Minority stress

Minority stress describes chronically high levels of stress faced by members of stigmatized minority groups.^[1] It may be caused by a number of factors, including poor social support and low socioeconomic status, but the most well understood causes of minority stress are interpersonal prejudice and discrimination.^[2][3] For example, numerous scientific studies have shown that minority individuals experience a high degree of prejudice, which causes stress responses (e.g., high blood pressure, anxiety) that accrue over time, eventually leading to poor mental and physical health.^[1][3][4][5] Minority stress theory summarizes these scientific studies to explain how difficult social situations lead to chronic stress and poor health among minority individuals. It is an important concept for psychologists and public health officials who seek to understand and reduce minority health disparities.

Theoretical Development

Emergence

Over the past three decades, psychological and epidemiological researchers noticed that minority individuals suffer from mental and physical health disparities compared to peers in majority groups. This research has focused primarily on racial and sexual minorities. For example, African Americans have been found to suffer elevated rates of hypertension compared to Whites.^[6] Lesbian, gay, and bisexual (LGB) individuals face higher rates of suicide, substance abuse, and cancer relative to heterosexuals.^[7][8][9] These health disparities impact day-to-day well-being as well as life expectancy, leading social scientists to ask: How can we reduce minority health disparities? In order to answer this question, it was first important to discover the underlying causes of the disparities.

Social Selection Hypothesis

The social selection hypothesis holds that there is something inherent to being in a minority group (e.g., genetics) that makes individuals susceptible to health problems.^[10][11] In general, this view has not been supported by empirical research. If minority individuals were indeed genetically predisposed to poor health outcomes, the vast majority of them should face health disparities. However, large-scale empirical studies have shown that not all LGB individuals suffer psychopathology and that many African Americans do not have heart disease.^[6][12] Instead, research suggests that environmental factors explain minority health disparities better than genetic or biological factors.^[13][14] While the social selection hypothesis is still debated, it is clear that genetic and dispositional factors do not fully explain the health disparities observed in minority groups.

Social Causation Hypothesis

A second hypothesis regarding minority health disparities suggests that minority group members face difficult social situations that lead to poor health. Social psychologists have long recognized that minority individuals have different social experiences compared to majority individuals, including prejudice and discrimination, unequal socioeconomic status, and limited access to health care.^[11][15][16] According to the social causation hypothesis, it is these difficult social experiences that cause health differences between minority and majority individuals, rather than genetic or biological differences between group members.

Overview

Minority stress theory extends the social causation hypothesis by suggesting that difficult social situations do not lead directly to poor health for minority individuals, but that difficult social situations cause stress for minority individuals, which accrues over time, leading to long-term health deficits.^[1][17] Furthermore, minority stress theory distinguishes between distal and proximal stress processes.^[4] Distal stress processes are external to the minority individual, including experiences with rejection, prejudice, and discrimination. Proximal stress processes are internal, and are often the byproduct of distal stressors; they include concealment of one’s minority identity, constant vigilance and expectations of prejudice, and negative feelings about one’s own minority group. Together, distal and proximal stressors accrue over time, leading to chronically elevated levels of stress that cause poor health outcomes. Thus, minority stress theory has three primary tenets:

1. Minority status leads to increased exposure to distal stressors.
2. Minority status leads to increased experience with proximal stressors, due to distal stressors.
3. Minority individuals suffer adverse health outcomes, which are caused by exposure to proximal and distal stressors.

Since its conceptualization, these three tenets of the minority stress hypothesis have been tested in over 134 empirical studies, most of which examined racial and sexual minority populations.^[3] Generally, these studies have confirmed that difficult social situations are associated with stress among minority individuals, and that minority stress is associated with poor health outcomes.

