Minority Stress, Spirituality and Psychological Quality of Life in a Lesbian, Gay and Bisexual Sample

MINORITY STRESS, SPIRITUALITY AND PSYCHOLOGICAL QUALITY OF LIFE IN

A LESBIAN, GAY AND BISEXUAL SAMPLE

Megan M. Purser, M.A.

Thesis Prepared for the Degree of

MASTER OF SCIENCE

UNIVERSITY OF NORTH TEXAS

August 2013

APPROVED:

Mark A. Vosvick, Major Professor Charles A. Guarnaccia, Committee Member Victor R. Prybutok, Committee Member Chiachih DC Wang, Committee Member Vicki Campbell, Chair of the Department of Psychology Mark Wardell, Dean of the Toulouse Graduate School Purser, Megan M. Minority stress, spirituality and psychological quality of life in a lesbian, gay and bisexual sample. Master of Science (Psychology), August 2013, 90 pp., 19 tables, 6 figures, references, 115 titles.

Unique factors associated with the experience of spirituality and religiosity for many in lesbian, gay and bisexual (LGB) communities include minority stress. Using structural equation modeling, we examined whether minority stress mediates the relationship between spirituality and psychological quality of life (QOL). Results indicate minority stress mediates the relationship between spirituality and psychological QOL for gay men and bisexuals. However, minority stress is not a significant mediator for lesbians. Therefore, lesbians may experience minority stress and its relationship to psychological QOL differently than gay men and bisexuals due to higher societal acceptance. This study provides support for examining lesbians, gay men and bisexuals separately rather than as one sexual minority group.

Megan M. Purser

ACKNOWLEDGEMENTS

I would like to thank my research advisor, Dr. Mark Vosvick, and thesis committee members for their time, feedback and guidance throughout this study. I would also like to thank Kwabena Boakye for spending extensive time guiding me through PLS and data interpretation. I also want to express my gratitude to the faculty and members of the Center for Psychosocial Health Research at the University of North

Texas, the local LGB service organizations for helping us recruit and the participants for making this study possible. I want to also thank my family and friends for all their love and support.

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TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS ...... iii

LIST OF TABLES ...... vi

LIST OF FIGURES ...... vii

CHAPTER 1 INTRODUCTION ...... 1 Lesbian, Gay and Bisexual ...... 2 Quality of Life in LGB Persons...... 5 Spirituality ...... 7 Definitions ...... 7 Dimensions of Spirituality ...... 9 Spirituality and Psychological QOL ...... 11 Spirituality and LGB ...... 16 Minority Stress Theory ...... 21 Minority Stress ...... 27 Stress ...... 27 Anger ...... 28 Research Question and Hypotheses ...... 29 Implications...... 31

CHAPTER 2 METHODS ...... 33 Participants ...... 33 Measures ...... 35 Short-Form 36 Health Survey (SF-36) ...... 36 Systems of Belief Inventory (SOBI) ...... 37 Spirituality Index of Well-Being (SIWB) ...... 37 Heartland Forgiveness Scale (HFS) ...... 38 Positive State of Mind Scale (PSOM) ...... 38 Kentucky Inventory of Mindfulness Skills (KIMS) ...... 39 Life Orientation Test-Revised (LOTR)...... 39 State Trait Anger Expression Inventory-2 (STAXI-2) ...... 40

Perceived Stress Scale (PSS) ...... 40 Shame Due to Heterosexism Scale (SDHS) ...... 41 Heterosexist Harassment, Rejection and Discrimination (HHRDS) ...... 41 Data Analyses ...... 42

CHAPTER 3 RESULTS ...... 46 Exploratory Factor Analysis ...... 46 Univariate Statistics ...... 52 Bivariate Statistics ...... 54 Multivariate Statistics ...... 54 Structural Equation Model ...... 56 LGB...... 58 Lesbians ...... 64 Gay Men ...... 65 Bisexuals ...... 67 Group Comparisons ...... 67

CHAPTER 4 DISCUSSION ...... 70 Hypothesis 1– Spirituality is Negatively Correlated with Minority Stress ...... 72 Hypothesis 2 - Minority Stress is Negatively Correlated with Psychological QOL ...... 73 Hypothesis 3.Minority Stress Mediates the Relationship Between Spirituality and Psychological QOL ...... 75 Limitations ...... 78 Clinical Implications ...... 80 Future Research ...... 81

REFERENCES ...... 82

LIST OF TABLES

Page

Table 1 Descriptive Statistics ...... 34

Table 2 Religious Affiliation ...... 35

Table 3 HFS Exploratory Factor Analyses ...... 47

Table 4 KIMS Exploratory Factor Analyses ...... 48

Table 5 LOTR Exploratory Factor Analyses ...... 48

Table 6 PSOM Exploratory Factor Analyses ...... 49

Table 7 SIWB Exploratory Factor Analyses ...... 49

Table 8 PSS Exploratory Factor Analyses ...... 50

Table 9 HHRDS Exploratory Factor Analyses ...... 50

Table 10 SDHS Exploratory Factor Analyses ...... 51

Table 11 STAXI Exploratory Factor Analyses ...... 51

Table 12 SF-36: Energy Exploratory Factor Analyses...... 52

Table 13 SF-36: Emotional Well-Being Exploratory Factor Analyses ...... 52

Table 14 Mean and Standard Deviation and Range by Group ...... 53

Table 15 Construct Correlations* ...... 55

Table 16 Reliability and Validity ...... 57

Table 17 Path Coefficients and t-Scores ...... 60

Table 18 Construct Factor Loadings Across Groups ...... 61

Table 19 Path Coefficients and Standard Errors between Latent Variables by Group ...... 69

LIST OF FIGURES

Page

Figure 1. Spirituality and religion...... 9

Figure 2. Spirituality, stress, mental health model (SSMH)...... 30

Figure 3. LGB SSMH (path coefficients represent t-scores)...... 58

Figure 4. Lesbian SSMH (path coefficients represent t-scores)...... 65

Figure 5. Gay SSMH (path coefficients represent t-scores)...... 66

Figure 6. Bisexual SSMH (path coefficients represent t-scores)...... 68

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CHAPTER 1

INTRODUCTION

The 2000 U.S. Census identified 304,148 gay men and 297,061 lesbians living in the United States, with 21,740 gay men and 21,172 lesbians living in Texas (Smith &

Gates, 2001). Despite the Census’ inquiries about sexual orientation, a serious problem of underreporting exists. Berg and Lien (2006) estimate that an extraordinarily high number of non-heterosexuals (approximately one-third) go unaccounted in the US

Census and suggest that a more accurate estimate of the number of non-heterosexuals is closer to 10.0 million for men, and 5.9 million for women. These large numbers of non-heterosexuals are uncounted because the only way information regarding sexual orientation can be extrapolated from the US Census is to examine cohabitation of unmarried couples and gender (Grant, n.d.). The US Census does not attempt to estimate the number of LGB people in the US, but rather attempts to obtain information on cohabitation among same-sex couples. With non-heterosexual identity calculated this way, many lesbian and gay people go unaccounted for, as only those living with their partners are recognized (Grant, n.d.). In Texas, the number who self-identify as gay or lesbian rose from 7,871 in 1990 to 42,912 in 2000 (Smith & Gates, 2001). This

445% increase may be due to an actual increase in the number of gays and lesbians living in Texas or an artifact of the United States becoming more accepting of diverse sexual orientations, which results in LGB people being more likely to disclose their sexual minority status. Regardless of the cause, this ever-increasing number of sexual minorities provides a strong argument for a proportionate increase in research on gay men and lesbians.

Specifically, quality of life and factors that improve quality of life are important

constructs to examine in this understudied group of people. One construct associated

with quality of life for heterosexuals is spirituality (Sawatzky, Ratner & Chiu, 2005).

However, this relationship is not thoroughly examined for gay men, lesbians and

bisexuals.

Lesbian, Gay and Bisexual

The history of the word ‘homosexual’ is filled with derogatory sentiments which often lead many people in the lesbian, gay and bisexual (LGB) communities to perceive discrimination. To begin with, Richard Krafft-Ebing (1894) introduced the term

‘homosexual’ to the scientific community in his book Psychopathia Sexualis. He described ‘homosexual’ as a perverse feeling toward the same sex and as a “strange manifestation of the sexual life” (Krafft-Ebing, 1894, p. 222). Krafft-Ebing (1894) further reports that homosexuality is a “functional sign of degeneration” and is often hereditary

(Krafft-Ebing, 1894, p. 225). Until 1973, “homosexuality” was defined as a clinical disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The term

“homosexual,” therefore, carries a negative connotation and suggests that gay men and lesbians are diseased or psychologically and emotionally disordered (GLAAD,

2010).The word ‘homosexual’ is often perceived as offensive to gay men and lesbians.

In fact, the Associated Press, New York Times and Washington Post restrict usage of the term “homosexual” (GLAAD, 2010). According to the Gay and Lesbian Alliance

Against Defamation (GLAAD, 2010), “gay” is the preferred “adjective used to describe people whose enduring physical, romantic and/or emotional attractions are to people of

the same sex”. “Lesbian” is often the preferred term for gay women. GLAAD (2010)

recommends using “lesbian” or “gay man” to describe people attracted to members of

the same sex instead of “homosexual”. “Bisexual” is the term used to describe “an

individual who is physically, romantically and/or emotionally attracted to men and

women”. A sexual experience is not required to identify as a gay man, lesbian or

bisexual (GLAAD, 2010).

“Transgender” is the preferred term for people whose gender identity and/or

expression is different from their sex assigned at birth (GLAAD, 2010). Transgender

people may identify as female-to-male (FTM) or male-to-female (MTF). Transgender individuals are often clumped with lesbians, gay men and bisexuals in order to study sexual minorities. However, it is important to note that transgender is not a sexual orientation. Transgender individuals may identify as either heterosexual, gay, lesbian or bisexual. Therefore, participants who describe their sexual orientation as “transgender” are not included in this study. Transgender participants who identify their sexual orientation as either lesbian, gay, bisexual or heterosexual are included in this study.

Researchers also typically combine lesbian, bisexuals and gay men into one sexual minority category. When lesbian, gay men and bisexuals are not classified as one category, they are often split into two separate categories: (1) gay and bisexual men and (2) lesbian and bisexual women. When sexual minorities are forced into one category such as these, important differences between these groups are overlooked.

For example, due to a small number of bisexuals in their sample, D’Augelli and

Grossman (2001) split participants into two groups (sexual minority men and sexual minority women) in their study of discrimination and victimization in sexual minorities.

Their results indicate men are significantly more often threatened, physically attacked, and threatened with weapons than women. Men also report significantly more internalized homophobia, alcohol use and suicidality related to their sexual orientation than women. Lastly, women who were victims of physical attacks report poorer current mental health than any other group (D’Augelli & Grossman, 2001). However, by dichotomizing sexual minorities in this way, the role of sexual minority variables in the lives of bisexual men and women are overlooked.

Balsam and Mohr (2007) argue that there is relatively little empirical evidence that compares the lives of bisexual men and women to lesbians and gay men.

Understanding the social contexts of bisexuals’ lives can help explain how their experiences may be different from lesbians and gay men. In addition to coping with heterosexism, bisexuals must also face negative attitudes, stereotypes and practices specific to bisexuality. One extreme manifestation of bi-negativity is the denial of bisexuality as a legitimate orientation, a belief rooted in the monosexist view that sexuality can only be specified to one gender (Rust, 2000). From the viewpoint of monosexism, bisexuals are often discriminated against by heterosexuals, gay men and lesbians. Mohr and Rochlen (1999) found lesbian and gay men who questioned the possibility of bisexuality as a sexual orientation are less willing to date a bisexual person or have a bisexual person as their best friend.

Bisexuals also encounter unique challenges in the sexual identity formation process. All LGB people must accept a sexual identity that differs from societal expectations. However, bisexuals also must cope with having a sexual identity that also deviates from expectations of lesbians and gay men, which may lead to the

development of higher levels of vigilance to stigma than lesbians or gay men (Balsam &

Mohr, 2007). Furthermore, bisexuals are less likely to have role models, contact with

peers of the same identity and less access to accurate information about their sexual

identity (Rust, 2002). Balsam and Mohr (2007) found that bisexuals report lower

subjective connection to sexual minority communities than lesbians or gay men. Also,

compared with lesbians and gay men, bisexuals report higher levels of identity confusion and are less “out.” In order to gain greater acceptance from the lesbian and

gay community, bisexuals will often disclose their non-heterosexual identity but not their

bisexual identity (Balsam & Mohr, 2007). Finally, Balsam and Mohr (2007) found that

“outness” was related to social support but not psychological well-being. Jorm, Korten,

Rodgers, Jacomb and Christensen (2002) indicate bisexuals have significantly higher

levels of anxiety, depression and negative affect than lesbians, gay men and

heterosexuals. However, lesbians and gay men experience significantly higher levels of

anxiety, depression, suicidality and negative affect than heterosexuals (Jorm et al.,

2002). Bisexuals also experience more adverse life events and financial difficulties than

lesbians and gay men (Jorm et al., 2002). In order to avoid problems associated with

the classifications discussed above, this study will not group lesbian, gay men and

bisexuals into one sexual minority category. Instead we will examine these groups

independently.

Quality of Life in LGB Persons

Several central characteristics of quality of life are agreed upon. First, quality of

life is patient-centered in that it is oriented toward the client’s experience (Basu, 2004).

Thus, an external expert cannot judge a client’s quality of life; only the person who lives

that life can assess QOL. Another central characteristic of quality of life is that it is subjective in nature. This subjective feature of quality of life can be broken down into perceptions of objective conditions (e.g. material resources) and perceptions of subjective conditions (e.g. satisfaction with resources). This can include information about functioning (e.g. “How many hours did you sleep?”), global evaluations of functioning (e.g. “How well do you sleep?”) and highly personalized evaluations of functioning (e.g. “How satisfied are you with your sleep?”). Lastly, another central theme of quality of life is that it is multi-dimensional in nature. At a minimum, quality of life includes the following: physical (perception of physical nature), psychological

(perception of cognitive and affective state) and social (perception of interpersonal

relationships and social roles; Basu, 2004) components. Some researchers include spirituality/religiosity as a dimension of quality of life (WHOQOL Group, 1995). Other studies examine quality of life by looking at: general health status, functional capacity, emotional function, level of well-being, life satisfaction, happiness, intellectual level,

pain, nausea and vomiting, level of symptoms, fatigue, sexual functioning, social

activity, memory level and job status (Gill, 1994).

