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Archives of Psychiatry and Psychotherapy, 2017; 3: 69–80 DOI: 10.12740/APP/75483 Minority stress among homosexual and bisexual individuals – from theoretical concepts to research tools: The Sexual Minority Stress Scale Grzegorz Iniewicz, Kinga Sałapa, Małgorzata Wrona, Natalia Marek Summary Minority stress is a relatively new concept that has emerged from the concept of stress. Its popularity among researchers who are interested in minority groups is increasing. Minority stress refers to the experiences of stigma, rejection and violence by the majority of society as experienced by the minority. The concept can be operationalised in a number of ways, for instance via a questionnaire such as the Sexual Minority Stress Scale (SMSS) presented in this paper. It concerns a clearly defined concept of minority stress and uses some stress indicators. It was translated and adapted into Polish. This paper presents the results of statistical analysis based on answers of 206 individuals describing themselves as homosexual and 62 de- scribing themselves as bisexual. High psychometric results of the questionnaire indicate that SMSS can be used in research on minority stress in bisexual and homosexual individuals. However, further research is required to verify its usefulness in the clinical setting as a screening tool to diagnose those who may be at risk from high levels of minority stress. minority stress, bisexuality, homosexuality, Sexual Minority Stress Scale (SMSS) questionnaire BACKGROUND emotional breakdowns produced by war-related stress are similar to reactions to ordinary every- From physiological to minority stress day stress [2]. These studies clearly showed that many life events, including positive ones, can Stress is one of the most frequently used terms in cause similar symptoms. Richard Lazurus [3,4] the field of mental health. In the classical mean- made major contributions to the study of stress. ing of Hans Selye [1], it is the body’s reaction to He focused on individual differences in experi- negative stimuli. Studies on stress were conduct- encing stress, conceptualizing cognitive process- ed after World War II to understand how the es as mechanisms that regulate people’s efforts to cope with a given situation. Nevertheless, agreement on the definition of Grzegorz Iniewicz1, Kinga Sałapa2, Małgorzata Wrona3, Natalia stress remains elusive. Some researchers believe Marek4: 1Institute of Psychology, Jagiellonian University, Krakow, that the definition should include the stimuli re- 2 Poland; Department of Bioinformatics and Telemedicine, Jagiello- sponsible for causing stress, some see it as the nian University Medical College, Krakow, Poland; 3Siemacha As- sociation, Krakow, Poland; 4Adolescent Psychiatric Intensive Care human reaction to stressful stimuli, and others Unit, Alpha Hospital, Bury, UK focus on the relationship between a stimulus Correspondence address: [email protected] and the way a person responds to it [5,6]. In this 70 Grzegorz Iniewicz et al. context, it is also worth mentioning the unre- People who belong to a minority group may solved issue of the relationship between stress experience both overt aggression (so-called tra- and emotions – i.e., whether emotions consti- ditional discrimination practices) and microag- tute an element of stress and can be considered ression (for a review of studies on violence expe- one of its indicators, or are rather just the result rienced by bisexual and homosexual people, see of experiencing stress [7]. It seems that these is- Iniewicz [13]). The latter term was introduced sues are essential, especially in the context of re- in the 1970s by Chester M. Pierce in relation search. This is because they influence the way to situations experienced by Black Americans. a study’s variables are conceptualized and op- Later, it was used in relation to other minority erationalized. groups. Microagression refers to behaviors re- Researchers typically distinguish between sulting from unconsciously maintained preju- physiological and psychological stress. Rachel dices, which are often invisible even to the per- Kaplan and Richard Lazurus [3,7] divide hu- petrator. The consequence of experiencing mi- man reactions in an unambiguous and simple croagressive behaviors is a deteriorating state of manner – things occurring in the mental sphere mind that leads to serious mental health prob- are referred to as psychological stress, whereas lems [14-18]. things occurring in the physiological sphere are It can be said that minority stress is a specif- referred to as physiological stress. Władysław ic type of social stress that results from belong- Łosiak [6] believes stress should be regarded as ing to a minority group. The concept of minority a uniform process, which may include variable stress encompasses various theoretical concepts factors and take a variable course. Charles Cofer in the field of psychology and sociology. In gen- and Mortimer Appley [8] focused their attention eral it refers to the conflict between two systems on a concept of importance in the