total and subscale scores from

.60 to .87 which also indicated construct validity for the LIHS.

The Internalized Misogyny Scale (IMS; Piggot, 2004). The Internalized

Misogyny Scale (See Appendix G) is a self-report measure created by Piggot (2004) to measure the construct of internalized sexism. The term internalized misogyny is another way to describe the experience of internalizing the sexism based on the greater

patriarchal culture in our society. The author argues that misogyny is a better term for the internalization of sexism because the degradation and devaluation of women is at the core of the power differential between men and women in our society (Johnson, 2014; Piggot,

2004; Szymanski & Henrichs-Beck, 2014). In the current study the IMS was used to measure experiences of internalized sexism. Sample items of the IMS include, “It is generally safer not to trust other women too much” and “Generally, I prefer to work with men.” The IMS consists of 17 items that are completed with a 7-point Likert scale from 1

(Strongly disagree) to 7 (Strongly agree). Scores can be totaled or averaged with higher scores indicating higher levels of internalized sexism. The current study used an overall mean score of internalized sexism which has been typically utilized in research

(Szymanski & Henrichs-Beck, 2014; Szymanski, Ikizler, & Dunn, 2016; Szymanski &

Kashubeck-West, 2008; Szymanski & Stewart, 2010). However, there is no empirical that we are aware of to support the use of total scores for the IMS (i.e., through confirmatory factor analytic results supporting either a bifactor, hierarchical or unidimensional model), which is a limitation of the measure.

The three factors of the IMS are: Devaluing of Women, Distrust of Women, and

Gender Bias in Favor of Men. An exploratory factor analysis using maximum likelihood extraction with oblique rotation was utilized and a 3-factor solution with the 17-items was adequately supported. The five-factor model accounted for 42.22% of the total variance. Full scale and subscales showed good reliability with Chronbach’s alphas ranging from .88 to .90 (Piggott, 2004; Szymanski et al., 2009). The scale has shown good construct validity with strong correlations with the IMS and measures of internalized heterosexism, modern sexism, depression, psychosexual adjustment, self-

esteem, and social desirability (Piggot, 2004; Shelby, 2014). Piggot (2004) completed a confirmatory factor analysis from a sample of 803 sexual minority women in five different countries showing strong reliability and validity across a cross-cultural sample.

No fit statistics were provided. Results indicated a significant positive relationship with internalized sexism and internalized homophobia across all countries.

The measure has also been validated with a sample of 171 heterosexual women and has proven to be a valid and reliable measure for both heterosexual and lesbian women (Szymanski et al., 2009). Szymanski and Henrichs-Beck (2014) also utilized the

IMS in their sample of 473 sexual minority women who identified as lesbian, bisexual, and not sure. The researchers used a modified version of the Kinsey scale when exploring identity and as was expected, there was much variation of identity. 39% of women indicated being attracted to only women, 39% indicated being attracted more to women than men, 11% indicated an attraction to both sexes, and 10% were attracted more to men than women. The sample ranged from 18 to 74 years and participants identified as White

(81%), African American/Black (3%), Asian American/Pacific Islander (5%),

Hispanic/Latina (5%), Native American (1%), Multiracial (4%), and Other (2%). This study replicated the reliability analysis of the earlier studies and showed strong reliability with a Chronbach alpha of α =.88. The IMS has been shown to be a good measure for internalized sexism in sexual minority women and a lesbian sample.

Procedures

Once Institutional Review Board (IRB) approval was obtained, participants were recruited from the social media and the online forum sites: Facebook and LGBT-specific

Reddit groups, ie. r/lgbt, r/ainbow, r/actuallesbians, r/lesbians, r/olderlesbians, r/queer,

and r/MeetLGBT, as well as snowball sampling. Potential participants were also asked to further post the link to the survey including all of the measures discussed above on their own social media/forum sites for individuals who meet study criteria. Potential participants were provided a link to Qualtrics to complete the study. All participants were given the optional offer to be entered into a raffle to win one of six $25 gift cards and their name and email address were collected but be de-identified from their responses.

The American Psychological Association (APA, 2002) ethical guidelines for research participation were taken into accord in the present study and all participants were treated ethically by these guidelines.

Participants who met inclusion criteria of being at least 18 years of age, identify as a woman or a transgender woman, and as “predominantly attracted to the same gender” or “exclusively attracted to the same gender” (5, 6, or 7 on the modified Kinsey scale in the sexual orientation demographics) were included in the study. Participants were provided an informed consent form (see Appendix I) and completed the demographic measure first with participants who met inclusion criteria continuing to the rest of the measures which were given at random (see Appendices A – G). A debriefing was provided at the conclusion of the study which also included information about intimate partner violence and mental health websites and resources available to participants.

Analytic Plan

Prior to analysis, data were inspected to determine if there were patterns in missing data and if the data violated any assumptions required for analyses. The data was also screened for univariate and multivariate normality (skewness, kurtosis) suggested by

Tabachnick and Fidell (2001). Missing data was handled utilizing available item analysis which has been found to be commensurate with multiple imputation and multivariate analyses (Parent, 2013). Means were calculated for participants who have completed at least 80% of a scale (Parent, 2013).

After completing the initial data screening, descriptive statistics and scale reliabilities were measured (i.e. means, standard deviations, Cronbach’s alpha). Bivariate correlations were also be completed in SPSS. SPSS and PROCESS (Hayes, 2013) was utilized to explore the interaction effects and moderated moderator models in the hypotheses. Hayes (2013) PROCESS macro for SPSS provides estimations of conditional effects in moderation relationships. Bootstrapping confidence intervals were utilized to analyze effect sizes and indirect effect sizes. Ferguson (2009) suggests when interpreting effect sizes that significant effects are identified by confidence intervals that do not contain a zero. The Bonferroni correction was also used in data analyses to minimize the chance of type 1 errors (Armstrong, 2014). Research questions and hypotheses were addressed as follows:

PTSD?

• H1: I predicted that perceived sexist discrimination, heterosexist discrimination,

internalized sexism, and internalized heterosexism would each be uniquely related

to higher PTSD symptom severity in lesbian women.

• Data Analysis Plan: In SPSS, a regression was conducted with PTSD severity

(PCL-5 scores) regressed on the four different predictors: sexist discrimination

(SSE scores), heterosexist discrimination (HHRDS scores), internalized sexism

(IMS scores), and internalized heterosexism (LIHS scores). The amount of

variance accounted for by the set of predictors was also explored as well as

individually. Squared semipartial correlation coefficients were analyzed to

examine the unique variance in PTSD severity by each predictor variable.