In this study, we are most interested in the psychological aspect of quality of life.

Psychological quality of life has been described as a feeling, such as depression or

anxiety (Wilson & Cleary, 1995). Impairment of psychological functioning can lead to the

inability to accomplish a task that requires psychological health such as making difficult

decisions or handling stressful situations (Wilson & Cleary, 1995). Psychological quality

of life can be assessed by measures that question feeling “down”, nervous, peaceful, blue/sad and/or happy (Ware & Sherbourne, 1992).

The research we present on quality of life in LGB persons will focus on psychological constructs. Meyer (2003) found that LGB people are at a greater risk of mental disorders and suicidal behavior than heterosexual people (Meyer, 2003).

Similarly, King et al. (2008) conducted a meta-analysis on mental disorders, suicide and deliberate self-harm in LGB people. Their results suggest that LGB people are at a higher risk of suicidal behavior, mental disorder and substance misuse and dependence than heterosexual people. LGB people’s risk of 12-month depression is at least twice that of heterosexuals. Similarly, LGB people also are at a higher risk of lifetime and 12- month prevalence of anxiety disorders compared with heterosexuals. Lastly, LGB people have increased lifetime and 12-month risk of alcohol and drug dependence when compared with heterosexuals, with significantly higher risk in lesbian and bisexual women (King et al., 2008). Meyer (2003) and King (2008) suggest that these mental disorders are not specific to being LGB but a result of minority stress. The stigma, prejudice and discrimination experienced by LGB people foster a hostile and stressful environment that leads to mental health problems (for more on the Minority Stress

Theory, see below pp. 19; Meyer, 2003).

Spirituality

Definitions

The relationship between quality of life and spirituality is well documented in the literature for heterosexuals (Sawatzky, Ratner & Chiu, 2005). Whether spirituality is

examined in the context of spiritual well-being, religiosity or self-transcendence, evidence exists for a positive association between spirituality and quality of life

(Sawatzky et al., 2005). The conceptualization of spirituality is particularly difficult, as there are a wide variety of perspectives and assumptions in the research literature on spirituality. Definitions of spirituality can be based on the perspective of organized religion with predefined beliefs and practices, or more loosely as an elusive and subjective human experience. The underlying meaning of spirituality alludes to a search or quest for the transcendent, the sacred in life and beyond and a search for answers to life’s most meaningful and vital questions (Thoresen, 1999). Elements of spirituality extend beyond the physical limits of time and space, matter and energy, yet certain aspects of spirituality are readily observable (e.g. spiritual practices). Spirituality can also be viewed as primarily relational, such as a relationship with the sacred in life or with something divine that extends beyond the self (Miller & Thoresen, 2003). Even though conceptualizations of spirituality vary, most definitions include a sense of meaning and purpose in life, connectedness to the self, the environment or a higher power and belief in a unifying force (Zullig, Ward & Horn, 2006). Spirituality is conceptually distinct from religiosity in a number of ways. For example, religion is characterized by an organized belief system that includes set rituals and practices that are acquired in places of worship (Zullig, Ward & Horn, 2006). Spirituality is conceptualized as a way of being that can be learned anywhere. People can be spiritual without performing formal religious practices, and spirituality often has different meanings for different people (Zullig, Warn & Horn, 2006). Although some believe that

religiosity is an outward demonstration of spirituality, religiosity does not guarantee

spirituality (Chandler, Holden & Kolander, 1992). Figure 1 below depicts the relationship between spirituality and religiosity that we use in this study. While religiosity is different from spirituality, spirituality cannot be discussed independently of religiosity. These two constructs do not completely overlap, but some define and express their spirituality through their religion. Therefore, religiosity is necessary to discuss in the context of spirituality and can be thought of as a subset of spirituality as seen in the figure below.

Figure 1. Spirituality and religion.

Dimensions of Spirituality

This multifaceted construct is hard to define, as clear-cut boundaries are not present, which highlights the difficulty of forming a tight operational definition. The assumption that spirituality cannot or should not be studied scientifically has led to a gap in research on spirituality (Miller & Thoresen, 2003). Therefore, even though a

multidimensional approach involving all aspects of spirituality is difficult to achieve, it is still important to advance the field for constructs that science may not fully understand.

Spirituality can be measured through many different avenues. Halkitis et al.

(2009) asked LGBT participants “what does spirituality mean to you?”. Ten themes emerged from this question and included: (1) belief in, knowledge of, relationship with a higher power, (2) understanding self, accepting self, being in touch with self, (3) manifesting goodness in the world, (4) interconnectedness between self, others and the universe, nature, (5) belief in soul, spirit, transcendent dimension of life, mystical and magical experiences, (6) meaning, purpose and understanding, (7) specific practices, contexts or experiences, (8) nothing, cannot explain; don’t know, (9) nothing to do with religion and (10) coping and resilience (Halkitis et al., 2009). In order to assess these varying dimensions of spirituality, we will examine spiritual beliefs and practices, meaning and purpose in life, mindfulness, forgiveness, optimism and positive states of mind.

Halkitis suggests many LGBT people define spirituality as the belief in, knowledge of, or relationship with a higher power. This construct assesses the degree to which one feels connected to a greater power. In order to assess this construct, we will measure spiritual beliefs and practices in this study. Other LGBT people define spirituality as a force that promotes understanding of one’s role in life, the cause of events and life’s purpose (Halkitis et al., 2009). In this context, spirituality is viewed as the root of insight and wisdom. We will assess meaning and purpose in life in this study to assess this construct. Halkitis et al. (2009) also found LGBT people define spirituality as understanding self, accepting self and being in touch with self. This construct

represents the ability to get in touch with feelings and true beliefs in order to achieve self-acceptance. We will measure mindfulness in this study to assess this construct.

Lastly, Halkitis et al. (2009) also found some LGBT participants define spirituality as manifesting goodness in the world, a prosocial orientation and positive emotions and attitudes. For example, some LGBT people believe spirituality is comprised of respecting all life, compassion, forgiveness and love, as well as the expression of positive attitudes and emotions. In order to assess this dimension of spirituality, we will measure forgiveness, optimism and positive states of mind in this study.

Spirituality and Psychological QOL

Spirituality is associated with psychological QOL (Sawatzy, 2005). Sawatzky

(2005) conducted a meta-analysis to examine the relationship between spirituality and quality of life. Their results indicate that spirituality is best seen as a unique construct that is conceptually distinct, yet related to quality of life. The research literature is replete with studies that attempt to understand the relationship between spirituality and quality of life. Some evidence suggests that spiritual or religious factors may benefit health through any combination of the following: health habits, social support, psychodynamic or other cognitive behavioral effects (e.g. psychoneuroimmunology) or supernatural effects (e.g. distant healing; Thoresen, 1999). Historically, individuals from certain religious groups (e.g. Mormons, Adventists) live longer and with less chronic diseases than other religious groups possibly due to healthy behaviors associated with religious practices, such as abstaining from alcohol or cigarettes, family support programs and nutritional restrictions including fasting (Cochran, Beeghley & Block,

1988). However, healthy habits and support programs may not be sufficient to account

for the relationship between spirituality and quality of life.

Several mechanisms may explain reductions in disease risk. The most sound

and empirically supported explanation is that spiritual and religious practices lower

sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA axis)

arousal (Thoresen, 1999). Chronic negative emotional states such as anger, fear and

depression are common sources of SNS and HPA axis arousal (Thoresen, 1999).

McEwen (1998) suggests that more spiritually active people may have their allostatic

load reduced, thus enhancing physiological functioning, through the resources offered in

religious organizations and their own spiritually enhancing beliefs. Allostatic load can be

defined as the health costs of physiological changes that restore and maintain the

body’s physiological stability in the face of perceived demands (McEwen 1998). The

body’s capacity to restore stability can be gradually lost due to prolonged arousal, which

can lead to disruptions in cardiovascular, metabolic, immune and brain functions

(McEwen, 1998). Perceived loss of control, lack of social emotional support, poverty,

and low social status are all factors which are thought to contribute to excessive and

increased chronic allostatic load (McEwen, 1998). Spiritual practices are thought to

alleviate some of these difficulties, thereby reducing allostatic load and improving

physiological functioning (McEwen, 1998).

Spirituality is also thought to play an important role in components of quality of life, such as psychological and social functioning (Sawatzky et al., 2005). As with physical functioning, several mechanisms may explain the relationship between spirituality and psychosocial functioning. For example, cognitive/motivational,

behavioral, interpersonal and sociocultural processes have all been implicated

(Thoresen, 1999). Cognitive processes may include perception of self-worth through perceived acceptance and approval by others and/or a higher power and increasing

self-efficacy to accomplish goals such as making friends and giving to others. Health

behaviors and habits (e.g. avoiding cigarettes, balanced diet, physical activity)

influenced by spirituality may also mediate or moderate health outcomes. Spiritual

beliefs and practices can also increase interpersonal resources by having friends who

share similar spiritual or religious beliefs, especially for those who attend religious

services (Thoresen, 1999). Sociocultural factors may also have a role in the relationship

between spirituality and psychosocial functioning. For example, beliefs about illness and

suffering may come from a social context that promotes health-enhancing behaviors,

cognitions and interpersonal relationships (Thoresen, 1999). These contexts may

reduce the beliefs and behaviors commonly associated with adverse health and quality

of life. An example of this can be seen in many African American churches in the United

States, where the church offers a safe and caring context that encourages making cognitive and behavioral changes in health-related beliefs and habits (Thoresen, 1999).

Several examples of how spirituality is associated with the psychosocial

component of quality of life in heterosexuals are reported. According to Koenig,

McCullough and Larson (2001) people who are spiritually directed or have a consistent

religious practice have greater marital stability, less alcohol and drug use, lower suicide

rates, and less anxiety and depression. Spiritual practice is also associated with less

stress, less cigarette smoking, lower blood pressure, lower cholesterol, less risky

behavior and lower sexually transmitted diseases (Grant, 2007). Further, spirituality and

religion are associated with psychological well-being, reductions in depressive symptomatology and instillation of hope during stress (Lease, Horne & Noffsinger-

Frazier, 2005). This study will examine the psychological component of quality of life in

LGB people.

Because some people express their spiritual beliefs through their religion, it is important to also examine the relationship between religiosity and psychological QOL.

Religiosity can lead to negative health and mental health outcomes. For example,

Pargament et al. (1998) suggests several ways in which religious coping has a negative association with mental and physical health. For example, Pargament et al. (1998) suggest that religious apathy, God’s punishment, anger at God, religious doubts, interpersonal religious conflict and conflict with the church dogma are most clearly related to poor mental health and event-related outcomes. These scales represent a tension between people and their religious worlds. Religious apathy is a religiously based devaluation of self or others and is correlated with negative self-esteem and poor problem solving skills. God’s punishment is the use of religion to punish the self for a stressful situation and is associated with low self-esteem, greater trait anxiety and negative mood. Religious doubts such as personal religious doubts and religious confusion are associated with increased anxiety, poor problem solving and negative mood. Interpersonal religious conflict is conflict with family, friends or church members and is associated with greater anxiety and negative mood. Lastly, conflict with the church dogma is associated with poor problem solving, negative mood and low self- esteem (Pargament, 1998).

Rippentrop, Altmaier, Chen, Found and Keffala (2005) studied the role of

spirituality in coping with chronic pain. Chronic pain patients felt more abandoned by

God than a random representative US sample. Within this chronic pain sample religious

activities such as prayer and meditation were associated with poorer physical health.

These findings do not necessarily suggest that religious activities lead to poor physical

health. Rippentrop et al. (2005) hypothesize that the patients who are doing physically

the worst may rely the most on their faith for comfort. Furthermore, lack of forgiveness

and negative religious coping contribute to poor mental health and higher pain intensity

(Rippentrop et al., 2005).

Bjork and Thurman (2007) suggest that as negative events increase, people

begin to reappraise their view of God which may lead to negative religious coping such

as questioning God’s love and support or perceiving an event as punishment from God.

When first encountering a stressor people will use habitual, normative coping responses

(e.g., positive religious coping; Caplan, 1964). However, as stress increases, people

add novel and/or trial-and-error strategies (e.g. negative religious coping). Bjork (2007)

suggests that as negative events increase, negative religious coping (novel) will

increase more than positive religious coping (habitual). Furthermore, after controlling for

religious participation, negative events and positive religious coping, negative religious

coping is related to increased depression and decreased life satisfaction. However,

positive religious coping seems to buffer the effects of negative events on functioning.

For example, if people continue to use positive religious coping despite an increase in

negative events depression rises less than for those who report low positive religious

coping. While negative religious coping in the face of increasing negative events has

detrimental effects on mental health, positive religious coping alleviates the impact of

accumulating events on depression (Bjork, 2007). Religious coping may be especially

important for LGB people who experience excess stress resulting from stigma and

discrimination in religious communities due to their minority position.

Spirituality and LGB

The majority of mainline Christian, Islamic and Judaic traditions firmly prohibit

LGB sexual behavior (Clark, Brown, & Hochstein, 1990; LeVay & Nonas, 1995; Melton,

1991). Buddhism is a more complex tradition and there is no scripturally based position on homosexuality. Some Buddhist traditions ban sexual behavior of any kind and perceive it as a hindrance to enlightenment; however, early Buddhists did not place a special stigma on LGB sexual behavior (Jackson, 1995). Most traditional western religions historically are intolerant of homosexuality, denying full inclusion of gays into their religious practices (Tan, 2005). Religious fundamentalism is positively associated with prejudice toward homosexuals (Laythe, Finkel & Kirkpatrick, 2001; Laythe, Finkel,

Bringle & Kirkpatrick, 2002). Some studies indicate that when LGB individuals participate in organized religion, it can have a detrimental effect on their psychological health (Ritter & Terndrup, 2002). Participation in certain organizations include receiving negative messages about an LGB sexual orientation through religious teachings, faith group activities directed at only heterosexual couples, prohibition of openly gay clergy or religious leaders and isolation or avoidance of identified LGB people in the faith group

(Ritter & Terndrup, 2002). For example, many sexual minorities are told that in order to be saved from eternal damnation, they must (1) repent of their homosexuality and

become heterosexual or (2) repress their sinful sexual impulses and live a non-sexual or heterosexual lifestyle (Ritter & Terndrup, 2002). These options lead to struggle and pain for LGB people and as a result many deny or attempt to change their basic nature, while feeling ashamed, evil and sinful.

