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Learn More. Evidence suggests that sexual minorities e. Minority stress theory suggests that this disparity is due to stigma experienced by sexual minorities. This review provided a systematic examination of research assessing the evidence for mediating factors that help explain such disparities. The review included 40 identified studies that examined mediators of sexual minority status and depressive outcomes using a between-group de i. Studies of adolescents and adult samples were both included. The most common findings were consistent with the suggestion that stressors such as victimization, harassment, abuse, and increased stress, as well as lower social and family support, may contribute to differing depression rates in sexual minority compared to heterosexual individuals.
Differences in psychological processes such as self-esteem and rumination may also play a role but have had insufficient research attention so far. However, caution is needed because many papers had important methodological shortcomings such as the use of cross-sectional des, inferior statistical analyses for mediation, or measures that had not been properly validated.
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Although firm conclusions cannot be drawn, the current evidence base highlights many factors potentially suitable for further exploration in high-quality longitudinal research or randomized studies intervening with the potential mediators. Systematic reviews have reported that compared to heterosexual people, sexual minority individuals e. A strong link has been consistently demonstrated between sexual minority status and depression in particular e.
A meta-analysis found that the risk of month prevalence of depression in sexual minority individuals was at least twice that of heterosexual controls King et al. Similar differences in prevalence rates have been found for heterosexual versus sexual minority youth e.
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Robust research evidence about the mechanisms through which such disparities come about would be both theoretically and clinically valuable. For example, the identification of intermediate factors that contribute to elevated rates of depression in this population would be instrumental for deing and refining effective prevention programs that would help protect at-risk LGB individuals and developing targeted therapeutic approaches for sexual minority people who experience depression.
Minority stress theory has been one of the main theoretical frameworks used to explain the differences in the rates of depression and other mental health problems between sexual minorities and heterosexuals Meyer, According to the theory, being a member of a minority group exposes individuals to discrimination, stigma, and prejudice. Such exposure creates a stressful social environment which contributes to the presence of mental health problems.
Meyer suggested that such minority stressors may be distal external to the person or proximal, i. Distal stressors include prejudice events such as discrimination and violence, while proximal events include sexual minority-specific internalized stressors such as internalized homophobia, expectations of rejection, and concealment stress. Indeed, evidence indicates that sexual minority individuals face multiple stressors, often starting early in their lives, including peer victimization, physical assault, abuse, and rejection from family and friends e. There is also a lot of research demonstrating that sexual minority individuals experience a multitude of internal minority stressors such as perceived stigma and expectations of rejection and discrimination, stress about disclosure and concealment, and internalized negative attitudes about their sexual identity see Meyer, for a review.
Hatzenbuehler expanded on minority stress theory by suggesting that the increased stress that sexual minority individuals are exposed to is likely to increase the likelihood of general maladaptive cognitive processes, unhelpful coping and emotion regulation strategies, and reduced social support, all of which may in turn increase the risk for mental health problems.
Mediators of the disparities in depression between sexual minority and heterosexual individuals: a systematic review
Furthermore, Hatzenbuehler emphasized the importance of examining whether general psychological processes that are known vulnerability factors in the general population are heightened in sexual minorities and whether they can therefore help explain the increased prevalence of mental health problems in sexual minorities compared to heterosexuals. In order to understand the intermediate factors that explain the causal relationship between sexual orientation and depression, it is important to look at research that examines mediating variables.
Mediation is a process whereby an independent variable is thought to cause change in an intervening variable which in turn causes change in the dependent variable Lockwood et al.
In this sense, a hypothesized mediation model will generally constitute a causal chain of events; the plausibility of each of these causal relationships needs to be considered and justified. The causal chain described above implies that the independent, mediator, and dependent variables should be measured separately in an ordered fashion in time.
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Therefore, studies measuring these variables longitudinally are generally considered methodologically Twin Embu sex chats. A review of research examining mediators should include the evaluation of the robustness of statistical methods used for mediation analysis.
Indeed, several considerations need to be made in assessing the quality of such methodology: Statistical methodology on mediation analysis has developed ificantly since the causal steps approach to mediation was developed by Baron and Kennyincluding the idea that if mediation is hypothesized, it is still important to do a mediation analysis even in the absence of an effect of the independent on the dependent variable Emsley et al. Mediation analyses now generally focus on a product of coefficients mediated effect a path x b bathwhich can be estimated efficiently in one step using the structural equation modeling SEM framework, tests of the t ificance of a and b paths, and the Sobel test of ificance of the indirect effect and bootstrapping to calculate mediated effect confidence intervals Goldsmith et al.
In addition, in recent years, mediation analysis has focused on sources of bias, such as confounding; researchers should adjust for baseline mediator and outcome measures and include all important potential confounders of the relations in the mediation models Dunn et al. In recent years, research has investigated factors contributing to the mental health disparities between heterosexual and sexual minority youth and adults by looking at mediators of the relation between sexual orientation and depressive symptomatology.
Examining mediators can help us better understand the mechanisms through which both sexual minority status and the stigma associated with it confer risk for depression Hatzenbuehler, Moreover, assessing the quality of statistical methodology and de e.
This would help provide robust evidence for appropriate targets for prevention and intervention that would help end disparities between sexual minorities and their heterosexual peers.
