Archives of Sexual Behavior: Vol 39 Issue 6 (Dec 2010)

254 Pages·1978·3 MB·English

by  Kenneth J. Zucker (ed.)

ArchSexBehav(2010)39:1207–1208
DOI10.1007/s10508-010-9634-z
LETTER TO THE EDITOR
The Importance of Measuring Internalized Homophobia/
Homonegativity
MichaelW.Ross • B.R.SimonRosser •
DerekSmolenski
Publishedonline:13May2010
(cid:2)SpringerScience+BusinessMedia,LLC2010
NewcombandMustanski(2009)aretobecongratulatedfor theabilitytointerpretthemagnitudeofanyobservedassoci-
attempting a meta-analysis of internalized homophobia/ ation,leavingonlythedirection.
homonegativity(IH)andforrecognizingthepotentialimpor- Second,theninedifferentIHmeasuresusedaresimplynot
tanceofthisconstructforHIV-relatedresearchinmenwhohave comparable,absentastudyinwhichthedifferentmeasuresare
sex with men (MSM). However, we disagree with their key given to the same population and the degree of association
conclusionthat‘‘researcherswouldbewell-servedtoconsider measured.Theoutcomemeasuresalsovaryacrossstudies,and
abandoningtheinvestigationofIHasapredictorofriskysexual thereareinsufficientdatatodeterminehowtheoutcomeswere
behaviorinordertofocusresourcesonmorepromisinglinesof actuallymeasuredandwhattheirdistributionswere.Thefact
research.’’Therearesevenconcerns. that some IH scales factor into several subscales (Ross &
First, their approach to meta-analysis used correlation Rosser,1996),somebutnotallofwhichmayberelatedtorisk
coefficients;however,correlationcoefficientsinmeta-analy- behaviors,furthercomplicatesacomparisonofIHmeasures
sesarenotandcannotbeeffectsizes.Suchstandardizedeffect (asNewcombandMustanskinote).
sizes‘‘cannotreliablymeetthegoalsofmeta-analysis’’(Cum- Third,onestudyusedcompulsivesexualbehavior(CSB)as
mings,2004,p.597)andGreenland,Maclure,Schlesselman, theoutcomemeasure.Thatisinappropriatesinceitsuperim-
Poole, and Morgenstern (1991) note that the arguments posesadeterministicrelationshipbetweenCSBandriskysex,
‘‘against traditionally standardized coefficients apply with nottheappropriateprobabilisticone.Unfortunately,thestrong
evengreaterforceagainsttheuseofcorrelationcoefficientsas correlationthereprobablycontributedtotheobservedeffect.
measures of effect’’(p. 392). They are inappropriate to use Fourth,therecommendationnottostudyIHfurtherisbased
because(1)theyareboundedbythedistributionalpropertiesof upontheirobservingnodirectrelationshipbetweenIHandHIV
each individual study; (2) following from that, a one SD risk. However, Newcomb and Mustanski readily acknowl-
changeinonesampleis,bydefinition,notequivalenttooneSD edgeandreferencestudiesshowingclearindirectrelationships
inanotherstudy;(3)evenifacorrelationishigh,theeffectsize that,inturn,maybehelpfultothedesignofinnovativeinter-
couldbequitemodest.Incontrast,alowerornocorrelation ventions. The existence of several moot correlations could
couldindicateacurvilinearrelationshiporvariationarounda indicate conflicting pathways that haven’t been explored.
strongerfixedeffect;and(4)analysisofcorrelationsnegates ShouldwedeterminesomecausalassociationofIHwithother
proximal determinants of riskbehavior, then we will havea
goodideaofhowtoappropriatelyinterveneonthosefactors.
M.W.Ross(&) Ignoring IH in further risk behavior studies would prevent
CenterforHealthPromotionandPreventionResearch,
developmentofculturallyspecificandrelevantinterventions
UniversityofTexasSchoolofPublicHealth,7000Fannin,
forMSM.
Suite2622,Houston,TX77030,USA
e-mail:[email protected] Fifth,therathernarrowchoiceofoutcomesassumesthatIH
hasadirecteffectonlyonsexualbehavior.Somedataalready
B.R.S.Rosser(cid:2)D.Smolenski
indicatethatIHoratleastonecomponentofitisassociated
HIV/STIInterventionandPreventionStudiesProgram,
withdrugandalcoholabuseinMSM,andweknowthatdrug
DivisionofEpidemiologyandCommunityHealth,University
ofMinnesotaSchoolofPublicHealth,Minneapolis,MN,USA andalcoholabusearerelatedtoriskysexualbehavior.Itwould
123
1208 ArchSexBehav(2010)39:1207–1208
makeclinicalaswellasresearchsensetoincludeotherrisk indirecthealthimpactsinnon-Westerncontextsandinnon-
outcomes,suchasdrugandalcoholabuse,and measuresof WesternMSMsubcultures.
mood and affect as effects of IH which may themselves In summary, while Newcomb and Mustanski have pro-
translateintosexualriskbehavior.Further,theimpactofIHon duced a most thought-provoking article summarizing some
drugandalcoholabuseandothernegativementalhealthout- studiesondirecteffectsofIHonHIVriskbehaviors,we
comes(Rosser,Bockting,Ross,Miner,&Coleman,2008)are encourage researchers to explore IH further, particularly
inthemselvesclinicallyimportantforMSM,whetherornot throughindirecteffectsandincontextswherehomonegativity
theytranslateintoriskysexualbehavior,andweconcurwith appearsamajorbarriertoHIVpreventionforMSM.Wedonot
NewcombandMustanskionthis. believe,astheysuggest,thatthe‘‘currentutilityofthiscon-
Sixth,wealreadyhavedatathatsuggestthatIHoperates structforunderstandingsexualrisktakingofMSMiscalled
throughinterveningvariables.Wedemonstrated(Ross,Ros- intoquestion’’forusebyHIV/STI,sexualityandmentalhealth
ser,Neumaier,&thePositiveConnectionsTeam,2008)that researchers.OutsideoftheWest,homophobiaandinternalized
IH is significantly associated with HIV/STI risk through at homophobiadostillmatter.
least two intervening pathways (but has no direct effect).