Additionally, individuals who hold more firmly to their religious beliefs tend to be more homophobic (Friedman & Downy, 1994). Therefore, the path for many LGB people to accept their sexual orientation consists of questioning and possibly rejecting the religion in which they were raised (Buchanan, Dzelme, Harris, & Hecker, 2001). A struggle exists because LGB people are asked to essentially choose between spiritual beliefs and their sexual orientation. Wagner et al. (1994) found that 69% of gay men in the general community turned away from their religion, accepting their sexuality when forced to choose.

The “coming out” process is often associated with feelings of self-hate, guilt, depression, fear or rejection from family, friends and society (Gluth & Kiselica, 1994).

Religious organizations add complexity by making the “coming out” process more difficult for those who have a religious upbringing. Wagner et al. (1994) suggests that religious involvement is associated with greater internalized homophobia or a self-image that includes a negative attitude toward homosexuality.

While it appears that many individuals choose to reject their religious beliefs in order to accept their sexuality, Wagner et al. (1994) argues that rejecting either the spiritual or sexual identity can have a negative effect on mental health. Further, they suggest gay men and lesbians who seek to integrate their homosexuality and spirituality encounter increased self-acceptance and increased mental health. Several ways of

integrating these two components of identity are proposed. To begin with, some religious organizations are becoming more tolerant to sexual minorities (Buchanan et al., 2001). Barret and Barzan (1996) suggest that liberation occurs when a person is rejected from traditional religious organizations and the experience of being free from an external authority allows LGB people to reflect on and integrate their own life experience, creating a personal and communal spirituality. Similarly, Helminiak (1995) described human integrity as the basic core of spirituality, where spiritual development is translated into affirming self rather than the beliefs of spiritual or religious organizations. Through this quest for spirituality, gay men and lesbians can build on their sexual identity by integrating personal life events and develop a healthy personal spiritual identity (Buchanan et al., 2001).

Many gay men and lesbians do integrate their spiritual identity with their sexual identity. Tan (2005) presents a sample of gay men and lesbians who achieve a high level of both religious and existential well-being and indicate a high sense of relating to

God and of life purpose and satisfaction. The results of this study indicate that gays and lesbians often have spiritually rich and meaningful lives, suggesting they overcame the difficulties often encountered with organized religions (Tan, 2005).

Even though the majority of organized religious groups are often heterosexist and unwelcoming of LGB individuals, LGB-affirming faiths have evolved by either altering traditional doctrine to be inclusive or creating denominations that specifically serve the LGB community (Borgman, 2009). Being a member of an LGB-affirming faith community is associated with less endorsement of internalized homonegativity and higher levels of spirituality among LGB people (Borgman, 2009). The negative

relationship between faith group affirmation and internalized homonegativity suggests that overt and accepting behaviors and attitudes from a faith group provide a contrast to the negative prevailing societal messages about an LGB sexual orientation (Borgman,

2009). Some LGB-affirming Christian denominations in the United States include: the

Episcopalian Church, Metropolitan Community Church, Evangelical Lutheran Church in

America and United Church of Christ. Bishops of the Episcopalian Church are given the choice to bless same-sex unions or allow for gay and lesbian marriages in states where it is legal (Goodstein, 2009). The Metropolitan Community Church (MCC), found in

1968, by Rev. Troy Perry was developed as a gay and lesbian-positive religious institution (Fact sheet for the Metropolitan Community Church, 2011). MCC offers holy unions, marriage and other commitment ceremonies to bless same-sex marriages (Fact sheet for the Metropolitan Community Church, 2011). The Evangelical Lutheran Church in America (ELCA) “recognizes, supports and publicly holds accountable life-long, monogamous, same gender relationships” (ELCA News Service, 2009) and the United

Church of Christ (UCC) describes themselves as “open and affirming” of LGB persons and declares same gender loving persons into the full life and ministry of the church.

The Dallas Cathedral of Hope, a congregation of the UCC, is known as the “world’s largest gay church” with over 4,000 members and a primary outreach to lesbian, gay, bisexual, transgender and queer/questioning people (FAQs Cathedral of Hope: A congregation of the United Church of Christ, n.d.). DignityUSA strives for respect and justice for all sexual orientations in the Roman Catholic Church, but is not associated with particular congregations or supported by the Catholic Church hierarchy.

DignityUSA believes that sexuality can be expressed in a loving, life-affirming manner

that keeps with Christ’s teachings (What is Dignity, n.d.).

LGB-affirming faiths outside of Christianity also exist. For example, Reform

Judaism supports civil rights, including marriage, for gay men and lesbian couples

(Central Conference of American Rabbis). Reconstructionist Judaism supports LGBT

civil rights and same-sex marriage. In fact, within Reconstructionist Judaism, the Jewish

Reconstructionist Federation welcomes congregations serving primarily LGBT Jews

(Jewish Mosaic: The National Center for Sexual and Gender Identity). The Al-Fatiha

Foundation is an international organization that provides a forum and safe space for

LGB Muslims to discuss common concerns and share experiences. The goal of this

organization is to reconcile sexual orientation with Islam (Al-Fatiha).

Even though a stark difference exists in spiritual acceptance between LGB

people and heterosexuals, a difference may also exist between sexual minorities and

their spiritual and religious experiences. For example, LGB people may experience

stigma, rejection and discrimination from religious organizations differently depending

on their sexual identity. This may contribute to varying experiences of spirituality and its

relation to psychological quality of life. Researchers have traditionally clumped lesbians,

gay men and bisexuals into one category of sexual minorities when examining

psychological quality of life and spirituality (Barret & Batzan, 1996; Buchanan et al.,

2001; Ritter & Terndrup, 2002; Wagner et al., 1994). Another option is to group gay and

bisexual men, and lesbian and bisexual women in order to increase statistical power

(Balsam, Beauchaine, Mickey & Rothblum, 2005). However, combining groups may

obscure differences between bisexual women and men’s mental health and that of

lesbians and gay men. Due to the unique differences associated with each sexual minority, the relationship between spirituality and psychological quality of life should be examined independently for lesbians, gay men and bisexuals.

Currently, no research examines differences in the experiences of lesbians, gay men and bisexuals in the context of spirituality, minority stress and psychological quality of life. However, the different experiences of lesbians, gay men and bisexuals highlight the importance of studying these three groups independently.

Minority Stress Theory

The Minority Stress Theory may explain why spirituality and quality of life may be different for LGB people than for heterosexuals. The Minority Stress Theory, proposed by Meyer (2003), provides insight into how rejection from the spiritual/religious community, as a result of being a sexual minority, can impact quality of life for LGB individuals.

‘Minority stress’ can be used to distinguish the excess stress experienced by individuals from stigmatized social categories as a result of their social and often minority position (Meyer, 2003). The concept of minority stress is based on several social and psychological theoretical orientations (Meyer, 1995). Minority stress comes from the juxtaposition of minority and dominant values. The minority person is likely to be exposed to conflict in the environment because cultural norms and social structures generally do not reflect those of the minority group. Minority group members are exposed to negative life events related to their minority status such as stigmatization and discrimination. Minority stress arises from the totality of the minority person’s

experience in a dominant society (Meyer, 1995). Lazarus and Folkman (1984) describe the essence of all social stress to stem from a conflict between individuals and their experience of society. Since the social environment provides people with meaning and organizes their experiences, not being accepted by their peer groups is damaging to their mental health. Further, negative regard from others leads to negative self-regard

(Meyer, 2003). Societal reaction theory postulates that deviance leads to labeling and negative social reaction (Meyer, 1995). As a result, stigmatized individuals develop adaptive and maladaptive responses that may include mental health symptoms (Meyer,

1995). Allport (1984) similarly describes “traits due to victimization” as defensive reactions for stigmatized people that may be caused by introverted mechanisms (e.g. self-hate, in-group aggression) and/or extroverted mechanisms (e.g. shyness, obsessive concern with the stigmatizing characteristic and rebellion).

Many studies examine the effect of minority status on mental health. However, they compare rates of psychopathology and distress between minority and nonminority groups as a means to show that minority stress is experienced more often by minority groups. The prediction is that if a minority position is stressful and if stress is related to psychological distress then minority groups will have higher rates of distress than nonminority groups (Meyer, 1993). However, studies that compare stress in African

Americans to European Americans; women to men and gays to heterosexuals have not found significant differences. The problems with these studies are many. To begin with, a central problem is selection bias in sampling. For example, when comparing gay and straight men, people who are not “out” and who do not accept themselves are less likely to participate in studies of gay men than individuals who accept themselves (Meyer,

1993). Since self-acceptance is related to better psychosocial adjustment and less distress, this selection bias leads to an overrepresentation of healthier members of the minority group which underestimates the rates of distress. Meyer (1993) however found support for minority stress formulations. His study found that although no differences in distress existed between gay and heterosexual men, when gay men become distressed, it usually occurs in areas that are consistent with minority stress, such as self-acceptance, alienation and paranoid symptoms (Meyer, 1993).

Meyer (2003) suggests that minority stress is: (a) unique in that it is additive to the usual stress experienced by most individuals who are not stigmatized; (b) chronic in that it is related to stable social and cultural structures; and (c) socially based since it comes from social processes, institutions and structures. The Minority Stress Theory indicates that among LGB individuals, the stigma, prejudice and discrimination often endured create a stressful environment that may lead to mental health problems, such as increased stress due to expectations of rejection, hiding and concealing and internalized homophobia. Meyer (2003) outlined a framework for understanding the implications of societal oppression for the mental health of LGB individuals. Four sources of minority stress are outlined as relevant to LGB individuals: (1) perceived experiences of prejudice, (2) expectations of stigma, (3) internalized homophobia and

(4) concealment of sexual orientation. This set of minority stressors is thought to promote psychological distress and reduce psychological quality of life of LGB persons

(see table below).

These four sources of minority stress can be seen in the context of spirituality for

LGB people. The first stressor, perceived experiences of prejudice, comes in many

forms including antigay violence and discrimination. D’Augelli (1989) found that 50% of gay and lesbian college students reported victimization based on sexual orientation which include overhearing disparaging comments, verbal insults, threats of physical violence and victims of physical assault. The experience of anti-LGB prejudice, harassment and victimizations are positively correlated with a variety of mental and physical symptoms (Diaz et al., 2001; Meyer, 1995):

• Anxiety • Insomnia

• Demoralization • Psychological distress

• Depression • Somatic symptoms

• Guilt • Suicidal ideation

Within the context of religious communities, LGB people experience prejudice from two sources. First, they may feel marginalized or experience prejudice by organized religions due to their sexual orientation. For example, the Vatican previously stated that

LGB people are objectively disordered and inclined toward evil (Ratzinger, 1986).

Second, they may experience alienation and criticism from members of the LGB community because they are religiously inclined or connected with a certain religious tradition rather than exploring their spirituality through more nontraditional paths (Ritter

& Ternrdrup, 2002).

The culture of prejudice and discrimination cultivates and promotes the second source of minority stress: expectations of anti-LGB prejudice and stigmatization. Meyer

(2003) suggests that in order to cope with prejudice and discrimination, LGB persons maintain a sense of vigilance by being aware of the possibility that others will be hostile or discriminatory to them. This constant sense of vigilance is stressful and can result in

greater symptomatology. For example, Meyer (1995) found that expectations of stigma

were positively correlated with demoralization, guilt and suicidal ideation in LGB people.

Similarly, Lewis et al. (2006) found depression, somatic symptoms and intrusive

thoughts to be positively correlated with expectations of stigma. In the context of

religion, the continuous experience of prejudice and discrimination may lead to

expectations of further harassment and rejection among LGB people.

The culture of anti-LGB prejudice and stigma can also promote internalization of

that stigma (i.e, internalized homophobia) in LGB individuals, the third source of minority

stress outlined by Meyer (2003). Internalized homophobia refers to the process by

which LGB people internalize society’s antigay attitudes (Meyer, 2003). LGB people

may direct society’s negative social values inward and thus may experience a

devaluation of the self, internal conflicts and poor self-regard. Internalized homophobia

is linked with (Meyer 1995; 2003):

• Anxiety • Guilt

• Body image dissatisfaction • Shame

• Demoralization • Substance use

• Depression • Suicidal ideation

Lesbians with high levels of internalized homophobia also report increased alcohol

consumption, negative affect, depression, low relationship quality, loneliness and

somatic symptoms (Balsam & Syzmanski, 2005; DiPlacido, 1998; Lewis et al., 2006;

Szymanski & Chung, 2003; Szymanski et al., 2001). In HIV positive gay and bisexual

men, baseline internalized homophobia was correlated with self-reported and clinician- rated distress two years later, even after controlling for HIV-illness stage and

psychological distress (Wagner, Brondolo & Rabkin, 1996). Religious organizations can further impact LGB people by instilling internalized homophobia through their beliefs and teachings that homosexuality is immoral and sinful. Wagner, Serafini, Rabkin &

Williams (1994) suggest that religious involvement may be associated with greater internalized homophobia or a self-image that is composed of negative societal attitudes toward homosexuality.

The last source of minority stress included in Meyer’s (2003) framework is sexual orientation concealment. In a sample of LGB individuals, concealment of sexual orientation was positively correlated with symptoms of depression, drug use, current mental health status and suicidal ideation (Lewis et al., 2001; D’Augelli et al., 2001).