Key Concepts

Minority status and distal stressors

The first tenet of minority stress theory holds that being in a minority group is associated with increased exposure to distal stressors, such as prejudice and discrimination. Indeed, despite significant improvement over the past several decades, numerous studies have confirmed that minority individuals continue to face distal stressors.^[18] For example, in large-scale national surveys, LGB individuals report high rates of prejudice and discrimination across the lifespan.^[19][20][21] One survey found that one-fourth of LGB adults have experienced victimization related to their sexual orientation, and another found that as many as 90% of LGB youth report hearing prejudiced remarks at school.^[22][23] Similarly, as many as 60% of African Americans report experiencing distal stressors throughout their lives, ranging from social rejection at school to housing discrimination and employment discrimination.^{[24][25][26][27]} In one study, 37 African American respondents recalled over 100 discrete experiences with racist prejudice in a two-year period.^[28] In another study, 98% of Black participants reported experiencing at least one incidence of prejudice in the past year.^[29]

Rates of exposure to distal stressors are much higher among racial and sexual minorities than among majority individuals. For example, LGB adults are twice as likely to recall experiencing prejudice throughout their lives compared to heterosexuals, and LGB youth report significantly higher rates of prejudice and discrimination compared to their heterosexual peers.^[23][30][31] In one carefully controlled study, researchers compared rates of victimization among LGB youth and their heterosexual siblings, and they found significantly higher rates of abuse among the LGB individuals.^[32] Comparing rates of perceived discrimination among African American and White individuals, researchers found significant differences in reports of discrimination between the groups: 30.9% of Whites reported experiencing “major discrimination” throughout their lives, compared to 48.9% of African Americans and 50.2% of other racial minorities. Similarly, 3.4% of Whites reported experiencing discrimination “often” in their lives, compared to 24.8% of African Americans and 17.4% of other racial minorities.^[33] Thus, research suggests that minority individuals face more frequent exposure to distal stressors compared to their majority group counterparts.^[2][34][35]

Minority status and proximal stressors

Proximal stressors are internal processes that are presumed to occur following exposure to prejudice and discrimination.^[4] Examples of proximal stressors include fear of rejection, rumination (psychology) on previous experiences with prejudice, and distaste for one’s own minority group following a prejudice event.^[1][17] Most research on this topic focuses on either sexual minorities or African Americans, and it is unclear whether the proximal stress processes are conceptually similar between groups. Thus, it is necessary to review stress processes separately for sexual minority and African American populations.

Proximal stressors among sexual minorities

A growing body of research indicates that exposure to distal stressors leads to proximal stress in LGB populations. For example, LGB youth and adults who have experienced prejudice about their sexual orientation and who fear future experiences with prejudice tend to conceal their sexual identity from others.^[36][37][38] Concealing such personal information causes significant psychological distress, including intrusive thoughts about the secret, shame and guilt, anxiety, and isolation from other members of one's minority group.^{[37][39][40][41]} Internalized homophobia is another proximal stressor prevalent among LGB individuals. It refers to the internalization of negative social views about homosexuality, which leads to self-hatred and poor self-regard.^[42][43] Internalized homophobia is thought to be caused by exposure to distal stressors, insofar as it only occurs because LGB individuals are exposed to negative societal attitudes toward homosexuality.^[44] Thus, previous experiences with prejudice are associated with proximal stress among LGB individuals, including concealment of their sexual identity and internalized homophobia.

Proximal stressors among African Americans

Among African Americans, proximal stressors were described by early social psychological theorists. For example, Erving Goffman observed that stigmatized individuals approach social interactions with a high degree of anxiety, because they have been discriminated against in the past.^[45] Similarly, Gordon Allport asserted that African American individuals display vigilance after exposure to prejudice, actively scanning the social environment for potential threats.^[15] Such vigilance is presumed to be taxing, sapping emotional and cognitive energy from minority individuals and thus becoming stressful. Proximal stressors also have been demonstrated among African Americans in terms of stereotype threat.^[46][47] Researchers have shown that, when African Americans are reminded of their racial minority status in an academic context, they face a high degree of anxiety, causing their intellectual performance to suffer.^[47]