Serodiscordant unprotected analintercourse is a function of
menbeinglessdisclosingoftheirHIVserostatus,itselfsig- References
nificantlyassociatedwithIH;andlowercondomusethrough
Cummings,P.(2004).Meta-analysisbasedonstandardizedeffectsis
lowercondomself-efficacyisitselfalsosignificantlyassoci-
unreliable.ArchivesofPediatricandAdolescentMedicine,156,
ated with IH. There are almost certainly other important
595–597.
indirectpathwaysthroughwhichIHoperatesonriskbehaviors Greenland,S.,Maclure,M.,Schlesselman,J.J.,Poole,C.,&Morgenstern,
waitingtobeelucidated. H.(1991).Standardizedregressioncoefficients:Afurthercritiqueand
reviewofsomealternatives.Epidemiology,2,387–392.
Finally, the most troubling aspect of their recommenda-
Newcomb,M.E.,&Mustanski,B.(2009).Moderatorsoftherelationship
tiontoabandonIHandHIVriskresearchisthatthestudies
between internalized homophobia and risky sexual behavior in
reviewedwereoverwhelminglyNorthAmerican.Studiesnot menwhohavesexwithmen:Ameta-analysis.ArchivesofSexual
inEnglishwereexcluded.Worldwide,homonegativityandIH Behavior.doi:10.1007/s10508-009-9573-8.
Ross,M.W.,&Rosser,B.R.S.(1996).Measurementandcorrelatesof
remainhugethreatstothewell-beingofMSM.Aswewrite,
internalized homophobia: A factor analytic study. Journal of
thereisawaveofhomonegativitysweepingAfrica.Uganda
ClinicalPsychology,52,15–21.
hasintroducedlegislationwhichprovidesforthedeathpenalty Ross,M.W.,Rosser,B.R.S.,Neumaier,E.R.,&thePositiveConnections
formalehomosexualacts.InSenegal,itisreportedthatthe Team. (2008). The relationship of internalized homonegativity to
unsafesexualbehaviorinHIVseropositivemenwhohavesexwith
bodiesofgaymenhavebeendugupanddesecrated.Outside
men.AIDSEducationandPrevention,20,547–557.
NorthAmericaandselectedWestEuropeanandAustralasian
Ross,M.W.,Smolenski,D.J.,Kajubi,P.,Mandel,J.S.,McFarland,W.,
countries,homonegativityappearsanoverwhelmingandever- & Raymond, H. F.(2010). Measurement of internalized homo-
present physical and psychological threat to MSM. To rec- negativity in gay and bisexual men in Uganda: Cross-cultural
propertiesoftheInternalizedHomonegativityScale.Psychology,
ommend not studying IH and its still poorly understood
HealthandMedicine,15,159–165.
associationswithriskbehavior,simplybecausestudiesinthe
Rosser,B.R.S.,Bockting,W.O.,Ross,M.W.,Miner,M.H.,&Coleman,
U.S. failed to observe direct relationships between IH and E. (2008). The relationship between homosexuality, internalized
sexual risk behavior, makes no sense. Our study on IH in homo-negativity,andmentalhealthinmenwhohavesexwithmen.
JournalofHomosexuality,55,185–203.
Ugandan MSM (Ross et al., 2010) will, we hope, stimulate
other researchers to explore the construct and its direct and
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ArchSexBehav(2010)39:1209–1211
DOI10.1007/s10508-010-9655-7
LETTER TO THE EDITOR
The Importance of Measuring Internalized Homophobia/
Homonegativity: Reply to Ross, Rosser, and Smolenski (2010a)
MichaelE.Newcomb • BrianMustanski
Publishedonline:16July2010
(cid:2)SpringerScience+BusinessMedia,LLC2010
Ross, Rosser, and Smolenski (2010a) provide a commentary continuous,theproduct-momentcorrelationcoefficientis
regardingourrecentlypublishedmeta-analysisoftherelation- thestraightforwardlyappropriateeffectsizestatistic.Indeed,
ship between internalized homophobia (IH) and risky sexual virtuallyallsuchresearchfindingswillbereportedin
behaviorinmenwhohavesexwithmen(MSM)(Newcomb& termsofthecorrelationcoefficientinoriginalstudies,
Mustanski,2009).Rossetal.raisedanumberofmethodological soitwillrarelybesensibletoconsideranyothereffect
andconceptualconcernsaboutthemeta-analysis,andtherefore sizestatistictorepresentthem’’(p.63).
disagree withourconclusion thatresearchers wouldbewell-
LipseyandWilsonfurtherdiscusstheneedtostandardizeES
servedtofocustheirresourcesonotherpredictorsofriskysexual r
usingFisher’srtoztransformationinordertoovercomeaprob-
behaviorthataremorepromisingintermsoftheirpredictive
lematicstandarderrorformulationwhichisusedinweighting
ability.Wewouldliketoaddressanumberoftheseconcernsin
effectsizesbasedonsamplesize.Byusingstandardizedand
ordertofurthersupportourconclusionthattheliteraturedoesnot
weightedES statistics,theanalystisabletomeaningfullycom-
supportacurrentsignificantbivariateassociationbetweenIH r
bine results across studies and make conclusions aboutcom-
andriskysexualbehavior.Wefurtherbelievethatfewviable
binedoveralleffectsize.
modelshavebeenproposedtoexaminethepotentialindirect
Rossetal.alsonotedthattheIHmeasuresusedinthemeta-
effectsofIHonrisk.
analysiswerenotcomparable.Whileitistruethattherehasbeen
First,Rossetal.raiseconcernsabouttheuseofcorrelation
somedisagreementintheliteratureabouthowbesttomeasureIH,
coefficients (ES) in meta-analysis and state that‘‘correlation
r oneofthepurposesofmeta-analysisistocombineresultsfrom
coefficientsinmeta-analysisarenotandcannotbeeffectsizes.’’