Among gay and bisexual HIV-positive men, concealment of sexual orientation was positively related to rapid advancement of HIV infection and higher rates of diseases such as cancer, pneumonia, bronchitis, sinusitis and tuberculosis, even after controlling for demographic variables, health practices, and other significant variables (Cole,

Kenney, Taylor, & Vischer, 1996; Cole, Kenney, Taylor, Visscher, & Fahey, 1996).

Among lesbians and bisexual women, concealment of sexual orientation was related positively to depression, alcohol consumption and negative affect (Ayala & Coleman,

2000; Diplacido, 1998; Szymanski et al., 2001). Further, the oppression experienced from religious organizations influences LGB individuals’ decisions to disclose sexual orientation. For example, Lease and Shulman (2003) conducted a study which examined the relationship between disclosure and religion. They found that 69% of participants indicated that their religion at the time their family member came out was either absolutely “unaccepting” or “somewhat unaccepting” of homosexuality. This

resulted in only 35% of participants telling friends in their congregation, 35% telling

clergy and 32% telling no one of their family member’s disclosure (Lease & Shulman,

2003). LGB people likely disclose their sexual orientation at a rate even less than their

family members to their friends in the congregation and clergy in order to avoid being

rejected or isolated from their religious community.

Minority Stress

Stress

According to the Minority Stress Theory (Meyer, 2003), prolonged exposure to stigma and discrimination, such as that experienced from religious groups, leads to increased stress among sexual minorities. Exposure to chronic stigma-related stress can affect coping and emotion regulation (Hatzenbuehler, 2009). Because stigma creates a devalued social identity, it creates stressors that contribute to negative affect.

Stress results in maladaptive coping and poor emotion regulation strategies. For example, chronic life stressors can lead to emotion regulation deficits, such as increased sensitivity to anger and inappropriate expression of emotion (Hatzenbuehler,

2009). Social exclusion and stigma are ego depleting in that exerting self-control on one task depletes resources for a following task requiring self-control. Stigmatized individuals, such as sexual minorities, are hypothesized to have used and depleted their self-control to manage their devalued social identity (Hatzenbuehler, 2009). Over time, the resources required to maintain this sense of self-control are depleted and the ability to understand and adaptively regulate their emotions are diminished (Hatzenbuehler,

2009).

Anger

Kopper and Epperson (1996) examined the relationship between expression of

anger and mental health variables (psychological quality of life) such as depression,

assertiveness, self-confidence, dependency, guilt and conflict avoidance. The three

types of anger assessed were: (1) aggressive acting out, (2) uncontrollable anger

expression and (3) anger suppression. Aggressive acting out includes behaviors such

as physical aggressiveness. Uncontrollable anger expression includes a high level of

anger proneness and acknowledged, poorly controlled verbal or indirect expression of

anger. Anger suppression includes suppression of anger, suspiciousness, irritability and

passive aggressiveness. Results indicate that aggressive acting out was positively

correlated with depression and negatively correlated with self-confidence and conflict

avoidance. Uncontrollable anger expression was positively associated with depression,

assertiveness and guilt and negatively associated with self-confidence and conflict

avoidance. Anger suppression was the only type of anger significantly correlated with all

mental health variables measured. For example, anger suppression was positively

correlated with depression, dependency, guilt and conflict avoidance and negatively

correlated with assertiveness and self-confidence. Similarly, several multiple regressions were run with the mental health variables as the dependent variables and the three types of anger, as well as other variables, as the independent variables.

Results indicate that anger suppression generally was the best predictor of the mental health variables. In sum, these results indicate that suppression of anger is the most damaging to mental health (Kopper & Epperson, 1996). Therefore, in this study, we will assess this type of anger.

Taken together, stress and anger are negatively correlated with psychological quality of life (Kooper & Epperson, 1996; Mays & Cochran, 2001; Meyer, 1993; Meyer,

1995). We hypothesize that stress, anger, shame due to heterosexism and heterosexist

harassment, rejection and discrimination are source of minority stress encountered in the spiritual environment of an LGB person and are associated with poor psychological quality of life.

Research Question and Hypotheses

According to the Minority Stress Theory, LGB people experience stigma and discrimination that leads to adverse health outcomes, such as increased and chronic stress (Meyer, 2003). One source of minority stress may come from spiritual and

religious organizations because sexual minorities are often stigmatized, marginalized

and rejected from such communities. Much research indicates a positive relationship

between spirituality and quality of life, but the literature is unclear as to what this

relationship looks like in LGB communities where individuals often experience minority

stress resulting from organized religions.

Using the minority stress theory as a template, we hypothesize that minority stress mediates the relationship between spirituality and psychological quality of life. We

expect that spirituality is associated with a decrease in minority stress that is then

associated with an increase in psychological QOL. Figure 2 depicts the hypothesized

relationship between these latent constructs (spirituality, minority stress and

psychological QOL).

Figure 2. Spirituality, stress, mental health model (SSMH).

Halkitis (2009) argues that spirituality contributes to forgiveness, mindfulness, optimism, positive states of mind, life scheme (meaning and purpose in life) and spiritual beliefs and practices. Minority stress comes from a minority status (e.g. sexual orientation) and may contribute to shame due to heterosexism (SDH) and heterosexist, harassment, reject and discrimination (HHRD), as well as increases in anger and stress

(Meyer, 1993; Meyer, 1995), The latent construct psychological QOL contributes to mental health and vitality (Ware & Sherbourne, 1992).

In order to evaluate our study aims and purpose, spirituality, minority stress and psychological quality of life are modeled together to understand the interdependencies between these constructs when acting in concert with one another. To delineate the efficacy of our model, the following hypotheses will be tested for (1) all LGB individuals as one group, as well as separately for (2) lesbians, (3) gay men and (4) bisexuals.

1. Spirituality is negatively associated with minority stress.

2. Minority stress is negatively associated with psychological QOL.

3. The relationship between spirituality and psychological QOL is mediated by minority stress.

Implications

If these hypotheses are supported, the results will provide support for the notion that spirituality plays an important role in the well being of LGB people. Such evidence would not only extend the research regarding spirituality among LGB people, it would also inform clinicians about the important influence spirituality has on the psychological quality of life of lesbians, gay men and bisexuals. This study also has implications for therapeutic interventions for LGB people who struggle to reconcile their spiritual and sexual identities. For example, this study will suggest that clinicians probe LGB clients around spirituality and religiosity rather than avoiding or diminishing this aspect altogether. Furthermore, this suggests that clinicians should explore their comfort level of exploring spirituality and religiosity in LGB people so they do not reject their clients’ sexual orientation or religious/spiritual preferences due to their personal religious beliefs. Also, this study will inform clinicians which constructs to focus on when helping

LGB individual’s in their spiritual journey and sexual identity development. For clients

who desire a spiritual or religious community, clinicians can direct LGB people to LGB- affirming faiths such as the Episcopalian Church, Metropolitan Community Church,

Evangelical Lutheran Church in America, United Church of Christ, Reform Judaism,

Reconstructionist Judaism and Al-Fatiha.

Knowledge of differences between lesbians, gay men and bisexuals in the relationship between spirituality and quality of life can also inform clinicians and community leaders of where to focus their services aimed at spirituality in LGB communities (e.g. minority stress). For example, this information may inform religious leaders who offer spiritual guidance for LGB people of where to focus their efforts (e.g. minority stress) to help LGB people overcome the barriers associated with their spirituality. This may help LGB people reconcile differences between their spiritual and sexual identities so they are able to accept both. Lastly, from a social justice standpoint, this research will further the efforts made in equality for LGB people by showing the importance of religious and spiritual organizations that accept all sexual orientations.

CHAPTER 2

METHODS

Participants

The appropriate institutional review board approved our study. Written informed consent was obtained from all participants prior to participation. Individuals 18 or older

that self identified as LGBT or heterosexual were recruited between 2008-2009 as part

of a larger project that examined health issues and associated psychosocial and

behavioral factors in the LGBT communities. Recruitment was solicited through local

community-based organizations and the gay pride parade in the Dallas/Fort Worth

metroplex area in Texas. Participants received a $25 incentive to complete our survey.

Our study uses a cross-sectional correlational design and examines self-report data

from questionnaires. Our diverse sample was stratified based on gender and sexual

orientation and consisted of 201 participants. Participants who described their sexual

orientation as transgender were removed from the data prior to analyses because

‘transgender’ is not a sexual orientation. In fact, transgender people can be lesbian,

gay, bisexual or heterosexual. However, transgender participants who described their

sexual orientation as LGB or heterosexual were kept in analyses. With regard to

gender, our sample consists of 82 males, 119 females, 10 male-to-female transgender

participants and 1 female-to-male transgender participant. Table 1 below illustrates the

breakdown of biological sex, ethnicity and the average age, income, and education for

lesbian, gay, bisexual and heterosexual participants. Heterosexual participants were

included in the study to examine differences in heterosexuals between lesbians, gay

men and bisexuals for exploratory purposes. Table 2 shows the breakdown of LGB

participants’ religious affiliation and current religious involvement.

Table 1

Descriptive Statistics

Age Income Education n Sex % Ethnicity % M(SD) M(SD) M(SD)

European American 60 Male 100 African American 16 35.96 $44,502 14.84 Gay 50 Latino 12 (13.26) (48,728) (5.68) Female 0 Other 12 European American 64 Male 10 African American 6 30.90 $34,880 15.41 Lesbian 49 Latino 16 (11.11) (38,127) (3.24) Female 90 Other 14 European American 60 Male 33 African American 15 28.85 $32,290 14.29 Bisexual 52 Latino 8 (12.24) (56,647) (5.13) Female 67 Other 17 European American 44 Male 20 African American 24 23.54 $29,034 13.08 Hetero 50 Latino 14 (3.67) (31,993) (5.78) Female 80 Other 18

Table 2

Religious Affiliation

n Percent

Denomination

Christian 75 49.7%

Jewish 2 1.3%

Buddhist 10 6.6%

Hindu 2 1.3%

Muslim 2 1.3%

Baha’i 1 0.7%

Agnostic 49 32.5%

Atheist 10 6.6%

Current Religious Involvement

Out of synch with fellow believers and no longer attend 25 16.6%

Out of synch with fellow believers and still attend 3 2.0%

Currently Attending 28 18.5%

Changed denomination or faith 24 15.9%

Stopped Attending 52 34.4%

Measures

Participants completed items on demographic characteristics, as well as items on health and wellness, medical issues, barriers to health and health disparities within the

LGB communities. Data on psychosocial and behavioral factors such as social support, stress and coping, pro-health and health seeking behaviors were also collected.

Short-Form 36 Health Survey (SF-36)

The SF-36 (Ware & Sherbourne, 1992) is a 36-item measure designed to assess quality of life. We used two subscales from the SF-36 (Mental Health and Vitality). The psychological QOL scale of the SF-36 consists of four subscales: mental health, vitality, social functioning and role-emotional. The role-emotional subscale consisted of only yes-no responses and therefore could not be used in the SEM model. We did not choose the social functioning subscale since we were more interested in the mental health and vitality of the participants rather than their social support. The Mental Health subscale is a 5-item subscale that assesses feelings of anxiety and depression. The

Likert-type scale ranged from 1 (All of the Time) to 6 (None of the Time), with higher scores indicating greater emotional well-being. Examples of items on this measure include “During the past 4 weeks have you been a nervous person?” and “During the past 4 weeks have you felt so down in the dumps that nothing could cheer you up?”

Brazier and colleagues (1992) report an internal consistency reliability (Cronbach’s alpha) of 0.95 for this subscale. The Vitality subscale of the SF-36 contains 4-items that assess fatigue and energy. The Likert-type scale ranged from 1 (All of the Time) to 6

(None of the Time), with higher scores indicating high energy. Examples of items include “Did you feel full of pep?” and “Have you felt calm and peaceful?” Brazier and colleagues (1992) reported a reliability coefficient (Cronbach’s alpha) of 0.96 for this subscale. The SF-36 demonstrates strong construct validity (Ware & Sherbourne,

1992).

Systems of Belief Inventory (SOBI)

We measured spirituality using the Beliefs and Practices subscale of the SOBI

(SOBI; Holland et al., 1998), a 15-item scale that asks participants about their religious and spiritual beliefs and practices and social support derived from their communities.

The Beliefs and Practices subscale measures personal beliefs, such as someone’s reflections on the meaning of life and death, illness and existential concerns (Holland et al., 1998). This subscale was chosen over the other subscale (social support) of the

SOBI because we were more interested in participants spiritual beliefs and practices rather than their level of social support obtained by their spirituality. This 10-item Likert- type scale ranges from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating high spiritual beliefs and practices. Examples of items on this measure include “I have experienced peace of mind through my prayers and meditation” and “I have experienced a sense of hope as a result of my spiritual beliefs and practices”.

Holland and colleagues (1998) report an internal consistency reliability coefficient

(Cronbachs alpha) of .92 for the Beliefs and Practices subscale. The SOBI demonstrates convergent, divergent and discriminant validity (Holland et al., 1998).

Spirituality Index of Well-Being (SIWB)

We measured forgiveness using the life-scheme (e.g. meaning and purpose in life) subscale of the SIWB (Daaleman and Frey, 2004). The other subscale of the SIWB

(self-efficacy) measured self-efficacy beliefs rather than meaning in one’s life.

Therefore, we chose to use the life-scheme subscale as another measure of spirituality.

This six-item Likert-type subscale ranges from 1 (Strongly Agree) to 5 (Strongly

Disagree) with high scores indicating high self-scheme. Examples of items on this measure include “I haven’t yet found my life’s purpose” and “I am far from understanding the meaning in life.” Daaleman and Frey (2004) reported the life-scheme subscale has an internal consistency coefficient of 0.86 and demonstrates convergent and discriminant validity.

Heartland Forgiveness Scale (HFS)

We measured forgiveness using the forgiveness of self (FOS) subscale of the

HFS (Thompson, Snyder & Hoffman, 2005). We chose this subscale because forgiveness of self appears to be more strongly related to aspects of mental health such as depression, anxiety and anger when compared to forgiveness of others (Mauger,

Perry, Freeman, Grove, McBride & McKinney, 1992). This eight-item Likert-type subscale ranges from 1 (almost always false of me) to 7 (almost always true of me), with higher scores indicating higher forgiveness of self. Examples of items on this subscale include “Although I feel badly at first when I mess up, over time I can give myself some slack” and “Learning from bad things I’ve done helps me get over them.”