General proximal stressors among minority individuals

The proximal stress processes reviewed above are unique to specific minority groups; for example, internalized homophobia is a proximal stressor unique to LGB individuals who experience prejudice about their sexual orientation, and vigilance against racism is unique to racial minorities who fear future experiences with race-based discrimination. It is also possible that more general psychological processes act as proximal stressors for minority individuals.^[48] For example, exposure to prejudice may lead to rumination, which is a common psychological phenomenon characterized by a maladaptive, repetitive, and obsessive focus on a past event that leads to depressive and anxious symptoms.^[49][50] Several recent studies have shown that distal stressors cause such general proximal stress processes in minority individuals. In one longitudinal study, researchers found that gay men who experienced distal stressors related to their sexual orientation had an increased tendency to ruminate, which was associated with increased depressive and anxious symptoms compared to gay men who did not experience distal stressors.^[51] In another study, LGB youth reported higher rates of rumination on days when they experienced distal stressors; rumination in turn was associated with psychological distress.^[52] Because minority individuals have been shown to face high rates of distal stressors compared to majority individuals, and because experiencing distal stressors appears to cause general psychological stress processes such as rumination and anxiety, these findings highlight the more general ways in which prejudice and discrimination may affect internal stress processes among minority individuals.

Minority stress and health outcomes

The bulk of minority stress research has examined the third tenet of the theory – namely, that distal and proximal stressors lead to adverse health outcomes for minority individuals. These health outcomes include both mental and physical disparities, which differ across minority groups. Again, studies have yet to systematically determine whether minority stress is associated with different health outcomes among different minority groups. Thus, it is necessary to review associations between minority stress and health separately for LGB and African American groups, as social scientists do not know whether stress causes similar or different outcomes across groups.

Minority stress and health outcomes among sexual minorities

LGB individuals face higher rates of psychopathology when compared to their heterosexual peers. For example, population-based studies have shown that LGB people are at risk for increased rates of substance abuse, suicide attempts, depression, and anxiety across the lifespan.^{[7][8][53][54][55]} In fact, one meta analysis found that LGB individuals are 2.5 times more likely to have a lifetime history of mental disorder compared to heterosexuals, and 2 times more likely to have a current mental disorder.^[1] In terms of physical health, LGB individuals are at heightened risks for some types of cancer and immune dysfunction.^[9] Several studies have linked these negative health outcomes to distal stressors. For example, in a national survey, LGB adults displayed higher rates of psychiatric morbidity and also reported significantly higher rates of prejudice and discrimination compared to their heterosexual peers; prejudice and discrimination fully explained the link between sexual orientation and psychiatric symptoms for LGB respondents.^[30] In another study, level of peer victimization partially explained associations between sexual orientation and suicide risk.^[56] Perceived level of discrimination has also been shown to predict anxiety and substance abuse disorders among LGB individuals.^[22][57] Proximal stressors have also been linked to negative health outcomes for sexual minorities. For example, internalized homophobia has been linked to self-harm and eating disorders as well as sexual risk-taking behavior.^[43][58] Internalized homophobia has also been linked to general psychological distress, which predicts long-term mental health outcomes.^[22] Thus, both distal and proximal social stressors are associated with negative mental health outcomes among sexual minorities. Scientists have yet to determine clear associations between minority stress and physical health in LGB communities.

Minority stress and health outcomes among African Americans

Distal stressors have also been linked to negative health outcomes among African Americans. For example, one study showed that perceived racism caused irregular blood pressure throughout the day, which is associated with long-term cardiovascular disease.^[59][60] Exposure to racial prejudice has also been linked to negative health behaviors, such as smoking and substance abuse, which are associated with poor cardiovascular health.^[29][61] Indeed, a recent meta analysis of 36 empirical studies revealed consistent effects of prejudice and discrimination on physical health (e.g., cardiovascular disease, hypertension, diabetes) among racial minorities.^[3] That same review revealed that racial prejudice and discrimination were related to depressive symptoms and psychiatric distress in 110 empirical studies.^[3] Thus, minority individuals are exposed to social stressors, which are in turn related to poor mental and physical health outcomes. These findings generally corroborate the minority stress theory of health disparities among racial minorities.

Criticism and Limitations

Despite multiple studies confirming minority stress theory, there are several methodological limitations and ongoing debates on this topic.

First, minority stress theory has been criticized as focusing too narrowly on the negative experiences of minority individuals and ignoring the unique coping strategies and social support structures available to them.^[62][63] While theoretical writings about minority stress do note the importance of coping mechanisms for minority individuals,^[1] it seems that researchers who use minority stress theory tend to focus on negative health outcomes rather than on coping mechanisms. It will be important for future studies to consider both positive and negative aspects of minority group membership, examining whether and why one of those aspects outweighs the other in determining minority health outcomes.