multiplestudiesonthesamerelationshipinordertoaccountfor
Infact,correlationcoefficientsarecommonlyusedaseffectsize
methodological and measurement differences between these
inmeta-analysisandareadequatemeasuresofeffectsizefor
studies.CombiningstudiesusingmultiplemeasuresofIHthat
meta-analysisgiventhatextrastepsaretakeninordertoover-
mayassessslightlydifferentcomponentsoftheconstructallow
come certain problematic properties of this statistic. In their
theanalysttomakemoregeneralconclusionsaboutIHthanwould
widely-usedbookonmeta-analysis,LipseyandWilson(2001)
bepossiblebyexaminingeachstudyindividually.Assuch,weare
stated:
betterabletomakegeneralconclusionsaboutthecurrentstateof
…whentheresearchfindingstobemeta-analyzedinvolve the literature on the association between IH and risky sexual
bivariaterelationshipsinwhichboththevariablesare behaviorbecausewedidnotrelyonasinglemeasureofIH.Infact,
itiscommonpracticeinmeta-analysistousedifferentmeasuresof
thesameconstruct.Forexample,awidely-citedmeta-analysisof
M.E.Newcomb(&) theeffectsofschool-basedinterventionprogramsonaggressive
DepartmentofPsychology(MC285),UniversityofIllinois behavior included multiple different measures of aggressive
atChicago,1007W.HarrisonStreet,Chicago,IL60607,USA
behavior,such asphysicalaggression, externalizing problems,
e-mail:[email protected]
fighting,bullying,actingout,disruptiveness,and/orconductand
B.Mustanski disciplineproblems(Wilson,Lipsey,&Derzon,2003).
DepartmentofPsychiatry,UniversityofIllinoisatChicago,
Chicago,IL,USA
123
1210 ArchSexBehav(2010)39:1209–1211
Whenmultiplemeasuresareused,itisalsopossibletotestfor betweenIHandriskysexualbehavior.Rossetal.state,‘‘Shouldwe
differencesineffectsbetweenmeasures.Toconsiderthis,we determine some causal association of IH with other proximal
includedthemostcommonlyusedmeasureofIH,theNungesser determinantsofriskbehavior,thenwewillhaveagoodideaof
HomosexualAttitudesInstrument(NHAI),asamoderatorof howtoappropriatelyinterveneonthosefactors.’’Here,weseem
therelationshipinafollow-upanalysis.Thisvariablewasnota toagreethatsuchproximalfactorsshouldbecomethefocusof
significant moderator, indicating that the NHAI was not dif- scarcepublichealthresourcesovermoredistalfactorsasIHwould
ferentiallyassociatedwithriskysexualbehaviorascomparedto thenbe.WherewedodisagreewithRossetal.isintheirstatement
othermeasures. that‘‘IgnoringIHinfurtherriskbehaviorstudieswouldpre-
Ross et al. also expressed concern about varying measures vent development of culturally specific and relevant interven-
of risky sexual behavior, specifically the inclusion of a study tionsforMSM.’’First,webelievethereisadangerindeveloping
assessingcompulsivesexualbehaviorastheoutcomevariable. interventioncontentbasedontheassumptionthattheinternali-
Themajorityofthestudiesincludedinthemeta-analysisassessed zationofanti-gayandheterosexiststigmaiscentraltotheunder-
unprotectedanalsexastheriskvariable,butseveralstudies standingofMSMriskbehaviors,whentheevidencedoesnotbear
includedmeasuresofunprotectedvaginalandoralsexandnum- thisout.Thismayleadtoamisdirectionofscarceintervention
berofsexualpartnersascomponentsofsexualrisk.Again,meta- resources.Forexample,itispossiblethattheexternalmanifes-
analysisshouldhelptoaccountformeasurementdifferences tationsofthisstigma,suchaslegislationthatpreventstwomen
acrossmultiplemeasuresofthesameorsimilarconstructs.While frombeingmarried,mayrepresentcriticalstructuralfactorsthat
itistruethatcompulsivesexualbehaviorislessfrequentlyusedas increaseriskforHIVamongMSM.However,thispolicymaynot
asexualriskvariable,removingthisstudyfromthemeta-analysis needtobepsychologicallyinternalizedbytheindividualinorder
didnotalterthepatternorsignificanceofanyofthefindings, forittoaffectrisktaking.Inouropinion,thisdeservesfurther
includingthemoderatingeffectofyearofdatacollectiononthe investigation. Second, we do not believe that a cultural factor
relationshipbetweenIHandriskysexualbehavior. needstobecorrelatedwithariskoutcomeinordertobeconsidered
Rosset al. suggested that, evenif there is no direct rela- for inclusion in making an intervention culturally specific and
tionship between IH and risky sexual behavior, the indirect relevant. For example, in the CDC’s ADAPT framework for
relationshipsreportedinsomestudiesrepudiateourconclu- adaptinganexistingHIVinterventiontoatargetgroup(McKleroy
sionsaboutthevalueoffurtherresearchonthisassociation. etal.,2006),changesweredeemednecessaryinordertomake
Inourarticle,wecitedstudiesthathavefoundevidencefor theinterventionculturallyappropriateandtoaddressuniquerisk
indirecteffectsofIHonriskysexualbehaviorinMSM.How- factorsandbehavioraldeterminants.IfIHisacorepartofthe
ever, relatively few studies have provided evidence for and culture,thenitmayverywellneedtobeaddressedinanHIV
replicated these indirect effects, and none have provided a preventionprogramevenifitisnotariskdeterminant.Individuals
strong rationale for why an indirect effect may exist in the maydisagreeabouttheextenttowhichIHiscurrentlyacorepart
absenceofadirectbivariaterelationship.Such‘‘inconsistent ofgayculture.