Thompson et al. (2005) report test-retest reliability coefficient of 0.69 and internal consistency reliability between 0.72 and 0.76 across studies. The HFS also demonstrates adequate convergent validity (Thompson et al., 2005).

Positive State of Mind Scale (PSOM)

To measure positive mood, we used the PSOM (Horowitz, Adler and Kegeles,

1988). This six-item scale ranges from 1 (unable to have it) to 4 (have it well), with

higher scores suggesting higher positive states of mind. Examples of items include

“Feeling able to attend to a task you want or need to do, without many distractions from

within yourself” and “Feeling relaxed, without distractions or excessive tension.”

Horowitz, Adler and Kegeles (1998) report an internal consistency reliability of 0.77 and

suggest the PSOM has appropriate convergent and discriminant validity.

Kentucky Inventory of Mindfulness Skills (KIMS)

We measured mindfulness using the Describe subscale of the KIMS (Baer, Smith

and Allen, 2004). This 8-item subscale measures the degree to which one can describe,

label or note observed phenomena through language. This subscale is chosen since a

lack of being able to describe phenomena is closely related to mental health (i.e.,

alexithymia; Baer, Smith and Allen, 2004). This Likert-type scale ranges from 1 (never)

to 5 (very often), with high scores indicating high ability to describe phenomena.

Examples of items on this measure include, “It’s hard for me to find the words to

describe what I’m thinking” and “Even when I’m feeling terribly upset, I can find a way to

put it into words.” Baer, Smith and Allen report an internal consistency reliability of 0.87

on this subscale. The KIMS demonstrates good concurrent and predictive validity (Baer,

Smith and Allen, 2004).

Life Orientation Test-Revised (LOTR)

We measured optimism using the LOTR, a six-item scale that assesses expectancies for positive experiences (Scheier, Carver and Bridges, 1994). This Likert-

type scale ranges from 1 (strongly disagree) to 5 (strongly agree) with high scores

indicating high optimism. Examples of items on this measure include “In uncertain

times, I usually expect the best” and “Overall, I expect more good things to happen to

me than bad.” Scheier, Carver and Bridges (1994) report an internal consistency

reliability coefficient of 0.78. The LOTR also demonstrates high convergent and

discriminant validity (Scheier, Carver and Bridges, 1994).

State Trait Anger Expression Inventory-2 (STAXI-2)

We measured anger using the Inward Expression of Anger subscale of the

STAXI-2 (Speilberger, 1999), an 8-item subscale that measures how often angry feeling are experienced but not expressed. While other subscales of the STAXI-2 exist, this subscale will be used because Kopper and Epperson (1996) indicate that suppression of anger is the most damaging to mental health. The Likert-type scale ranges from 1

(almost never) to 4 (almost always), with high scores indicating high inward expression of anger. Examples of items on this measure include “I keep things in” “I boil inside but I don’t show it”. Speilberger (1999) report an internal consistency reliability coefficient

(Cronbachs alpha) between 0.73 and 0.95 for the subscales of the STAXI-2. The

STAXI-2 demonstrates discriminant and convergent validity (Speilberger, 1999).

Perceived Stress Scale (PSS)

We measured stress using the Perceived Stress Scale (Cohen, Kamarck, &

Mermelstein, 1983). This scale is a 14-item measure that assesses the degree to which situations in one’s life are appraised as stressful. The Likert-type scale ranges from 0

(never) to 4 (very often) with high scores indicating high amounts of stress. Examples of

items on this measure include “In the last month, how often have you been upset because of something that happened unexpectedly?” and “In the last month, how often have you found that you could not cope with all the things that you had to do?”. The

PSS demonstrates concurrent and predictive validity (Cohen, Kamarck & Mermelstein,

1983). Cohen, Kamarck and Mermelstein (1983) report an internal consistency reliability coefficient (Cronbachs alpha) of 0.85 for the PSS.

Shame Due to Heterosexism Scale (SDHS)

We measured shame due to heterosexism using the SDHS (Dickey-Chasins,

2001). This scale is an 11-item measure that measures the experience of shame caused by societal heterosexism. The Likert-type scale ranges from 1 (never) to 5

(always) with high scores indicating high amounts of shame and experienced stigma.

Examples of items on this measure include “I feel disappointed in myself for being gay/lesbian” and “I tell my straight friends the truth about my lesbian/gay dating and relationships.” Dickey-Chasins (2001) reports an internally consistency reliability coefficient of 0.87 on the SDHS.

Heterosexist Harassment, Rejection and Discrimination (HHRDS)

In order to measure heterosexist events we used the Harassment and Rejection scale of the HHRDS (Szymanski, 2006). This measure was originally designed to assess heterosexist events experienced by lesbians. Therefore, wherever the word

“lesbian” appeared in the survey, “LGBT” was placed instead. This 7-item scale assesses heterosexist events and psychological distress. The Likert-type scale ranges

from 1 (never) to 6 (almost all of the time), with high scores indicating high experience of heterosexist events. Examples of items on this measure include “How many times have you been rejected by friends because you are LGBT” and “How many times have you been treated unfairly by your family because you are LGBT?” Szymanski (2006) reports an internal consistency value of 0.89 and suggest the HHRDS has adequate convergent validity.

Data Analyses

An a priori spirituality stress mental health (SSMH) model (Figure 2) is developed

based on Meyer’s minority stress model (2003). Structural equations modeling is used

to analyze the relationships between the latent constructs that characterize the effect of

spirituality on quality of life indicants in context of minority stress often experienced by

members of the LGB community. In the SSMH model, spirituality acts as an antecedent

causal factor in a coping process aimed at mitigating the effects of anger and stress as

LGB individuals manage their psychological well-being. Spirituality is measured by

forgiveness of self (HFS), mindfulness (KIMS), optimism (LOTR), positive states of mind

(PSOM), purpose and meaning in life (SIWB) and religious beliefs and practices (SOBI).

In contrast, minority stress includes stigma due to heterosexism (SDH), heterosexist

harassment and discrimination (HHRD), self-destructive anger (STAXI) and personal

stress (PSS). The quality of life (QOL) indicants for mental health and vitality are used

to define the adaptational outcome of the spiritual coping process among LGB

individuals, namely improved psychological well being. As specified, our model predicts

that the relationship between spirituality and psychological QOL will be mediated by

minority stress. We tested our SSMH model using cross-sectional archival data to evaluate our study’s aims and hypotheses.

Prior to structural equation analyses, initial data analysis was conducted to examine the archival data for outliers and missing values. Cronbachs’s alpha is calculated for each subscale used in our model, and because structural equation modeling relies heavily upon the assumptions of univariate and multivariate normality, these modeling assumptions were validated.

After exploring and cleaning our data, we conducted several statistical analyses to better describe our data. First, we conducted univariate analyses to examine our demographic variables and measures. Next, we calculated the range and average age, income and education level of our participants. Finally, we determined the average scores, ranges and reliabilities of each of our measures. We also conducted multivariate analyses. We conducted several exploratory ANOVAs, with appropriate

Bonferonni adjustments, to examine differences in our measures in lesbian, gay, bisexual and heterosexual participants. Planned comparisons were used to determine if significant differences exist between lesbian, gay, bisexual, and heterosexual participants.

Mediation was tested for Hypotheses 3 by using the total direct and indirect effects in a path analysis of our model. Similarly, path analyses were used to confirm the directionalities specified by Hypotheses 1 and 2. The factor loadings for the manifest variables that define psychological QOL were used to quantify how minority stress effects the relationship between spirituality and psychological QOL. Additionally, the factor loadings for the variables that define minority stress were examined in light of

an individual’s propensity for spirituality. While factor loadings, in general, provide

useful information about the relative importance of the underlying observed variables,

the most salient aspects of the SEM analyses are the resulting parameters for each

pathway in our model.

The data was analyzed using structural equation modeling (SEM); however, the

sample size was not large enough to satisfy the power requirements associated with covariance-based SEM approaches. Therefore, a partial least squares (PLS) approach

to SEM was used to test the models overall significance. PLS allows researchers to test

model parameters and structural paths like covariance-based SEM. Covariance-based

SEM approaches use maximum likelihood estimation to obtain model parameters and

PLS uses a component based least squares method. PLS focuses on the strength of

the individual component relationships instead of the overall fit of the proposed model to

observed covariance’s among the variables. Another advantage of PLS is it avoids

many of the restrictive assumptions associated with covariance-based techniques such

as large sample sizes and multivariate normal data distributions. Like other SEM

methods, PLS approaches cannot generally be taken as evidence of causation (Kline,

2011). In fact, according to Kline (2011), no statistical technique can prove causality in

non-experimental designs, such as this. Because a true causal model is rarely known in

the behavioral sciences, we can hypothesize a causal model, and then test that model

with sample data. The model may or may not fit the data, but through SEM-based

approaches, we cannot claim that our model or any paths within our model are proven.

The fact that SEM does not prove or suggest causality is important to note throughout

this paper, especially when seemingly causal language is used.

PLS is well suited for small data. Chin (1998) suggests that at least 10 cases are required per the largest number of predicting constructs in the model. In the hypothesized model, psychological QOL has the largest number of predictors, namely two predictors. Therefore, our sample size of 151 is more than sufficient to satisfy the

PLS sample size requirements of 20 data points. Furthermore, when evaluating the model in the various groups, the smallest sample is 49, which also represents sufficient sample size necessary to satisfy the requirement of PLS.

PLS models were evaluated in two stages: first we conducted an assessment of the measurement model, followed by an evaluation of the structural model. The measurement model in PLS was evaluated by examining its internal reliability, convergent validity and discriminant validity. PLS uses an alorgithm that calculates an

“inner model,” which includes the latent variables with their hypothesized relationships, and an “outermodel,” consisting of the measurement model of the manifest variables.

An iterative procedure of bootstrapping was conducted to establish path significances.

This procedure generated 500 sub-samples of cases randomly selected, with replacement, from the original data. Path coefficients were then generated for each sub- sample. Path significances were generated using t-statistics.

CHAPTER 3

RESULTS

Exploratory Factor Analysis

We conducted several exploratory factor analyses (EFA) using varimax rotation to determine the structure of our measures and subscales (Tables 3a-3k). We first conduct an EFA on the Forgiveness of Self subscale of the Heartland Forgiveness

Scale (HFS) and force one factor (the Forgiveness of Self subscale) to be extracted.

The items comprising the HFS explain approximately 36.5% of the variance in the HFS.

Two items on this subscale were below the recommended cutoff loading of 0.5 (items

22 and 24); however, they were retained in our analyses since they represent the

Forgiveness of Self subscale of the HFS. We also conducted an EFA on the Describe subscale of the Kentucky Inventory of Mindfulness Skills (KIMS) and found one factor was extracted and which accounted for 67.05% of the variance in the KIMS. Similarly, items comprising the Life Orientation Test-Revised (LOTR) were best explained by one factor, which accounted for 66.09% of the variance in the LOTR. The Positive States of

Mind scale (PSOM) was also best explained by one factor and accounted for 60.84% of the variance. Items on the life-scheme subscale of the Spirituality Index of Well-Being

(SIWB) were also best explained by one factor and explained 61.80% of the variance in the SIWB. Items on the Beliefs and Practices subscale of the Systems of Belief

Inventory (SOBI) were also best explained by one factor and explained 65.28% of the variance. One factor was extracted from the perceived stress scale (PSS) and accounted for 42.60% of the variance in the PSS. While two items were below the recommended cutoff of 0.5, they were retained in analyses because they were deemed

as important items to the minority stress construct since they load significantly on a second factor. Items 12, 7, 13 and 6 were deleted from the PSS as the factor loadings were below the recommended 0.5 cutoff value. One factor was also extracted from the

HHRDS and accounted for 51.30% of the variability. On the SDHS, items 1, 3 and 7 were deleted because their factor loadings were below the recommended cutoff of 0.5.

Therefore, one factor was extracted and accounted for 51.84% of the variance. Items on the Inward Expression of Anger subscale of the State Trait Anger Expression Inventory

(STAXI) were comprised of one factor and accounted for 50.51% of the variance. Items on the energy subscale of the Short Form- 36 (SF-36) were best explained by one factor and accounted for 66.90% of the variance. Lastly, items on the emotional well- being subscale of the SF-36 were best explained by one factor and accounted for

59.52% of the variance.

