13
Black LGB Health and Well-Being
Juan Battle and Martha Crum
1 Introduction
Two landmark publications during the mid-1970s, Thomas McKeown’s The Modern Rise of Population (1976) and John Cassel’s “The contribution of the social environment to host resistance” (1976), helped rekindle interest in how social factors influence health. Realization that communities and social structures affect the health of populations and affect them differentially was not new. Associations between poverty and ill health are centuries old and were key to the activist-oriented U.S. public health movement at the turn of the twen- tieth century. However, the ascendancy of the germ theory during the last decades of the nineteenth century dampened interest in poverty and other socially constructed conditions as significant pathways to ill health. However “wrong” the theory of miasma—that disease was caused by the fetid air produced by the overcrowded and unsanitary conditions of the urban poor—the theory at least focused public health initiatives on improving the lives of economically marginalized people.
With its decline, health initiatives moved from living conditions to the laboratory.
As chronic disease began to surpass infectious disease as a source of morbidity and mortality in industrialized countries, epidemiologists and academic medicine more broadly elevated the role of the “host” in the “host–agent–environment” paradigm of disease, with an emphasis on individual-level behavioral risk factors. Yet as critics have pointed out, this emphasis was completely decontextualized from how both host and environment are shaped by social and material factors (Pearce, 1996; Susser & Susser, 1996; Kreiger, 2000b). Although a recent resurgent interest in social causation of disease is attempting to break the intellectual lock that the “risk factor” paradigm has had on the epi- demiologic scholarship (and, importantly, on interventions), the field is still dominated by more individualistic approaches to understand- ing health and disease.
Interest in social causes of disease has been especially important to the Black1population and more recently to the lesbian, gay, and bisex- ual populations. Compared to Whites, Black people suffer from excess morbidity and mortality across a broad spectrum of diseases, includ- ing diabetes, hypertension and other cardiovascular disease, human immunodeficiency virus infection/acquired immunodeficiency disease (HIV/AIDS), renal disease, and many common cancers (Kreiger et al., 1993; Kaufman et al., 1997; Schultz et al., 2000). Research on health dis- parities affecting lesbian, gay, and bisexual (LGB) people has focused primarily on mental health issues and HIV/AIDS, with more recent scholarship attempting to understand health disparities more broadly.
Research on health disparities affecting the intersection of these two stigmatized populations—Black LGBs—is almost nonexistent.
Social epidemiologists have developed comprehensive models to explain how social marginalization compromises the physical or mental health of marginalized people (Kreiger, 2001; Link & Phelan, 2001). These models are similar in scope and dimension to how other scholars have conceptualized the effects of racism on the health of Black Americans (Clark et al., 1999; Jones, 2000). Empirical work informed by these models is in its infancy. Studies on health effects of perceived discrimination, for example, have tended to focus on mental health rather than physical health (Kreiger, 2000a). There is little work on the health effects of structural inequality. Studies on social causation compete for institutional support with the better-funded individual- behavior paradigm, where diseases such as HIV/AIDS, diabetes, and cardiovascular health are perceived, in varying degree, to be a function of individual life-style choices, leading to interventions focused on individual behavioral change. As a relatively small community, one might be tempted to dismiss Black LGBs as a serious object of academic inquiry. From a standpoint theory point of view (Collins, 2003) however, this population is of particular interest because it stands at the intersection of multiple stigmatized populations. To understand the health consequences of marginalization is to understand just how high are the individual and social costs of discrimination in its multifarious forms. To understand the pathways through which marginalization expresses itself physiologically and psychologically is to understand potential points of intervention. To understand if and how Black LGB identity can mediate the negative health effects of marginalization and empower Black LGBs in the struggle against oppression is to under- stand how to unleash a powerful resource not only for Black LGBs but potentially for LGBs, for Blacks, and for other marginalized groups. It
1Throughout this text, we will use the term Black to refer to people of African Diaspora, and to such populations that reside within the United States. To some, African Americans are a subgroup within the larger Black community.