mediation’’occurswhenthe indirectand directeffectarein Rossetal.alsonotedthatourmeta-analysisonlyexamined
oppositedirectionsandthereforecanceleachotheroutinthe onepotentialoutcomeassociatedwithIH,andthatanindirect
estimation of the direct relationship (i.e., a ‘‘suppression’’ relationshipbetweenIHandriskysexualbehaviormayexistvia
effect)(MacKinnon,Krull,&Lockwood,2000).Inthesemore theassociationbetweenIHandotheroutcomes,suchasmental
rarelyreportedcasesofsuppression,itisparticularlyimportant health and substance use. As is noted in our discussion in the
for researchers to explicate a reasonable model for under- meta-analysis of the relationship between IH and risky sexual
standingthereasonandimplicationsforsuppression.Wefound behavior,wealsoconductedameta-analysisoftherelationship
nosuchexplanationsorevenpatternsofcorrelationsconsis- between IH and internalizing mental health problems, which
tent with suppression in the published papers we reviewed foundamoderateeffectsizeforthisrelationship(Newcomb&
reportingindirecteffects.InreadingthearticlecitedbyRoss Mustanski,2010).WeagreewithRossetal.thattheeffectsofIH
et al. as evidence for indirect effects, we found no report, onmentalhealthareimportanttoconsiderinbothresearchand
description, or explanation of an indirect effect between IH clinicalwork.Wealsoconsideredconductingmeta-analysesof
andsexualrisktaking(Rossetal.,2010b).Webelievemuch therelationshipsbetweenIHandalcoholanddruguse,butthere
strongerempiricalevidenceandtheoreticaljustificationforthe werenotenoughstudiesontheserelationshipstowarrantmeta-
existenceofanimportantindirectrelationshipbetweenIHand analysis.Whileweagreethattheremaybearelationshipbetween
risky sexual behavior is needed before public health deci- IHandsubstanceuse,wecautionreadersfromdrawingthecon-
sions should be made based on the existence of an indirect clusionthatthisisevidenceforanindirectlinkbetweenIHand
relationship. riskysexualbehavior.Thedirectassociationbetweensubstance
Furthermore,ifanindirectrelationshipwasfirmlyestablished, useandsexualriskhasnotbeenconsistentintheliterature,par-
thismakesthecaseforfocusingresearchandinterventions ticularlyforalcoholuse(Cooper,2006),andconflictingfindings
onthosemoreproximalprocessesthatmediatetherelationship havebeenreported.Similarly,theassociationbetweensexualrisk
123
ArchSexBehav(2010)39:1209–1211 1211
andmentalhealthoraffectivestateshasbeeninconsistent(Cre- promising in terms of empirical or theoretical support given
paz&Marks,2001;Mustanski,2007). scarcepublicresourcesavailabletostudytheseprocesses.
Finally,weagreewithRossetal.thatIHmaybedifferently
experiencedinnon-Westernculturesandthatitplausiblymay
predictriskysexualbehaviorinothercultures.Weonlyincluded References
studies in our meta-analysis from Western cultures that were
Cooper,M.L.(2006).Doesdrinkingpromoteriskysexualbehavior?
conductedinEnglishasbothlanguageandculturemayaffectthe
CurrentDirectionsinPsychologicalScience,15,19–23.
experienceofIHandthusrenderitimpossibletomakemean-
Crepaz,N.,&Marks,G.(2001).Arenegativeaffectivestatesassociated
ingfulcomparisonsacrossstudies.Ourconclusionthat‘‘research- withHIVsexualriskbehaviors?Ameta-analyticreview.Health
erswouldbewell-servedtoconsiderabandoningtheinvestigation Psychology,20,291–299.
Lipsey,M.W.,&Wilson,D.B.(2001).Practicalmeta-analysis.Thou-
of IH as a predictor of risky sexual behavior’’applies to the
sandOaks,CA:SagePublications.
countriesorculturesinwhichthestudiesincludedinthemeta-
MacKinnon,D.P.,Krull,J.L.,&Lockwood,C.M.(2000).Equivalence
analysiswereconducted.However,weencourageresearchersto ofthemediation,confoundingandsuppressioneffect.Prevention
continuetobemindfulofthedifferencebetweenIH,whichisan Science,1,173–181.
McKleroy,V.S.,Galbraith,J.S.,Cummings,B.,Jones,P.,Harshbarger,
internalpsychologicalprocess,andexternalanti-gaybehaviors
C.,Collins,C.,etal.(2006).Adaptingevidence-basedbehavioral
andpolicies.Victimizationresultingfromhomophobiadoesnot
interventions for new settings and target populations. AIDS
always lead to IH, and determining which individuals under EducationandPrevention,18,59–73.
whichconditionsinternalizeheterosexismwouldbehelpfulfor Mustanski,B.(2007).TheinfluenceofstateandtraitaffectonHIVrisk
behaviors:AdailydiarystudyofMSM.HealthPsychology,26,
cliniciansworkingwiththiscommunity.Wedoverymuchagree
618–626.
withRossetal.abouttheimportanceofstudyingthehealthand
Newcomb,M.E.,&Mustanski,B.(2009).Moderatorsoftherelationship
development of LGBT individuals and MSM in non-Western betweeninternalizedhomophobiaandriskysexualbehaviorinmen
contexts.ItisnotourintenttoarguethatIHisnotworthstudying who have sex with men: A meta-analysis. Archives of Sexual
Behavior,doi:10.1007/s10508-009-9573-8.
outsidetheWestinresearchonriskysexualbehaviororthatIH
Newcomb,M.E.,&Mustanski,B.(2010).Therelationshipbetween
doesn’tmatterasaconstructthatisrelevanttomentalhealthand
internalized homophobia and internalizing mental health prob-
socialjustice.However,itisourintenttoencourageresearchersto lems:Ameta-analyticreview(underreview).
bemindfulofthescienceandrationaleinfluencingtheirdecisions Ross,M.W.,Rosser,B.R.S.,&Smolenski,D.(2010a).Theimportance
ofmeasuringinternalizedhomophobia/homonegativity[Letterto
todoso.
the Editor]. Archives of Sexual Behavior, doi:10.1007/s10508-
In conclusion, we stand by the conclusions of our meta-
010-9634-z.
analysisaboutanoveralllackofdirectassociationbetweenIH Ross,M.W.,Smolenski,D.J.,Kajubi,P.,Mandel,J.S.,McFarland,W.,
andriskysexualbehaviorinMSMinstudiespublishedinEng- &Raymond,F.H.(2010b).Measurementofinternalizedhomo-
negativity in gay and bisexual men in Uganda: Cross-cultural
lish withWesternsamples. Wealso believe thereisnotwell
propertiesoftheInternalizedHomonegativityScale.Psychology,
developedevidenceorexplanationsforindirecteffectsinthe
Health,andMedicine,15,159–165.