context of mi- of values: the minority system, characteristic of nority stress. They believe the term psychologi- a stigmatized group, and the majority system, cal stress is essentially broader and refers to cer- which is preferred in the social environment in tain circumstances that cause stress. Kaplan [7] which members of the minority group must op- addresses this issue by broadening the perspec- erate. Conflicts of this kind, which are experi- tive on stress, pointing out that emotional states enced in the social context, constitute the es- associated with stress can be a consequence sence of social stress as well (minority stress has of adverse psychosocial events that may have been described elsewhere [11-13,19,20]). Virgin- a symbolic meaning. This leads us to the concept ia Brooks [19], who invented the concept of mi- of social interactionism put forward by George nority stress, defined it as stress connected with Mead [9], according to whom our personality is a lower social status that involves experiencing shaped mainly by social interactions and, in the discrimination in everyday life. She regarded course of development, human beings should belonging to a minority group as a factor that adapt to the culture in which they live. increases the probability of developing mental This last point is particularly relevant with health problems; thus, she believed it should regard to the functioning of bisexual and ho- be considered a risk factor for such problems. mosexual people in a heteronormative soci- It should be noted that affiliation with a minor- ety. As Bruce Dohrenwend [10] puts it, stress ity group can also be a source of support. It is may be caused by problems in our everyday life therefore important to assume that the main is- which do not have to be directly connected with sue lies in the relationship between a minority stressful events. In accordance with the concept group and the majority in a given society. of social stress, stress can be produced not only by personal events, but also by conditions of liv- ing related to the social context [11,12]. Thus, RESEARCH ON MINORITY STRESS social stress refers mainly to people belonging to minority groups who are stigmatized for var- Over the past dozen years, there has been an ious reasons, such as their economic situation, increase in research related to minority stress race, gender, background, or aspects of their models and the relationship between social sta- sexuality. tus and mental health [21-23]. The common as- Archives of Psychiatry and Psychotherapy, 2017; 3: 69–80 Minority stress among homosexual and bisexual individuals – from theoretical concepts to research... 71 sumption is that prejudice and discrimination Ilan Meyer proposed a model of minori- are factors that can significantly contribute to ty stress that is useful for research and clinical mental and somatic problems. practice [11,12,31,32]. He conducted studies on Minority stress has been variously defined, for the model in the 1990s, and the model has con- instance by using the “peer judges” method that sistently been verified by subsequent studies. assesses the narrative about the subject’s life ac- The model primarily incorporates elements such cording to specific criteria. Sometimes, an in- as internalized homophobia, expectation of re- terviewer, in accordance with a prepared list, jection and concealing one’s sexual preferences verified whether a subject experienced circum- (outness), along with concepts such as connect- stances connected with affiliation to a minority edness or identification with the minority com- group, which could be the cause of stress [24- munity [40,41]. As this model has already been 26]. However, a questionnaire is the method described in Polish research literature [13,20], used most often. A number of studies primari- a detailed description of it will not be attempt- ly measured the experience of racism, or stigma ed here. Instead, we will present a tool that has in psychiatric patients [27-29]. Later, tools that emerged in relation to this model. This tool is of addressed the issue of sexual orientation were interest because it can be used in both research developed [30]. and clinical practice. Studies of minority stress using a question- naire mainly rely on one variable as a stress in- dicator. Less commonly, a combination of var- MATERIALS AND METHODS iables is used. The most common indicators of minority stress are internalized homophobia Sexual Minority Stress Scale (SMSS) [31,32], sexism or heterosexism [33,34], or con- cealment [35]. These scales usually comprised As already mentioned, questionnaires are the relatively few items – e.g. a dozen questions in- most common method of measuring minority vestigating negative life events connected with stress. One such questionnaire is the Sexual Mi- sexual orientation or witnessing such events. nority Stress Scale (SMSS), designed to aid clini- The questions or statements typically referred cal identification of stressful areas of life [42]. The to events within a specific time-frame, e.g.

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