Because our discussion purposely includes those who may be first-generation immigrants or who, for whatever reason, do not identify as African American, we employ the term “Black.” Furthermore, we capitalize it to distinguish the racial category and related identity from the color. Similarly, we capitalize the word White when referring to race.
is this latter point that underscores the standpoint theorists’ position that the most marginalized may well have the most to teach us.
This chapter reviews some of the major works on health and mar- ginalization and on identity and health, both theoretical and empirical.
After assessing the significance of the literatures for the health and well-being of Black LGBs, we return to the issue of how the experiences of Black LGBs can inform larger struggles for freedom.
2 Pathways to Ill Health and Reduced Life Chances
There is a long tradition of scholarship on stigma and its adverse con- sequences for the stigmatized (Allport, 1954/1979; Goffman, 1963;
Crocker & Major, 1989; Crocker et al., 1998). More recently, scholars have begun to hypothesize and test a variety of pathways through which stigma, and its consequent marginalization, leads to poorer health and well-being. The most comprehensive models (Clark et al., 1999; Jones, 2000; Kreiger, 2001; Link & Phelan, 2001) tend to include three major pathways: disadvantageous social structures, perceived discrimination, and internalization of stigma.
Structural pathways include what is known in the literature on race inequality as institutionalized racism. This is conceptualized as com- promised access to material well-being and power as a function of race (Jones, 2000). Thinking more broadly about stigmatized groups, we might think of these structural factors as the unique contribution to reduced chances for health, well-being and longevity that accrues from being subject to a particular “ism,” in the hypothetical case where the person had no idea he or she was a member of the group subject to the
“ism.” In other words, the effects of this type of “ism” do not have to be seen or perceived to be felt. For example, both Black men and gay men, as populations, are disadvantaged in the labor market, and this disadvantage goes beyond differential educational achievement (itself a marker of institutionalized racism) (Badgett, 1995; Darity et al., 1996; Darity, 1998). Segregation has also been associated with higher mortality (Collins & Williams, 1999). Structural determinants affect people’s material environments, regardless of how any specific event or trend is “interpreted.” The environment then becomes the pathway—through differential exposure to pollution, crime, neighbor- hood services, food availability, good schools, information, and the like—to the health disparity.
The link between health and perceived discrimination, on the other hand, is largely conceptualized in terms of social psychological processes in which the perceived discrimination is experienced as a stigma-related stressor. An important part of this conceptualization is the coping resources or styles a given individual uses to mediate stigma-related stressors. Too exclusive a reliance on this model, however, has been criticized as overly individualistic (Kreiger, 2001;
Link & Phelan, 2001). Kreiger, for example, has argued that “the study of why some people swim well and others drown when tossed into a river displaces the study of who is tossing whom into the current—and what else might be in the water” (Kreiger, 2001, p. 670).
The psychosocial paradigm of perceived discrimination initially focused on mental health outcomes and disparities. More recently, the stress paradigm from the medical literature has been incorporated into the discrimination effects framework for a richer, more multidimen- sional understanding of the effects of perceived discrimination. In the medical literature, chronic stress is hypothesized to have a direct path- ogenic pathway to physical disease (Sapolsky, 1994; McEwen, 1998;
Solarz, 1999) and thus to physical health disparities. Whether the path- ways from perceived discrimination to ill health are physiologic, psy- chological, or both, a key component is that the discrimination is personally mediated. In other words, this type of “ism” follows from someone interpreting or experiencing a particular act, behavior, or event as discriminatory.
Finally, internalized “isms” have been posited as having ill effects on the health and well-being of marginalized people through lowered self- esteem and consequent mental health morbidity. This literature traces its roots to the social interaction theory, particularly the “looking glass theory,” where the self concept is at least in part constructed from a reflection of how others see you (Mead, 1934; Cooley, 1956). As we shall see in looking specifically at Black and LGB populations, this theory has worked in unexpected and differential ways for these two popu- lations, perhaps as a function of conceptual subtleties in different types of stigma first identified by Goffman (1963).