absenceofdirecteffects.WhiletheexperienceofIHmayhave Wilson,S.J.,Lipsey,M.W.,&Derzon,J.H.(2003).Theeffectsof
importantimplicationsforotherhealth-relatedoutcomes(e.g., school-based intervention programs on aggressive behavior: A
meta-analysis.JournalofConsultingandClinicalPsychology,71,
mentalhealth),wemaintainthatisitcriticalforfutureresearchto
136–149.
focusoninvestigatingpredictorsofsexualriskthataremore
123
ArchSexBehav(2010)39:1213–1215
DOI10.1007/s10508-010-9658-4
LETTER TO THE EDITOR
Depressive Symptoms Among Same-Sex Oriented Young Men:
Importance of Reference Group
RitchC.Savin-Williams • KennethM.Cohen •
KaraJoyner • GerulfRieger
Publishedonline:21July2010
(cid:2)SpringerScience+BusinessMedia,LLC2010
Arecentmeta-analysisindicatedstrongsupportforthecom- Udry & Chantala, 2005). Indeed, the effect size for male
monlyobservedfindingthat,incontrasttoheterosexualmen, sexualorientationdifferenceappearstobeamongthelargest
same-sexorientedmenareatgreaterriskformentalhealthprob- sex-dimorphicdiscrepanciesinthedevelopmentalliterature
lems,especiallyaffectivedisorders(Kingetal.,2008).Themost (Bailey&Zucker,1995).Inarecentreview,Bailey(2009)
commonexplanationsforthesefindingsaretheincreasedprev- notedthatsame-sexorientedmenare,onaverage,moresex
alenceofsocietalprejudice,stigma,andviolencethatallegedly atypicalintheirself-concepts,motorbehavior,bodymove-
generate‘‘minority-stress’’effects (King et al., 2008; Meyer, ments,occupationalcareers,andrecreationalintereststhan
2003;Saewyc,2007).Hatzenbuehler(2009,p.707)notedthat heterosexualmen.AccordingtoarecentFinnishtwinstudy,
stigma-relatedstress‘‘getsundertheskin’’byinducingeleva- substantialgeneticeffectsaccountforvariationinbothsex-
tions in emotional dysregulation, which, in turn, confers risk atypical behavior and adult sexual orientation, suggesting
forincreasedpsychopathologyamongnonheterosexualpopu- that at least part of this co-variation is due to biological
lations.Althoughthisexplanationisreasonable,fewother influences(Alankoetal.,2010).
hypotheses have been proposed for the apparent elevation of Given therobustfindingthatinsomerespectssame-sex
depressivesymptomsamongsame-sexattractedindividuals. orientedmenaremoresimilartoheterosexualwomenthan
Thealternativeconsideredhereisthatmentalhealthdiscrep- heterosexualmen,wespeculatethatthebasicprincipleofa
anciesamongmalesexualorientationgroupsareillusorybecause correctlychosenreferencegroupiscriticalinascertainingthe
theyare derived frominappropriate(i.e., same biologicalsex) existence of male sexual orientation differences in mental
groupcomparisons.Weadoptinasex-inversionperspective— health. To our knowledge, sex-atypical endorsement of
that cross-sex comparisons are more suitable for situations in sexuallydimorphicmentalhealthpatternshasnotbeensys-
whichnonheterosexualmenareassessedonsexuallydimorphic tematically addressed. We hypothesize that same-sex ori-
variables. ented men more closely resemble mental health patterns
An extensive literature documenting cross-sex behavior observedamongheterosexualwomenthanmen.Thiswould
amongnumerousdomainshasconsistentlyreportedthat,asa particularlybethecaseformentalhealthdisordersthatare
group,nonheterosexualmenscoresignificantlymoresimilar especiallysexdimorphic,suchasdepression.Indeed,ameta-
totheoppositesexthanheterosexualmenonvariousmea- analysisofsexdifferencesindepressionrevealedthat,begin-
sures of gender nonconformity (Bailey & Zucker, 1995; ninginearlyadolescenceandcontinuingthroughadulthood,the
Cohen,2002;Lippa,2005;Rieger&Savin-Williams,2010; prevalence of depression is more than twice as high among
womenasmen(Twenge&Nolen-Hoeksema,2002).Thissex
differencewasreplicatedinKingetal.’s(2008)meta-analysis
R.C.Savin-Williams(&)(cid:2)K.M.Cohen(cid:2)G.Rieger
fordepression,anxiety,andsuicidality.
HumanDevelopment,CornellUniversity,MVRHall,
Ithaca,NY14853,USA To address this possibility, we analyzed data drawn from
e-mail:[email protected] Wave3ofAddHealth,acomprehensive,representativeschool-
basedstudyofU.S.youth(Harrisetal.,2003;Udry&Bearman,
K.Joyner
1998). For Wave 3 (2001–2002), the project re-interviewed
DepartmentofSociology,BowlingGreenStateUniversity,
BowlingGreen,OH,USA 15,197oftheoriginalWave1in-homeparticipants,nowaged
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1214 ArchSexBehav(2010)39:1213–1215
18–28years.TheresponseratesforWaves1and3were79% depressed.’’Itemswereratedona4-pointscale,rangingfrom
and77%,respectively.Allincludedparticipantshadtoreport 0(never/rarely)to3(mostofthetime/allofthetime).
the same sex at both waves to qualify for the sample. After Analyses incorporated survey design procedures to take
excluding participants with missing data on main variables intoaccountAddHealth’sweighting(usingthegrandsample
(sexualorientationanddepression)andnolongitudinalgrand longitudinal weight for participantsinWaves1 and3)and
sample weight, the final sample was 13,992, of which 6,615 cluster design. Means and their 95% confidence intervals
were heterosexual and nonheterosexual men and 6,351 were (CIs)werecalculatedtoexaminehowdepressivesymptoms
heterosexual women (the remainder were nonheterosexual differedbysexandsexualorientation.Consideredasagroup
women,notincludedinthisstudy). andthenasthreesexualorientationsubgroups(mostlyhet-
Interviews were conducted by professional staff who erosexual,bisexual,andhomosexual),nonheterosexualmen
enteredsubjects’answersonalaptopcomputer.Forsensitive were compared to heterosexual men. These comparisons
questions, such as sexual orientation, interviewers handed werethenrepeatedwithheterosexualwomenasthereference
participantsthelaptoponwhichtheycompletedacomputer- group.