Table 3

HFS Exploratory Factor Analyses

Factor 1 Communality

HFS1 0.66 0.43

HFS2 0.66 0.44

HFS3 0.53 0.28

HFS4 0.76 0.58

HFS5 0.59 0.35

HFS6 0.74 0.55

HFS22 0.28 0.08

HFS24 0.46 0.21

Table 4

KIMS Exploratory Factor Analyses

Factor 1 Communality

KIMS2 0.89 0.80

KIMS6 0.81 0.65

KIMS10 0.78 0.61

KIMS14 0.84 0.70

KIMS18 0.90 0.80

KIMS22 0.72 0.52

KIMS26 0.83 0.69

KIMS34 0.77 0.60

Table 5

LOTR Exploratory Factor Analyses

Factor 1 Communality

LOTR1 0.74 0.54

LOTR3 0.78 0.60

LOTR4 0.73 0.53

LOTR7 0.85 0.72

LOTR9 0.77 0.59

LOTR10 0.79 0.63

Table 6

PSOM Exploratory Factor Analyses

Factor 1 Communality

PSOM1 0.77 0.59

PSOM2 0.83 0.68

PSOM3 0.80 0.64

PSOM4 0.80 0.64

PSOM5 0.78 0.61

PSOM6 0.68 0.46

PSOM7 0.79 0.63

Table 7

SIWB Exploratory Factor Analyses

Factor 1 Communality

SIWB7 0.80 0.63

SIWB8 0.77 0.59

SIWB9 0.84 0.70

SIWB10 0.87 0.75

SIWB11 0.68 0.46

SIWB12 0.75 0.57

Table 8

PSS Exploratory Factor Analyses

Factor 1 Communality

PSS1 0.77 0.60

PSS2 0.75 0.63

PSS3 0.78 0.62

PSS4 0.23 0.06

PSS5 0.48 0.23

PSS8 0.64 0.42

PSS9 0.59 0.52

PSS10 0.63 0.54

PSS11 0.68 0.48

PSS14 0.78 0.60

Table 9

HHRDS Exploratory Factor Analyses

Factor 1 Communality

HHRDS8 0.72 0.52

HHRDS9 0.71 0.51

HHRDS10 0.78 0.61

HHRDS11 0.73 0.53

HHRDS12 0.72 0.51

HHRDS13 0.66 0.43

HHRDS14 0.70 0.48

Table 10

SDHS Exploratory Factor Analyses

Factor 1 Communality

SDHS2 0.61 0.37

SDHS4 0.70 0.49

SDHS6 0.70 0.49

SDHS8 0.77 0.60

SDHS10 0.81 0.65

SDHS11 0.71 0.51

Table 11

STAXI Exploratory Factor Analyses

Factor 1 Communality

STAXI29 0.63 0.40

STAXI33 0.57 0.33

STAXI37 0.75 0.57

STAXI41 0.75 0.56

STAXI45 0.76 0.58

STAXI49 0.66 0.43

STAXI53 0.71 0.51

STAXI57 0.82 0.67

Table 12

SF-36: Energy Exploratory Factor Analyses

Factor 1 Communality sf36_23 0.73 0.54 sf36_27 0.84 0.70 sf36_29 0.83 0.70 sf36_31 0.87 0.75

Table 13

SF-36: Emotional Well-Being Exploratory Factor Analyses

Factor 1 Communality sf36_24 0.71 0.51 sf36_25 0.80 0.64 sf36_26 0.73 0.53 sf36_28 0.80 0.63 sf36_30 0.82 0.67

Univariate Statistics

A univariate analysis was conducted to examine each measure (HFS, KIMS,

LOTR, PSOM, SIWB, SOBI, PSS, HHRDS, SDHS, STAXI, Energy and Emotional

Wellbeing) for LGB as well as for each group separately (Table 14). Heterosexuals did not complete the HHRDS or SDHS because these measures assess levels shame or harassment LGB people experience as a result of heterosexism (i.e., societal attitudes

and biases that favor oppsite-sex relationships and sexuality). Therefore, univariate

statistics are not available for heterosexuals on the HHRDS or SDHS.

Table 14

Mean and Standard Deviation and Range by Group

LGB Lesbian Gay Bisexual Hetero Possible M(SD) M(SD) M(SD) M(SD) M(SD) Range Range Range Range Range Range

38.93(7.42) 39.51(7.03) 38.90(7.91) 38.42(7.40) 39.78(7.53) HFS 8-56 15-56 26-56 15-56 25-55 25-54

28.95(7.12) 29.00(7.57) 30.44(6.24) 27.46(7.28) 28.60(5.78) KIMS 8-40 8-40 14-40 14-40 8-40 14-40

14.35(5.57) 13.78(5.72) 13.42(4.56) 15.79(6.09) 13.89(5.05) LOTR 6-30 6-29 6-29 6-25 6-29 6-29

23.83(4.66) 24.88(3.53) 24.08(4.86) 22.60(5.17) 24.32(4.22) PSOM 7-28 7-28 15-28 7-28 7-28 14-28

21.21(5.75) 22.08(5.48) 21.26(6.12) 20.34(5.61) 22.18(6.57) SIWB 6-30 6-30 8-30 6-30 6-30 6-30

25.26(8.98) 25.27(9.43) 26.88(8.64) 23.69(8.74) 31.60(9.10) SOBI 10-40 10-40 10-40 11-40 10-40 10-40

23.62(5.68) 23.43(6.16) 22.22(5.21) 25.13(5.37) 23.07(5.59) PSS 0-40 10-37 11-37 12-33 13-36 10-34

12.32(5.60) 13.61(5.76) 11.42(5.77) 11.98(5.13) HHRDS 7-42 --- 7-38 7-33 7-38 7-27

11.17(4.27) 10.65(3.72) 10.78(4.16) 12.02(4.78) SDHS 6-30 --- 6-26 6-19 6-25 6-25

17.20(5.07) 16.83(4.56) 16.66(5.02) 18.06(5.55) 17.33(5.29 STAXI 8-32 8-30 9-28 8-30 9-29 8-29

16.07(4.29) 16.20(4.01) 16.80(4.10) 15.23(4.66) 16.43(4.03) Energy 4-24 7-22 7-22 8-24 6-24 5-23

22.19(4.73) 22.45(4.64) 23.28(4.28) 20.88(5.01) 22.73(4.73) Well-being 5-30 10-30 11-28 13-30 10-30 10-29

Bivariate Statistics

We conducted a bivariate correlation analysis to determine relationships among variables to obtain a better understanding of our sample (Table 15). The diagonal cells represent the square root of the average variance extracted (AVE), which is necessary information to establish discriminant validity (see section below: Structural Equation

Modeling).

Multivariate Statistics

We conducted several ANOVAs with Bonferonni planned contrasts to compare differences between groups. We examined differences on the scales that comprise the spirituality, minority stress and psychological quality of life latent constructs. Lesbians, gay men, bisexuals and heterosexuals were significantly different from each other on the SOBI (F(3, 214) = 8.76, p < 0.001). Heterosexuals scored significantly higher on the

SOBI than gay men (p = 0.03), lesbians (p = 0.001) and bisexuals (p < 0.001). The four groups were marginally significantly different from each other on the PSOM (F(3, 214) =

2.45, p = 0.06), with lesbians scoring higher than bisexuals (p = 0.07). Similarly, the difference between the four groups on the PSS approached marginal significance (F(3,

214) = 2.48, p = 0.06), with bisexuals scoring higher than gay men (p = 0.06).

Differences between the four groups also approached marginal significance on the emotional well-being subscale of the SF-36 (F(3, 214) = 2.51, p = 0.06), with bisexuals scoring lower than gay men (p = 0.06).

Table 15

Construct Correlations*

being

- Spirituality HFS KIMS LOTR PSOM SIWB SOBI Minority Stress PSS HHRDS SDHS STAXI P QOL Energy Emotional Well Spiritua- 0.50 lity HFS 0.65 0.60 KIMS 0.65 0.32 0.82 LOTR 0.81 0.50 0.44 0.77 PSOM 0.79 0.43 0.36 0.53 0.78 SIWB 0.73 0.50 0.27 0.48 0.53 0.79 SOBI 0.39 -0.01 0.12 0.28 0.22 0.17 0.81 Minority -0.79 -0.57 -0.47 -0.65 -0.63 -0.63 -0.19 0.47 Stress PSS -0.67 -0.45 -0.37 -0.62 -0.56 -0.50 -0.16 0.86 0.67 HHRDS -0.21 -0.17 -0.12 -0.13 -0.13 -0.21 -0.09 0.45 -0.20 0.71 SDHS -0.35 -0.29 -0.17 -0.23 -0.32 -0.41 0.08 0.38 0.17 0.23 0.70 STAXI -0.67 -0.52 -0.45 -0.52 -0.47 -0.20 -0.20 0.83 0.54 0.17 0.19 0.71 Psych 0.70 0.52 0.33 -0.67 0.58 0.54 0.15 -0.69 -0.69 -0.20 -0.25 -0.52 0.73 QOL Energy 0.57 0.46 0.29 -0.57 0.40 0.48 0.08 -0.43 -0.59 -0.26 -0.26 -0.43 0.92 0.82 Emo Well- 0.71 0.49 0.31 -0.67 0.65 0.51 0.19 -0.52 -0.67 -0.12 -0.21 -0.52 0.94 0.72 0.77 being Indicates significance at the 0.01 level. Indicates significance at the 0.05 level . *Diagonal elements represent the square root of the AVE. Off-diagonal elements represent the correlations among the constructs. For discriminant validity, the diagonal elements should be larger than the off diagonals.

We found no significant differences between lesbians, gay men, bisexuals and

heterosexuals on the HFS (F(3, 214) = 0.37, p = 0.77), KIMS (F(3, 214) = 1.73, p =

0.16), LOTR (F(3, 214) = 2.04, p = 0.11), SIWB (F(3, 214) = 1.10, p = 0.35), STAXI

(F(3, 214) = 0.76, p = 0.52) and Energy subscale of the SF-36 (F(3, 214) = 1.33, p =

0.27). Similarly, lesbians, gay men and bisexuals were not significantly different on the

HHRDS (F(2, 148) = 2.08, p = 1.29) or the SDHS (F(2, 148) = 1.61, p = 2.04).

Structural Equation Model

The psychometric properties of the data are evaluated by examining the factor structure (Table 16) which includes the reliability, convergent and discriminant validity of the indicators. As recommended, the composite reliability and Cronbach’s alpha

coefficient were all larger than 0.70 which suggested an adequate level of internal

consistency. Each item loading was significant at the 0.05 level, however, the loading

for a few items was below the recommended level of 0.70. Nevertheless, these items

were retained in analyses as they were statistically significant. The Average Variance

Extracted (AVE) for most constructs was above 0.50. AVE measures the average

variance of measures accounted for by the construct. Taken together, the items

loadings and AVE suggest sufficient convergent validity. Discriminant validity was

established since the smallest square root of the AVE is 0.60, which is larger than any

correlation between constructs and all items loaded most heavily on their intended

construct (Table 15). In sum, the psychometric properties of internal consistency,

convergent validity and discriminant validity were all demonstrated. Therefore,

evaluation of the structural model was warranted.

Table 16

Reliability and Validity

Composite Cronbach Construct Items Mean S.D. AVE Reliability Alpha SPIRITUALITY 45 ------0.86 0.83 0.25 HFS 8 38.93 7.42 0.81 0.73 0.36 KIMS 8 28.95 7.12 0.94 0.93 0.67 LOTR 6 14.35 5.57 0.90 0.86 0.60 PSOM 7 23.93 4.66 0.92 0.89 0.61 SIWB 6 21.21 5.75 0.91 0.87 0.62 SOBI 10 25.26 8.98 0.95 0.94 0.65 MINORITY STRESS 30 ------0.87 0.86 0.22 PSS 9 23.62 5.68 0.87 0.84 0.45 HHRDS 7 12.32 5.60 0.88 0.83 0.51 SDHS 6 11.17 4.27 0.85 0.81 0.49 STAXI 8 17.20 5.07 0.89 0.86 0.50 PSYCHOLOGICAL 9 ------0.91 0.89 0.54 QOL ENERGY 4 16.06 4.29 0.89 0.83 0.67 EMOTIONAL WELL-BEING 5 22.18 4.73 0.88 0.83 0.59

LGB

Table 7 shows the path coefficients for the SSMG for LGB participants, as well as for each individual group (lesbian, gay and bisexual). For the LGB group, each path coefficient was significant at the 0.05 level (Figure 3).

Figure 3. LGB SSMH (path coefficients represent t-scores).

The direct path between spirituality and psychological QOL was significant

(coefficient = 0.70, t = 16.79) and spirituality explained 48.9% of the variance in

psychological QOL. The path between spirituality and minority stress was also significant (coefficient = -0.79, t = 23.60) and spirituality explained 61.8% of the variance in minority stress. The path from spirituality and minority stress to psychological QOL was also significant (coefficient = -0.34, t = 4.30). Together, spirituality and minority stress explained 54.3% of the variance in psychological QOL Lastly, after controlling for minority stress, the path between spirituality and psychological QOL was still significant

(coefficient = 0.41, t = 4.87). In order to test for mediation in the model, the Sobel test was used. The Sobel test indicated minority stress mediates the relationship between spirituality and psychological quality of life (Sobel = 4.26, p < .001). The direct relationship between spirituality and psychological QOL was statistically significant, but when the mediator (minority stress) is added, the indirect relationship between spirituality and psychological QOL was reduced. Since the indirect relationship is still statistically significant, minority stress was a partial mediator in the relationship between spirituality and psychological QOL.

Before comparing the three groups, it was necessary to ensure that the measurement items were equivalent across groups. Table 18 shows the loadings for all items across all groups. While the majority of items loaded relatively high and equivalently across groups, some items did not significantly for each group. For example, for lesbians and bisexuals, item 22 (“When I am wronged, I act like everything is okay so that people won’t think I’m bitter or petty”) on the HFS did not load significantly on the HFS. The majority of items on this subscale ask about perception of oneself, while this item asks about others perceptions.