Also, few studies have been able to test minority stress theory in full. Most studies have examined one of the three links described above, demonstrating that minority individuals face heightened rates of prejudice, that minority individuals face health disparities, or that prejudice is related to health disparities. Together, findings from these three areas corroborate minority stress theory, but a stronger test of the theory would examine all three parts in the same study. While there have been a few such studies,^[30] further replication is necessary to support the minority stress theory.

Most studies of minority stress are correlational.^[3] While these studies have the advantage of using large, national datasets to establish links between minority status, stressors, and health, they cannot demonstrate causality. That is, most of the existing research cannot prove that prejudice causes stress, which causes poor health outcomes among minority individuals, because correlation does not imply causation. One way to remedy this limitation is to employ experimental and longitudinal research designs to test the impact of social stressors on health. Indeed, several recent studies have begun to use these more stringent tests of minority stress theory.^[64][65] Additional studies are needed to confidently state that prejudice causes poor health for minority individuals.

Finally, it is unclear whether different minority groups face different types of minority stress and different health outcomes following prejudice. Minority stress theory was originally developed to explain associations between social situations, stress, and health for LGB individuals.^[1] Still, researchers have used the same general theory to examine stress processes among African Americans as well, and findings have largely corroborated the minority stress model. Thus, it is possible that the minority stress model applies broadly to members of diverse minority groups. However, studies have yet to directly compare experiences, stress responses, and health outcomes among individuals from diverse minority groups; instead, most studies of minority stress focus exclusively on either LGB or African American populations.^[3] Systematic comparisons are necessary to understand whether the minority stress theory applies to all minority individuals broadly, or whether different models are required for different groups.

Practical Applications

Minority stress research has demonstrated that several specific processes are associated with minority health disparities. For example, existing studies highlight the differences between distal and proximal stressors, drawing attention both to socio-cultural factors (e.g., high rates of prejudice against minority individuals) as well as individual processes (e.g., rumination) that affect minority well-being. By separating the socio-cultural and individual aspects of minority stress, the theory suggests that practical interventions must occur at both the individual and social levels.^[17]

Social Applications

On the societal level, minority stress research shows that prejudice and discrimination are common for minority individuals, and that they have damaging effects on individual well-being. This information has been used by law enforcement, policymakers, and social organizations to target and minimize the occurrence of distal stressors and, thus, to improve minority health on a large scale.^[17] For example, evidence that prejudice is associated with minority stress has been used in several amicus curiae briefs to settle important court cases regarding prejudice and discrimination against minority groups.^[66][67] Evidence that prejudice and discrimination cause stress that harms well-being for LGB individuals has also been invoked in the congressional debate about anti-harassment protection for LGB youth at the federal level.^[17] In the future, the minority stress concept can be used to advocate for federal funding for nationwide campaigns and interventions that aim to reduce intergroup prejudice. If successful, these programs may reduce the rate of distal stressors, significantly improving the mental and physical health of minority individuals.

Individual Applications

On the individual level, minority stress research has uncovered differences in how some minorities react to prejudice. For example, studies have shown that some minority individuals ruminate on experiences with prejudice, which is linked to anxiety and depression.^[51] This information can be used to develop effective therapies for use with minority individuals, which teach them not to ruminate on experiences with prejudice in order to improve well-being. Similarly, minority stress research has revealed that internalized stigma (i.e., distaste for one's own minority group) is associated with negative health outcomes. From these findings, clinicians have developed some interventions to decrease internalized stigma and improve well-being for minority individuals.^[17][68] When paired with structural interventions, these clinical applications of minority stress theory may help improve the pervasive health disparities observed in minority communities.^[17]

See also

• Center for Minority Health
• Community Health
• Ego-dystonic sexual orientation
• Health equity
• Homosexuality and psychology
• Hopkins Center for Health Disparities Solutions
• Inequality in disease
• Perry v. Schwarzenegger
• Population health
• Race and health
• Social determinants of health
• Social epidemiology
• Suicide among LGBT youth
• Stress (physiology)
• Stress (psychological)

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