assistedself-interview;thisenabledtheyoungadultstoenter As expected, when compared to heterosexual men, non-
responses to questions that appeared on screen and were heterosexual men and heterosexual womenreportedsignifi-
heard on tape with earphones. Participants were asked to cantlyhighervalues for depressivesymptoms (Table1).By
choose the description that best fits how they think about nonheterosexual subgroup, mostly heterosexual and homo-
themselves. Options were 100% heterosexual (straight); sexualmenendorsedhighervaluesofdepressivesymptoms
mostly heterosexual (straight), but somewhat attracted to thanheterosexualmen.Despitereportingthehighestdepres-
peopleofyourownsex;bisexual—thatis,attractedtomen sive value, bisexual men did not differ significantly from
andwomenequally;mostlyhomosexual(gay),butsomewhat heterosexualmalesbecauseoftheirsmallsamplesize.Non-
attracted to people of the opposite sex; 100% homosexual heterosexual men as a group and all nonheterosexual sub-
(gay);ornotsexuallyattractedtoeithermalesorfemales.The groupsdidnotdiffersignificantlyfromheterosexualwomenin
small number of participants who failed to report attrac- depressivesymptoms.
tionsweredropped(n=49).Duetothesmallsamplesizeof Giventhewidelydocumentedsexatypicalityofsame-sex
mostly homosexuals, they were combined with 100% attracted men across multiple domains, it may not be sur-
homosexuals.Depressivesymptomswereassessedwitha10- prising that the elevation of affective symptoms among
item derivative CES-D scale (Meadows, Brown, & Elder, nonheterosexualmencloselyresembledthatofheterosexual
2006).Scalealphawas0.81.Includedwerequestionsabout women. Although this finding has not been previously
thefrequencyofeventsduringthepastweeksuchas‘‘Youfelt reported, it can be detected by re-analyzing King et al.’s
Table1 Sexualorientationand
Males(n=6615)
depressivesymptomsbymale
andfemalereferencegroup Percentage/M SD 95%CI t
Sexualorientation(males)
100%heterosexual(n=6238) 0.944 (.936–.952) –
Allnonheterosexuals(n=377) 0.056 (.048–.064) –
Mostlyheterosexual(n=204) 0.032 (.026–.038) –
Bisexual(n=41) 0.006 (.003–.008) –
Homosexual(n=132) 0.018 (.013–.023) –
Depressivesymptomsa
100%heterosexualmales 4.61 0.07 (4.47–4.77) –
Allnonheterosexualmales 6.05 0.31 (5.42–6.68) 4.65***
Mostlyheterosexualmales 6.11 0.48 (5.16–7.08) 3.22**
Bisexualmales 6.32 0.97 (4.34–8.31) 1.81
Homosexualmales 5.84 0.45 (4.94–6.75) 2.69**
**p\.01;***p\.001 100%heterosexualfemales(n=6351) 5.90 0.09 (5.71–6.10) –
(two-tailedsignificancetest
Allnonheterosexualmales 6.05 0.31 (5.42–6.68) 0.45
ofdifferenceindepressive
symptoms 100%heterosexualmales 4.61 0.07 (4.47–4.77) -12.15***
a Absoluterange,0–30. Mostlyheterosexualmales 6.11 0.48 (5.16–7.08) 0.44
Symptomsbetweenthisgroup Bisexualmales 6.32 0.97 (4.34–8.31) 0.44
and100%heterosexualmales
Homosexualmales 5.84 0.45 (4.94–6.75) -0.15
orfemales
123
ArchSexBehav(2010)39:1213–1215 1215
(2008)meta-analysis:thepercentofdepressionamongnon- atypicalbehaviorandadultsexualorientation.ArchivesofSexual
heterosexual men (13.7%) was considerably closer to het- Behavior,39,81–92.
Bailey,J.M.(2009).Whatissexualorientationanddowomenhaveone?
erosexual women (10%) than to heterosexual men (5.9%).
InD.A.Hope(Ed.),Nebraskasymposiumonmotivation:Vol.54:
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sexualorientation:Aconceptualanalysisandquantitativereview.
Whereas a minority-stress model would explain these
DevelopmentalPsychology,31,43–55.
findingsbyhighlightingasharedpatternofdevaluation,pre- Cohen, K. M. (2002). Relationships among childhood sex-atypical
judice, and discrimination among nonheterosexual men and behavior, spatial ability, handedness, and sexual orientation in
heterosexualwomen,webelievethatasex-inversionper- men.ArchivesofSexualBehavior,31,129–143.
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may explain similarities between homosexual men and het- deliberate self harm in lesbian, gay and bisexual people. BMC
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Lippa,R.A.(2005).Sexualorientationandpersonality.AnnualReview
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ted by nonheterosexual men are not remarkable or even lesbian, gay, and bisexual populations: Conceptual issues and
unexpected.Byquestioningtheappropriatereferencegroup researchevidence.PsychologicalBulletin,129,674–697.
Rieger,G.,&Savin-Williams,R.C.(2010).Sexualorientation,gender
forcontrastinglevelsofmentalhealth,ourfindingscontrib-
nonconformity,andwell-being.Manuscriptsubmittedforpubli-
utetoagrowingcallfordepathologizingindividualswhoare cation.
notheterosexual(Savin-Williams,2005;Savin-Williams& Saewyc, E. M. (2007). Contested conclusions: Claims that can (and
Joyner,2010). cannot)bemadefromthecurrentresearchongay,lesbian,and
bisexualteensuicideattempts.JournalofLGBTHealthResearch,
3,79–87.