Table 17

Path Coefficients and t-Scores

LGB Lesbian Gay Bisexual

coeff. t coeff. t coeff. t coeff. t

SpiritualityPsychological 0.70 16.79 0.73 4.96 0.73 11.30 0.64 7.72 QOL (direct)

SpiritualityPsychological 0.41 4.87 0.59 4.11 0.43 3.29 0.27 1.27 QOL (indirect)

Spirituality  Minority Stress -0.79 23.61 -0.68 6.96 -0.76 11.17 -0.83 14.46

Minority Stress  -0.37 4.30 -0.21 1.53 -0.40 2.96 -0.45 1.92 Psychological QOL

Spirituality  HFS 0.66 11.51 0.62 3.08 0.76 12.29 0.65 6.54

Spirituality KIMS 0.65 10.17 0.60 3.61 0.59 4.67 0.75 18.92

Spirituality  LOTR 0.81 27.32 0.79 3.17 0.90 39.38 0.76 12.12

Spirituality  PSOM 0.79 29.89 0.79 10.75 0.78 13.88 0.80 23.84

Spirituality  SIWB 0.73 17.64 0.70 7.73 0.82 20.26 0.70 9.04

Spirituality  SOBI 0.39 3.61 0.26 0.73 0.54 3.81 0.42 2.08

Minority Stress  PSS 0.86 37.82 0.85 15.56 0.87 24.80 0.87 20.72

Minority Stress  HHRDS 0.43 4.87 0.59 4.39 0.60 6.13 0.23 0.89

Minority Stress  SDHS 0.38 4.71 0.49 2.45 0.55 4.81 0.32 1.28

Minority Stress  STAXI 0.83 22.77 0.80 14.00 0.83 10.73 0.90 24.96

Psychological QOL  Energy 0.92 48.88 0.93 42.32 0.95 64.37 0.89 18.25

Psychological QOL  0.94 81.35 0.95 68.81 0.96 71.75 0.92 37.11 Emotional Wellbeing

Item 6 (“Being able to commune with others in an empathetic, close way, as in talking, walking, going out or just being together”) did not load significantly on the PSOM for lesbians.The majority of items on the PSOM inquired about states of mind related to

oneself; however, this question inquired about connections with others. Items 10, 11, 4,

6 and 8 did not significantly load on the SDHS for lesbians and bisexuals. Therefore, the

only item which significantly loaded on the SDHS was item 2 (“I feel disappointed in

myself for being gay/lesbian”). This item was the only item on the SDHS which solely

related towards one’s feeling about their sexual orientation. All other questions related

to the coming out process or others perceptions. Finally, none of the items on the SOBI

loaded significantly on the spirituality construct for lesbians. This subscale of the SOBI

measures beliefs and practices of spirituality. The items comprising this variable seem

to measure religiosity and include questions such as, “Religion is important in my day- to-day life.” For bisexuals, no items on the HHRDS significantly loaded on the minority stress latent construct. For gay men, item 4 on the PSS did not significantly load on the

PSS. Item 4 (“In the last month, how often have you felt you dealt successfully with day to day problems?”) assessed how a person handles stressful situations rather than the degree to which a person is stressed.

Table 18

Construct Factor Loadings Across Groups

LGB Lesbian Gay Bisexual SPIRITUALITY HFS HFS1 0.63 0.62 0.69 0.58 HFS3 0.56 0.54 0.61 0.50 HFS5 0.55 0.65 0.47 0.57 HFS2 0.69 0.58 0.69 0.76 HFS22 0.26 0.25 0.43 0.09 HFS24 0.50 0.46 0.44 0.65 HFS4 0.76 0.79 0.71 0.81 HFS6 0.73 0.76 0.76 0.67 KIMS KIMS10 0.79 0.83 0.78 0.78 (table continues)

LGB Lesbian Gay Bisexual KIMS (continued) KIMS2 0.89 0.90 0.90 0.86 KIMS6 0.81 0.85 0.77 0.82 KIMS14 0.83 0.85 0.84 0.79 KIMS18 0.90 0.90 0.89 0.90 KIMS22 0.72 0.60 0.76 0.76 KIMS26 0.83 0.78 0.86 0.85 KIMS34 0.76 0.84 0.75 0.74 LOTR LOTR1 0.72 0.80 0.64 0.71 LOTR10 0.79 0.79 0.63 0.86 LOTR4 0.73 0.62 0.80 0.76 LOTR3 0.78 0.80 0.71 0.82 LOTR7 0.85 0.83 0.82 0.88 LOTR9 0.77 0.80 0.70 0.82 PSOM PSOM1 0.78 0.80 0.80 0.75 PSOM2 0.83 0.84 0.85 0.83 PSOM3 0.80 0.83 0.87 0.74 PSOM4 0.81 0.76 0.85 0.83 PSOM5 0.78 0.93 0.86 0.75 PSOM6 0.66 0.22 0.84 0.66 PSOM7 0.78 0.68 0.78 0.81 SIWB SIWB10 0.87 0.84 0.92 0.81 SIWB11 0.66 0.68 0.75 0.55 SIWB12 0.77 0.70 0.80 0.82 SIWB7 0.79 0.71 0.83 0.81 SIWB8 0.77 0.87 0.84 0.59 SIWB9 0.84 0.81 0.88 0.85 SOBI SOBI1 0.79 0.62 0.82 0.79 SOBI10 0.86 0.86 0.87 0.83 SOBI11 0.81 0.85 0.82 0.76 SOBI12 0.75 0.89 0.77 0.69 SOBI14 0.78 0.36 0.74 0.76 SOBI15 0.72 0.60 0.72 0.81 SOBI2 0.72 0.84 0.84 0.78 SOBI4 0.78 0.29 0.77 0.78 SOBI6 0.77 0.17 0.81 0.81 SOBI8 0.88 0.71 0.88 0.88

(table continues)

LGB Lesbian Gay Bisexual MINORITY STRESS PSS PSS1 0.75 0.78 0.75 0.69 PSS11 0.70 0.71 0.67 0.72 PSS14 0.70 0.80 0.56 0.71 PSS2 0.80 0.81 0.80 0.73 PSS8 0.65 0.71 0.64 0.57 PSS10 0.73 0.72 0.85 0.56 PSS4 0.37 0.32 0.19 0.68 PSS5 0.51 0.44 0.54 0.56 PSS9 0.70 0.75 0.65 0.62 HHRDS HHRDS10 0.75 0.67 0.84 0.85 HHRDS11 0.77 0.81 0.78 0.77 HHRDS12 0.74 0.80 0.73 0.57 HHRDS13 0.66 0.69 0.77 0.41 HHRDS14 0.63 0.49 0.70 0.57 HHRDS8 0.78 0.84 0.74 0.78 HHRDS9 0.64 0.51 0.79 0.48 SDHS SDHS2 0.79 0.74 0.71 0.87 SDHS10 0.81 0.10 0.92 0.77 SDHS11 0.60 -0.52 0.89 0.34 SDHS4 0.56 -0.30 0.51 0.55 SDHS6 0.71 0.57 0.65 0.73 SDHS8 0.70 -0.01 0.67 0.74 STAXI STAXI29 0.60 0.52 0.40 0.78 STAXI33 0.58 0.57 0.75 0.45 STAXI37 0.76 0.72 0.78 0.77 STAXI41 0.73 0.68 0.75 0.76 STAXI45 0.76 0.73 0.76 0.78 STAXI49 0.66 0.49 0.75 0.73 STAXI53 0.74 0.70 0.83 0.65 STAXI57 0.83 0.81 0.84 0.84 Psychological QOL Energy SF36_23 0.75 0.79 0.74 0.71 SF36_27 0.85 0.88 0.82 0.83 SF36_29 0.82 0.72 0.88 0.84 SF36_31 0.85 0.85 0.85 0.85

(table continues)

LGB Lesbian Gay Bisexual Emotional Wellbeing SF36_24 0.70 0.48 0.77 0.78 SF36_25 0.78 0.76 0.71 0.83 SF36_26 0.74 0.80 0.80 0.64 SF36_28 0.79 0.86 0.75 0.76 SF36_30 0.83 0.87 0.82 0.80

Lesbians

Table 7 and Figure 4 show the path results for the SSMH model in each of the groups. For lesbians, the direct path between spirituality and psychological QOL is significant (coefficient = 0.74, t = 4.96), which suggests as spirituality increases, psychological QOL increases. Spirituality explained 53.9% of the variance in psychological QOL. Also, the direct path between spirituality and minority stress was significant (coefficient = -0.70, t = 6.96), and indicates as spirituality increases, minority stress decreases. Spirituality explained 46.1% of the variance in minority stress. The path from spirituality and minority stress to psychological QOL was marginally significant (coefficient = -0.22, t = 1.53) and indicates as minority stress increases, psychological QOL increases. Together, spirituality and minority stress explained 56.9% of the variance in psychological QOL. The indirect relationship between spirituality and psychological QOL was significant (coefficient = 0.59, t = 4.11). However, the Sobel test indicates minority stress did not mediate the relationship between spirituality and psychological QOL for lesbians (Sobel = 1.49, p = 0.14).

Figure 4. Lesbian SSMH (path coefficients represent t-scores).

Gay Men

For gay men, the direct path between spirituality and psychological QOL was significant (coefficient = 0.73, t = 11.30) and suggests as spirituality increased, psychological QOL increased (Table 7, Figure 5). Spirituality explained 52.7% of the variance in psychological QOL. The direct path between spirituality and minority stress was also significant (coefficient = -0.76, t = 11.16) and indicated as spirituality increased, minority stress decreased. Spirituality explained 57.9% of the variance in

minority stress. The path from spirituality and minority stress to psychological QOL was also significant (coefficient = -0.40, t = 2.96) and suggested as minority stress increased, psychological QOL decreased. Together, spirituality and minority stress explained 60% of the variance in psychological QOL. Lastly, after controlling for minority stress, the path between spirituality and psychological QOL was still significant, but the coefficient was reduced (coefficient = 0.43, t = 3.30). Therefore, the Sobel test indicates minority stress partially mediated the relationship between spirituality and psychological

QOL (Sobel = 2.74, p < .001) for gay men.

Figure 5. Gay SSMH (path coefficients represent t-scores).

Bisexuals

For bisexuals, the path between spirituality and psychological QOL was

significant (coefficient = 0.64, t = 7.72) and indicated as spirituality increased,

psychological QOL increased (Table 7, Figure 6). Spirituality explained 40.7% of the

variance in psychological QOL. The path between spirituality and minority stress was

also significant (coefficient = 0.27, t = -0.83) and suggests as spirituality increased,

minority stress decreased. Spirituality explained 68.3% of the variance in minority

stress. After controlling for spirituality, the path between minority stress and

psychological QOL was also significant (coefficient = -0.45, t = 1.92) and indicated as

minority stress increased, psychological QOL decreased. Together, spirituality and

minority stress explained 47.1% of the variance in psychological QOL. Finally, after

controlling for minority stress, the path between spirituality and psychological QOL was not significant (coefficient = 0.27, t = 1.27). The Sobel test used to examine if minority stress was a significant mediator in the relationship between spirituality and minority stress was marginally significant (Sobel = 1.91, p = 0.06). The direct relationship between spirituality and psychological QOL was significant; however, once minority stress was controlled for, the relationship between spirituality and psychological QOL was no longer significant. Therefore, minority stress fully mediated the relationship

between spirituality and psychological QOL in bisexuals

Group Comparisons

Pairwise t-tests were conducted to examine differences between the path

estimators of the three groups. Table 9 shows the path estimates and the standard error

of the three groups. Results indicated no differences in paths between any groups.

Figure 6. Bisexual SSMH (path coefficients represent t-scores).

When comparing gay men and lesbians, the path between spirituality and minority stress (t(97) = 0.20), the path between spirituality and psychological QOL (t(97) = 0.31) and the path between minority stress and psychological QOL (t(97) = 0.47) were not significantly different from each other. When gay men and bisexuals were compared, the path between spirituality and minority stress (t(100) = 0.19), the path between

spirituality and psychological QOL (t(100) = 0.52) and the path between minority stress and psychological QOL (t(100) = 0.08) were also not significantly different from each other. Lastly, when lesbians and bisexuals are compared, the path between spirituality and minority stress (t(99) = -0.38), the path between spirituality and psychological QOL

(t(99) = 0.52) and the path between minority stress and psychological QOL (t(99) =

0.47) were not significantly different from each other.

Table 19

Path Coefficients and Standard Errors between Latent Variables by Group

Spirituality  Spirituality  Minority Stress 

Minority Stress PQOL PQOL

PATH SE PATH SE PATH SE

Gay Men (n = 50) -0.76 0.07 0.59 0.14 -0.40 0.14

Lesbians (n = 49) -0.68 0.10 0.59 0.14 -0.22 0.14

Bisexuals (n = 52) -0.83 0.06 0.27 0.21 -0.45 0.23

LGB (n = 151) -0.79 0.03 0.41 0.08 -0.37 0.08

CHAPTER 4

DISCUSSION

In the present study, we explore the relationship between spirituality, minority stress and psychological QOL in an LGB sample. These constructs are each comprised of representative measures and items. Items from the Heartland Forgiveness Scale

(HFS), Kentucky Inventory of Mindfulness Skills (KIMS) KIMS, Life-Orientation Test-

Revised (LOTR), Postivie States of Mind (PSOM), Spirituality Index of Well-Being

(SIWB) and Systems of Belief Inventory (SOBI) create the spirituality construct. The

minority stress construct is made up of items from the Perceived Stress Scale (PSS),

Heterosexist Harassment, Rejection and Discrimination Scale (HHRDS), Shame Due to

Heterosexism Scale (SDHS) and State-Trait Anger Expression Inventory (STAXI).

Lastly, the psychological QOL construct is made up of items from the energy and emotional-well being subscales of the Short Form – 36 (SF-36). Through the use of the

these three constructs, we hypothesized that (1) spirituality is associated with increased

psychological QOL, (2) minority stress is associated with decreased psychological QOL

and (3) minority stress mediates the relationship between spirituality and psychological

QOL.

We first examined differences between groups on the measures that comprise the three latent constructs and found heterosexuals report significantly greater levels of spiritual beliefs and practices as measured by the SOBI than gay men, lesbians and bisexuals. We also found marginally significant differences between groups on the

PSOM, PSS and emotional well-being subscale of the SF-36, with gay men reporting higher emotional well-being than bisexuals, bisexuals reporting greater stress than

heterosexuals and lesbians reporting greater positive states of mind than bisexuals.

Consistent with previous research (Balsam & Mohr, 2007), these results suggests bisexuals experience more mental health problems (e.g., increased stress, minority stress, lower positive states of mind, emotional well-being, spiritual beliefs and practices and psychological QOL) than either gay men, lesbians or heterosexuals. The increased levels of stress as well as lowered optimism, emotional well-being, spiritual beliefs and practices and psychological QOL for bisexuals found in this study may be a direct result of bi-negativity. Due to bi-negativity, bisexuals often experience discrimination from not only heterosexuals due to their non-heterosexual identity, but also from gays who may view bisexuals as being ‘in transition’. Furthermore, some heterosexuals and gays do not view bisexuality as a legitimate sexual orientation and instead have a monosexist view that sexuality and attraction are specified to one gender (Rust, 2000). As a result of this bi-negativity, bisexuals often experience higher levels of anxiety, depression and negative affect than lesbians, gay men and heterosexuals (Jorm et al., 2002).