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No study to date has systematically reviewed between-group studies that use mediation analysis to examine evidence regarding different psychosocial factors that may explain the differences in rates of depression between heterosexual and sexual minority individuals. Therefore, the aim of the present study is to identify the factors that mediate the relation between sexual minority status and depressive symptoms by systematically reviewing research studies in the literature that use mediational approaches to investigate the disparities among heterosexual and sexual minority individuals.
The study also reports the theoretical models used to derive the hypotheses tested in the included studies.
Additional studies were retrieved by cross-referencing of selected articles, and through hand searches. The literature search was completed on October 27,and was Twin Embu sex chats on October 21, We included studies that: 1 were published in peer reviewed journals; 2 included a statistical group comparison between heterosexual and sexual minority status individuals; 3 used a measure of depressive symptoms or a diagnosis of depression as an outcome variable; 4 used analyses that tested hypothesized mediation effects with sexual orientation as the independent variable and depression as the dependent variable.
We excluded studies that: 1 were non-empirical reviews or theory papers ; 2 did not have the full description of the study available e. We did not exclude studies based on publication year, sample size, age groups used, or whether they used a subsample of the population of interest. An initial screening of all title and abstracts returned using the aforementioned search strategy was conducted by the first author.
Studies that met the eligibility criteria based on the initial screening were screened using the full-text papers by the first author and a subgroup were also screened by an independent reviewer. The kappa statistic was used to measure inter-rater agreement. As studies were methodologically and statistically Twin Embu sex chats, a meta-analysis or other methods of statistical pooling to synthesize the findings were not appropriate.
The theoretical models, methodology,and limitations of the studies are therefore qualitatively summarized in the and Discussion sections, with much supporting detail provided in the tables and the Appendix. A quality assessment measure developed for treatment mediation studies by Lubans et al.
The quality assessment focused on the mediation hypotheses of the studies that were relevant to this review. A score for each study was computed by asing a value of 0 no or 1 yes to each of 12 questions listed in Table 1. If a study did not explicitly report information related to an item, it was ased 0 for that item. A total score was calculated by summing the scores of the 12 items for each of the studies.
Studies which scored 0—4 were classified as of poor quality, 5—8 were classified as of fair quality, and 9—12 were classified as of good quality. Quality assessment ratings were done by two raters. The searches identified studies, of which were duplicates. Of the remaining studies, were excluded based on the title or the abstract when it was evident that they either did not meet the inclusion criteria or at least one of the exclusion criteria.
Information about the relevant inclusion and exclusion criteria for the studies excluded in the first stage of the screening was not recorded. The of full-text articles assessed for eligibility was Discrepancies were resolved through discussion relevant to the inclusion and exclusion criteria. The final of studies meeting the inclusion and exclusion criteria and therefore included in the review was Figure 1 illustrates the flow of studies.
The of the quality assessment are shown in Table 2. Most studies were rated as having fair methodological quality. Five studies were rated as being of good quality and seven studies rated as being of poor methodological quality. Study characteristics are summarized in Table 3. Of the 40 studies, 28 had a cross-sectional de and 12 had a longitudinal de. The longitudinal studies either measured sexual orientation and mediator at time 1 and depression at time 2 or sexual orientation at time 1 and mediator and depression at time 2, with none of the studies collecting measures of the three variables at three different time points.
Most of the studies took place in the U. One study took place in both the U. Information about the sample is provided in Table 3 with additional information in the Appendix. Although a few studies did not provide a specific age range, of the 40 studies, 13 seemed to have had predominantly early to late adolescent samples 11 to 19 years14 had young adult or university student samples 17 to 29 years11 used exclusively adult samples 18 years and overwhile one study used both a young adult and an older adult cohort and another study used a young adult and mid-adult sample.
Some of the studies used subsamples of the population, such as sexual assault survivors, victims of intimate partner violence, or exclusively Black American participants.
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Some studies used other samples that may limit the generalizability of their findings, including samples of twin siblings, children of registered nurses, medical students, and undergraduate psychology students. Several studies used the same or overlapping samples, and it is therefore not possible to report an overall of participants investigated across the included papers. Similarly, other studies explored general psychosocial processes that have been established as risk factors in the general population and sought to explore their specific associations with sexual minority identity.
Sexuality was assessed in a of ways. Most studies used sexual identity or sexual orientation questions and response options.
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Seven studies asked about sexual or romantic attraction, and one asked about preference for romantic partners. One study asked about the gender of individuals with whom participants were in relationship and two studies inquired about the of the same-sex and the opposite-sex people respondents had sexual intercourse with. A study asked both about identity and behavior, while another study averaged the responses from three items asking about fantasies, attraction, and behavior.
One of the studies asked about identity but encompassed behavioral indicators in the response options e. Two studies did not report how they assessed sexuality. Sexuality-related response options available also varied greatly with studies using from three to seven of sexuality, and one study using a fill-in-blank response.
Most studies categorized sexual minority and heterosexual individuals into two groups, with some citing power concerns as the reason they did not distinguish among more sexual minority groups. Studies often included response such as mostly homosexual, mostly heterosexual, other, and questioning, but they varied on how they later treated these responses. For example, while some of the studies included participants who selected mostly heterosexual in the sexual minority group, two studies categorized them as a distinct group, another study placed them in the heterosexual group despite having a bisexual category in their analysis, and another study excluded them from the analysis.