Acknowledgments ThisresearchuseddatafromAddHealth,apro-
Savin-Williams,R.C.(2005).Thenewgayteenager.Cambridge,MA:
gram project directed by Kathleen Mullan Harris and designed by
HarvardUniversityPress.
J.RichardUdry,PeterS.Bearman,andKathleenMullanHarrisatthe
Savin-Williams,R.C.,&Joyner,K.(2010).Diversityamongsexual
UniversityofNorthCarolinaatChapelHill,andfundedbygrantP01-
orientationgroupsindepressivesymptomlevels:Examiningthe
HD31921fromtheEuniceKennedyShriverNationalInstituteofChild
mediatingroleofriskybehavior.Unpublishedmanuscript,Cornell
Health and Human Development, with cooperative fundingfrom 23
University,Ithaca,NY.
otherfederalagenciesandfoundations.Specialacknowledgmentisdue
Twenge, J. M., & Nolen-Hoeksema, S. (2002). Age, gender, race,
RonaldR.RindfussandBarbaraEntwisleforassistanceintheoriginal
socioeconomic status, and birth-cohort differences on the Chil-
design.InformationonhowtoobtaintheAddHealthdatafilesisavail-
dren’sDepressionInventory:Ameta-analysis.JournalofAbnor-
ableontheAddHealthwebsite(http://www.cpc.unc.edu/addhealth).
malPsychology,111,578–588.
No direct support was received from grant P01-HD31921 for this
Udry,J.R.,&Bearman,P.S.(1998).Thenationallongitudinalstudyof
analysis.Useofthisacknowledgmentrequiresnofurtherpermission
adolescenthealth.RetrievedApril30,2003,fromhttp://www.cpc.
fromthepersonsnamed.
unc.edu/projects/addhealth/.
Udry,J.R.,&Chantala,K.(2005).Riskfactorsdifferaccordingtosame-
sexandopposite-sexinterest. JournalofBiosocial Science,37,
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ArchSexBehav(2010)39:1217–1219
DOI10.1007/s10508-010-9670-8
LETTER TO THE EDITOR
The Right Comparisons in Testing the Minority Stress Hypothesis:
Comment on Savin-Williams, Cohen, Joyner, and Rieger (2010)
IlanH.Meyer
Publishedonline:31August2010
(cid:2)SpringerScience+BusinessMedia,LLC2010
Savin-Williams,Cohen,Joyner,andRieger(2010)suggest moresuitableforsituationsinwhichnonheterosexualmenare
that purported ‘‘mental health discrepancies among male assessedonsexuallydimorphicvariables.’’Thisclaimisbased
sexual orientation groups are illusory.’’They suggest that onvastresearchthatshowedthatgay andbisexualmen are
their findings regarding gay men’s depressive symptoms more like heterosexual women than heterosexual men on
rebutminoritystressexplanationofsexualorientationmental variousmeasures(e.g.,Bailey,2009;Bailey&Zucker,1995).
healthdisparities.Butasitpertainstominoritystresstheory, Forexample,Savin-Williamsetal.citeBailey(2009),whohas
theirrationaleisflawed. showedthat‘‘same-sexorientedmenare,onaverage,moresex
Minoritystressisafrequentlyusedframeworkforunder- atypical in their self-concepts, motor behavior, body move-
standing observed health disparities between sexual minor- ments, occupational careers, and recreational interests than
ity and heterosexual populations (Herek & Garnets, 2007). heterosexualmen.’’Followingthisrationale,Savin-Williams
Minority stress suggests that (1) lesbians, gay men, and etal.goontoshowthatgayandbisexualmen’slevelofdepres-
bisexuals(LGB)compriseadisadvantagedsocialgroupthatis sivesymptomsisnotdifferentfromthatofheterosexualwomen.
subject to stigma and prejudice; (2) stigma and prejudice Thus, they conclude‘‘once recontextualized, the depressive
relatedtosexualorientationpredisposeLGBtoexcessstress; symptomsreportedbynonheterosexualmenarenotremark-
and(3)inturn,thisexcessstressmayleadtoadversehealth ableorevenunexpected.’’
outcomesand,thus,observedhealthdisparities(Meyer,2003). Evenifonewouldconcedethepremiseoftheargument—
Studiesusingtheminoritystressperspectivehaveconsistently that‘‘same-sexorientedmenaremoresimilartoheterosexual
documentedmentalhealthdisparitiesbetweenLGBandhet- womenthanheterosexualmen’’—thereisnomerittotheclaim
erosexual populations. This is evidenced, for example, in thatthesefindingsunderminetheminoritystressperspective.
studies that used meta-analysis to summarize this literature The main reasonfor this is that Savin-Williamset al. make
(Kingetal.,2008;Meyer,2003). theirargumentbasedononesexualminoritysubgroup—gay
Savin-Williamsetal.arguedthattheobserveddisparityis andbisexualmen,excludinglesbiansandbisexualwomen—
faultybecauseresearchershaveusedaninappropriaterefer- andoneoutcome—depressivesymptoms,excludinganxiety
ence group in studying mental health outcomes in gay and andsubstanceusedisorders.Thischerry-pickedcomparisonis
bisexualmen.Typically,researcherscomparegayandbisex- not sufficient to test minority stress theory. Minority stress
ualmenwithheterosexualmenwhentheydocumentmental rests on sociological theory that links social structure with
healthdisparities;Savin-Williamsetal.suggestthatgayand healthoutcomes(throughtheimpactofstress).Therefore,it
bisexualmenshouldbecomparedwithheterosexualwomen, makes predictions about differentially situated groups (dis-
notmen.Thereasonforthisisthat‘‘cross-sexcomparisonsare advantaged versus advantaged groups) and predicts similar
patternsacrossvariousmentaldisorders(Schwartz&Meyer,
2010).Savin-Williamsetal.erronbothcounts.