Furthermore, Diamond (2008) suggests that bisexuality may be interpreted as a stable pattern of attraction to both sexes in which the balance of same-sex to opposite-sex attraction fluctuates with regard to interpersonal and situational factors. Weingber,

Williams and Pryor (1994) describe this variability in attraction as a “lack of closure” for bisexuals. This “lack of closure” may lead a bisexual person to experience identity confusion, which may explain increased levels of stress and lower optimism and emotional well being in this group.

Our study also found heterosexuals report significantly greater levels of spiritual beliefs and practices than lesbians, gay men and bisexuals. Spiritual beliefs and

practices were assessed by the SOBI, which asks questions such as “religion is

important in my day-to-day life” and “I believe God will not give me a burden I cannot

carry.” Therefore, it seems this measure may assess religiosity more than spirituality.

Lesbians, gay men and bisexuals may experience significantly lower levels of spiritual

beliefs and practices as measured by the SOBI as a result of stigma and discrimination

from religious organizations. For example, some religious organizations preach negative

messages about an LGB sexual orientation (Ritter & Terndrup, 2002). LGB people are

often given messages from religious organizations, which suggest in order to be saved

they must become heterosexual or live a non-sexual lifestyle (Ritter & Terndrup, 2002).

Given these options, some LGB people turn away from religion. An LGB person is

essentially asked to choose their religious/spiritual identity or their sexual identity.

Furthermore, Wagner (1994) suggests that involvement with religious organizations is

often associated with internalized homophobia and negative self-image for LGB people.

Based on our SSMH model, we used structural equation modeling to test our

three hypothesis.

Hypothesis 1– Spirituality is Negatively Correlated with Minority Stress

Our results indicate that spirituality is negatively correlated with minority stress for the LGB group, lesbians, gay men and bisexuals. This is consistent with previous studies, which suggest that interaction with an affirming faith group is correlated with decreased internalized homonegativity (Lease, Horne & Noffsinger-Frazier, 2005).

Lease, Horne and Noffsinger-Frazier (2005) suggest overt and accepting behaviors from one’s faith group provide a direct contrast to the generally negative societal

messages about a non-heterosexual identity, which therefore lead to an associated

reduction in minority stress. However, it is important to note that our conceptualization

of spirituality includes more than religiosity. Therefore, other factors such as

forgiveness, mindfulness, a positive state of mind, optimism and knowledge of meaning

and purpose in life contribute to an associated reduction in minority stress.

Hypothesis 2 - Minority Stress is Negatively Correlated with Psychological QOL

Our results suggest minority stress is negatively correlated with psychological

QOL in the LGB group, gay men and bisexuals. Consistent with previous research,

minority stress seems to be associated with a decrease in psychological QOL (Kooper

& Epperson, 1996; Mays & Cochran, 2001; Meyer, 1993; Meyer, 1995). Furthermore, several researchers suggest minority stress is associated with a plethora of mental health symptoms that relate to psychological QOL such as: suicidal ideation, anxiety, depression, guilt, insomnia, demoralization, psychological distress, substance use and shame to name a few (Diaz et al., 2001; Meyer, 1995; Meyer, 2003).

However, the relationship between minority stress and psychological QOL is only marginally significant in lesbians, such that as minority stress decreases, psychological

QOL increases. The relationship between minority stress and psychological QOL may not be as strong for women as for other groups as a result of superior coping strategies.

Szymanski and Owens (2008) suggest coping is a variable that may ameliorate the negative effects of minority stress. Lazarus and Folkman (1984) define coping as

“cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (p. 141).

Problem-focused coping (i.e., attempts to alter a stressful situation through planning, taking action, etc.) and emotion-focused coping (i.e., attempts to minimize or regulate emotional distress) are two broad types of coping. Emotion-focused coping is comprised of both active and avoidant strategies. Active strategies, such as seeking emotional support from others, is generally thought to be more adaptive that avoidance coping strategies, such as behavioral disengagement. D’Augelli and Grossman (2001) report sexual minority men endorse significantly more alcohol use as a coping mechanism (i.e., avoidant coping) than sexual minority women. However, Lehavot

(2012) suggests lesbians, in particular, may employ more effective coping strategies.

For example, Lehavot (2012) reported bisexual women engage in more maladaptive coping strategies and are more likely to use substances than lesbians, which provides support for our results which suggest that minority stress and psychological QOL are significantly negatively correlated for bisexuals.

Meyer (2003) suggests discrimination and minority stress provide a context for

LGB people to learn to cope effectively. Therefore, when faced with a stressor, sexual minorities may be better equipped to employ effective coping strategies than heterosexuals. For example, Arena et al. (2007) compared coping strategies of lesbian and heterosexual women after they were diagnosed with breast cancer. Heterosexual women used denial more frequently, whereas lesbians were more likely to utilize adaptive coping strategies, such as planning and positive reframing. Arena et al. (2007) hypothesized that lesbians had more opportunities to learn to manage and cope with stress than heterosexual women. Lesbians may also have an advantage over gay men when it comes to coping. Lesbians may have learned effective coping strategies at an

earlier age than gay men as a result of sexism. Therefore, when faced with a stressor

such as discrimination or stigma from being a sexual minority, lesbians may be better

equipped to deal with stress because they learned effective coping strategies as a result

of being female.

Hypothesis 3.Minority Stress Mediates the Relationship Between Spirituality and Psychological QOL

In order to test Hypothesis 3, we used a PLS approach. As previously stated, it is important to note that we hypothesized a causal model in SEM and then tested that model by using our sample data. However, causality cannot be assumed through SEM-

based approaches. We found minority stress to be a partial mediator in the relationship

between spirituality and psychological QOL for the LGB group and for gay men. The

mediation model was marginally significant for bisexuals and suggests that minority

stress fully mediates the relationship between spirituality and psychological QOL. As

with all LGB people and gay men, this suggests that spirituality is associated with a

decrease in minority stress, which is associated with an increase in psychological QOL.

The model was not significant for lesbians, which suggests minority stress is not a

mediator in the relationship between spirituality and psychological QOL for lesbians. We

also made group comparisons on the paths of the overall model and found no

significant differences between groups in any of the paths. For example, both the direct

and indirect paths between spirituality and psychological QOL; the path between

spirituality and minority stress; and the path from spirituality and minority stress to

psychological QOL are similar across groups.

These results show the importance of spirituality in the lives of lesbians, gay men

and bisexuals. For gay men and bisexuals, spirituality is associated with a decrease in

minority stress, which is associated with an increase in psychological QOL. For

lesbians, spirituality is associated with both a decrease in minority stress and an

increase in psychological QOL. For lesbians; however, minority stress does not explain

the relationship between spirituality and psychological QOL. This suggests that for

lesbians, minority stress may not impact psychological QOL in the same was it does for

gay men and bisexuals. This may be due to differences in coping strategies for

lesbians, gay men and bisexuals (as discussed in Hypothesis 2: Minority stress is

negatively correlated with psychological QOL), or a result of greater societal acceptance

of sexual minority women. Herek (2002) reported that heterosexuals are more likely to

regard gay men as mentally ill than lesbians. Also, heterosexuals are more likely to

support adoption rights for lesbians than for gay men. Furthermore, bisexuals

experience bi-negativity: the result of experiencing discrimination and oppression from both the gay community and the heterosexual community which is associated with

increased stress and lower psychological QOL (Balsam & Mohr, 2007; Rust, 2002).

Therefore, society may be more accepting of lesbians than gay men and bisexuals,

which may influence the relationship between minority stress and psychological QOL.

Nonetheless, spirituality still plays an important role in mitigating the many effects of

being a sexual minority.

Minority stress theory (Meyer, 2003) suggests minorities experience excess

stress as a result of their social and minority position. Minority stress stems from the

divergence of minority and dominant values. For LGB people in particular, stigma,

discrimination and prejudice create a stressful environment that is associated with

mental health problems such as increased stress and anger (Meyer, 2003) and ultimately lowered psychological QOL. The results of this study suggest spirituality may reduce minority stress and therefore may increase psychological QOL among some

LGB people. These results are especially important in light of the way many LGB people experience religion (a subset of the dimension spirituality). Religious organizations have the potential to increase minority stress in LGB people. For example, religious LGB people may continuously experience prejudice and discrimination from their religious organization which can ultimately lead to internalized homophobia. LGB people may also feel marginalized both by religious organizations due to their sexual orientation and by the LGB community as a result of their religious beliefs rather (Ritter & Terndrup,

2002). Finally, as a result of religious discrimination, internalized homophobia and alienation, LGB people may decide not to disclose their sexual minority status. For LGB people, these experiences meet Meyer’s (2003) criteria of minority stress, which are correlated with negative mental health outcomes.

Based on minority stress theory (Meyer, 2003), if we solely used religion as a measure of spirituality, we would hypothesize that spirituality is correlated with increased minority stress. However, religiosity was used as only one dimension of spirituality in this study. This study found that high levels of spirituality are associated with lowered minority stress for LGB people. These findings highlight the importance of viewing spirituality as a broad construct, of which religion may be part. When spirituality is measured as a multidimensional construct and includes optimism, forgiveness, mindfulness, spiritual beliefs and practices, meaning and purpose in life and positive states of mind, spirituality is positively associated with psychological QOL. In fact,

spirituality partially acts through minority stress to increase psychological QOL.

These results also underscore the importance of examining lesbians, gay men and bisexuals as separate groups instead of one sexual minority category (LGB). For example, minority stress partially mediated the relationship between spirituality and minority stress for all LGB individuals. For gay men, minority stress acts as a partial mediator in the relationship; minority stress is marginally significant as a full mediator for bisexuals; and minority stress did not significantly mediate the relationship for lesbians.

Had we only examined the relationship for all LGB people, we would not be aware of these subtle differences between groups. Also, bisexuals appear to experience significantly greater stress, minority stress and significantly less positive states of mind, emotional well-being, spiritual beliefs and practices and psychological QOL than other groups.

Limitations

Our results may be limited due to several factors. First, the design of our study was cross-sectional and correlational. Therefore, we cannot infer causality. Second, our participants were obtained through convenience sampling through LGB service organizations. This limits the extent to which we can generalize our findings since certain characteristics may be met by participants who are willing to participate in a study of LGB people. For example, our participants may be more “out” and have a greater acceptance of their sexual orientation than those who were not willing to participate. Those who are less “out” may have increased difficulty integrating their spiritual identity and sexual identity and, therefore, may not experience the same

associated decrease in psychological quality of life as those who are “out”. Furthermore,

since participants were obtained from community based organizations, they may have greater access to mental health services, whereas many LGB people either do not have access to or do not utilize this type of care and may experience higher levels of mental health problems or lower levels of psychological QOL. The heterosexual participants were also significantly younger and poorer than the lesbian, gay or bisexual groups because they were college students. Lastly, our sample was obtained through one geographic location. Therefore, our findings may not generalize to areas outside of

Texas or the southern United States or be representative of spirituality, minority stress and psychological QOL in LGB people across the nation.

Other limitations of our study concern the measurement model for each group.

While all items load significantly for the LGB group as a whole, the measurement items were not necessarily equivalent across groups. For example, no items on the SOBI significantly load onto the spirituality latent construct for lesbians. Therefore, the SSMH model may look different for lesbians than for gay men and bisexuals. Similarly, no items on the HHRDS significantly load onto the minority stress latent construct for bisexuals, indicating that the SSMH model may also look different for bisexuals.

However, all items were retained in the SSMH model (i.e. all models were identical) for each lesbian, gay and bisexual group in order to make comparisons across groups.

A PLS approach to SEM also comes with some limitations. For example,

Reinartz, Haenlein and Henseler (2009) suggest parameter consistency and accuracy is poor when compared with covariance-based SEM approaches. The term “PLS-SEM bias” refers to the fact that PLS-SEM parameter estimates are not optimal when it

comes to bias and consistency (Hair, Ringle and Sarstedt, 2011). Furthermore, PLS is inferior to covariance-based SEM approaches when it comes to confirming theory. For example, Hair, Ringle and Sarstedt (2011) suggest a covariance-based SEM approach should be used when the research objective is to test and/or confirm theory.

Nevertheless, a PLS approach to SEM is preferred when sample sizes are small, such as in this study.

Clinical Implications

People with minority identities continue to experience minority stress due to the discrepancy between society’s ideals and values and the values of the minority person.

For LGB people, minority stress may come in the form of stigma, stress, anger and heterosexist harassment, rejection and discrimination. This study suggests minority stress is associated with lower psychological QOL. However, spirituality is associated with decreased minority stress, which is associated with increased psychological QOL.

These results provide support for the important role that spirituality plays in the lives of some LGB people, especially in the context of minority stress and psychological

QOL. This study has implications for therapeutic interventions for clinicians who work with LGB clients with low psychological QOL. For example, clinicians may want to inquire about an LGB client’s spirituality (e.g., optimism, forgiveness, spiritual beliefs and practices, meaning and purpose in life, positive states of mind and mindfulness) as well as their level of minority stress (e.g., stress, anger, stigma and heterosexist, harassment, rejection and discrimination). Clinicians may want to implement interventions aimed at increasing these components of spirituality, and/or direct clients

who wish to express their spirituality through religion to LGB-affirming faiths and organizations.

Clinicians may also wish to pay particular attention to bisexual clients as they appear to experience higher levels of stress and minority stress as well as lower levels of positive states of mind, psychological QOL, spiritual beliefs and practices and spirituality. Bisexuals are at an increased risk of psychological problems as a result of bi-negativity. Furthermore, clinicians should also consider the sexual minorities who carry another minority identity (e.g., gender, ethnicity/race, religion, physical disability, etc.) as they often experience higher rates of psychological distress and discrimination

(Meyer, 2003).

Future Research

Additional research should be conducted to assess other types of quality of life to determine the effects of spirituality and minority stress. For example, researchers should examine physiological aspects of quality of life to determine the role of spirituality and minority stress in reducing physical symptoms. Researchers may also want to assess sociological aspects of quality of life and its relationship with spirituality and minority stress. A longitudinal study would also be valuable to assess psychological

QOL in sexual minorities over time, as the relationships with minority stress and spirituality may depend on participant factors such as age, sexual identity stage, etc.

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