I.H.Meyer(&) First, minority stress suggests that sexual minorities are
MailmanSchoolofPublicHealth,ColumbiaUniversity,
sociallydisadvantagedinoursocietyduetohomophobiaand
AllanRosenfieldBuilding,722West168thStreet,
heterosexismasagroup—thatis,acrossallsubgroups,such
Room533,NewYork,NY10032,USA
e-mail:[email protected] asthosedefinedbygender,race/ethnicity,etc.Forthestudy
123
1218 ArchSexBehav(2010)39:1217–1219
ofminoritystress,therefore,thegroupscomparedoughttobe heterosexualwomeninpatternsofsubstanceuseddisorders.In
allsexualminorities—menandwomen—versusallhetero- fact,thisisnotthecase:gayandbisexualmenhaveamuch
sexuals.Similarly,ifgenderinequalitywasstudied,theref- higherprevalenceofsubstanceuseproblems,includingsub-
erence group for women would be men; if race/ethnic stance use disorders,than heterosexual women (King et al.,
inequality was studied, the reference group for race/ethnic 2008;Meyer,2003).Asaresult,whenallmentaldisordersare
minorities would be whites. This is because in each com- considered,gayandbisexualmenhavehigherlevelsofdis-
parisonweareinterestedintheaverageeffectonthedisad- orderthanheterosexualwomen.Thisfindingisconsistentwith
vantagedversusadvantaged,thatis,acrossdiversesubgroups the minority stress hypothesis but not with Savin-Williams
within (Schwartz & Meyer, 2010). Savin-Williams et al.’s etal.’sreferencegrouphypothesis.
hypothesis is refuted when one examines LGB as a group In summary, examining the evidence on sexual orienta-
versusheterosexualsasagroup.Consistentwiththeminority tion,stress,anddisorder,wefindthatsexualminoritieshave
stress hypothesis, in such comparisons, LGB populations greaterexposuretostress(Meyer,Schwartz,&Frost,2008)
have higher rates of mental disorders than heterosexuals andtheyhavetheexpectedresultanthigherratesofdisorder
(Kingetal.,2008;Meyer,2003). whencomparedwithheterosexuals(Kingetal.,2008;Meyer,
Second,minoritystress(andsocialstresstheorymoregen- 2003).WhenweexamineSavin-Williamsetal.’sreference
erally)isasociologicaltheorythatpredictsthatdisadvantaged grouphypothesiscarefullyinlightofthisevidence,wemust
social status affects the aggregate of mental disorders, rather refuteit.
than any particular disorder—we are interested in whether a Finally,Savin-Williamsetal.contendthattheirarguments
disadvantagedgroupmemberhasanydisorderthatiscausedby ‘‘contribute to a growing call for depathologizing individ-
minoritystress.Thisisbecausesocialdisadvantageandresul- ualswho are notheterosexual.’’I rejectthe implication that
tantstressarethoughttobegenericpathogens.Minoritystress minoritystresstheorypathologizesLGBindividuals.Minor-
does not predict a specific impact on, say, depression versus itystresstheorypositionsthesourceofstress,andtherefore
anxiety and substance use disorders. Although this is not an mentalhealthproblems,asstemmingfromprevailingsocie-
infallible rule, researchers should provide a good reason to tal-levelsexualstigma,prejudice,anddiscriminationandnot
excludeonedisorderoranother.Areasontoexcludeadisorder a reflection of individual traits. Although some politically-
would be, for example, that stress has no part in causing the motivated persons may use evidence that LGB individuals
disorder.Insuchahypotheticalsituation,ifstressdoesnotplaya have a higher prevalence of disorder than heterosexuals to
causalrole,theresearchercouldnotreasonablyhypothesizethat pathologize, stigmatize, and discriminate against LGB per-
minoritystresswouldleadtoexcessdisorderinthedisadvan- sons,suchargumentsaremisguidedastheydefylogic.During
tagedgroup. the debates that led to the removal of homosexuality as a
ThisprobleminSavin-Williamsetal.’sproposedreference mentaldisorderfromDSM-IIin1973,Marmor(1980)noted
grouphypothesisisreminiscentofa1970sdebateinthesoci- howillogicalitistoassociatefindingsaboutprevalenceof
ologyofmentalhealthaboutgenderrolestressanddisorder. pathologyinthegroupwithpathologizingthegroupitself:
GoveandTudor(1976)claimedthatahigherlevelofdepression
…thebasicissue…isnotwhethersomeormanyhomo-
inwomencomparedwithmenisevidenceofwomen’sgender
sexualscanbefoundtobeneuroticallydisturbed.Ina
role stress. Critics argued, as we argue here, that selecting
society like ours where homosexuals are uniformly
depression alone of all mental disorders is wrong because it
treatedwithdisparagementorcontempt—tosaynoth-
providesopportunisticsupportforafavoritetheory.Whenall
ing about outright hostility—it would be surprising
mentaldisorderswerecompared,itbecameevidentthatwomen
indeedifsubstantialnumbersofthemdidnotsufferfrom
andmenhavesimilarlevelsofdisorders,refutingtheproposed
animpairedself-imageandsomedegreeofunhappi-
gender role hypothesis (Dohrenwend & Dohrenwend, 1976).
ness with their stigmatized status….It is manifestly
Analternativehypothesiswasofferedforthedifferingpatterns
unwarrantedandinaccurate,however,toattributesuch
ofdisorders,suggestingthatmenandwomen’sstressresponse
neuroticism,whenitexists,tointrinsicaspectsofhomo-
differed:Womeninternalizestress,resultinginhigherlevelsof
sexualityitself.(p.400)
mooddisorders,andmenexternalizestress,resultinginhigher
levelsofsubstanceusedisordersandantisocialbehaviors(Ro- Minoritystresstheorypointstopathogenicsocialcondi-
senfield,1999). tionsthatstigmatizeLGBpeopleandtreatthemasinferiorto
If we relied on these gendered patterns of difference heterosexuals.Evenattheriskthatresearchfindingscanbe
between internalizing and externalizing disorders that are misusedbysome,studiesonthepsychiatricepidemiologyof
characteristicofmenandwomeninthegeneralpopulation,we LGB individuals are important to help guide funding by
would expect, based on Savin-Williams et al.’s proposed governmentalandotheragenciesandtodirectresearchand
hypothesis, that gay and bisexual men would be similar to preventionefforts.
123