The distinctions between structural and psychosocial pathways are not always clear-cut, particularly as they interact across time and the life course. Although we highlight research involving structural determinants, perceived discrimination, and internalization of stigma, it is important to understand that marginalization does not “travel” in single pathways, nor does it result in single “outcomes.” Link and Phelan (2001) noted that most research on stigma proceeds by looking at one stigma and one outcome at a time. They argued, however, that stigma affects many life chances and that any particular outcome is affected by multiple stigmatizing circumstances. Therefore, they caution that stigma processes have a “dramatic and probably a highly underestimated impact” on life chances (p. 381), a caution that is likely to apply to Black LGBs.
2.1 Structural Determinants of Health
Social and economic determinants provide structural pathways for the systematic shaping of life chances. Skyrocketing asthma rates in Harlem, New York, for example, are not the direct result of individu- als making decisions based on racial or ethnic stereotypes. Rather, they are the result of, among other things, poverty and segregation. The maze of pathways that leads to elevated asthma rates among Harlem youth likely includes substandard housing (which tends to have high rodent and roach infestation and therefore a high density of rodent and roach feces—triggers for asthma attacks); city planning practices that have resulted in a disproportionate number of the city’s bus terminals being housed in the immediate vicinity, creating excess smog and air pollution (also a trigger for asthmatics); high crime rates, which keep
the children of concerned parents and guardians off the streets and
“safely” cloistered in their toxic home environments; and lack of employment opportunity, which keep large portions of the population medically uninsured and therefore less likely to have access to the pre- ventive and educational resources so crucial to managing chronic health conditions (Epstein, 2003).
Understanding disparities in socioeconomic status and how those disparities manifest in the material and social environment is a cruc- ial context for understanding disparities in health. Social and econo- mic determinants provide a key pathway between racism and Black Americans’ disadvantaged health outcomes. To the degree these Black/White disparities exist in the larger population, it stands to reason they also exist in the LGB community.
The Council on Economic Advisors for the President’s Initiative on Race (1998) has documented just how disadvantaged Black men are vis-à-vis the labor market. Black men have experienced unemployment rates that are roughly twice as high as those for White men over the past 50 years. Among the college-educated, Black men are four times more likely to experience unemployment compared to Whites, and the Black male labor force participation rate has declined at a faster rate than that of White men. Furthermore, the Black/White household income gap has remained remarkably stable since the 1950s, and Black men working full time still earn only 74% of the median full-time wages of White men (Sigelman & Welch, 1991; Hacker, 1993; Business Week, 2003). Additionally, analysis of the Black/White differential in socioeconomic status has shown strong and persistent effects for both social capital (lower attainment levels of income-related characteristics such as education, occupational status, metropolitan location, and English fluency, among others) and for labor market discrimination (lower returns for the same level of attainment of income-related char- acteristics) (Darity, 1998).
The impact of the socioeconomic status disadvantage on the health of Black Americans is likely to be underestimated in the health dis- parities literature. Some social scientists have argued that much of the
“cause” of health disparities in the literature that has traditionally been attributed to race is in fact attributable to differential socioeconomic status (Kaufman et al., 1997; Kreiger, 2000a). This is because conven- tional “controls” for socioeconomic status include crude categoriza- tions, such as above or below the poverty line, and do not take into consideration that Blacks are considerably poorer than Whites within the ordinal categories typically associated with socioeconomic status analyses. Thus many analyses are flawed by residual confounding, erroneously pointing to “racial differences” and leading to a search for genetic causal factors to explain disparities. Other scholars have shown that there are substantial differences in wealth between Blacks and Whites that are not captured by using income alone to define socio- economic status (Oliver & Shapiro, 1997). Conley (1999) showed that controlling for wealth attenuates (sometimes to zero) or actually reverses the direction of race disparities in multiple domains of social life, such as educational achievement, out-of-wedlock childbirths, labor
market participation, and employment. However, his work does not explore race-related disparities in health.
It is less clear what role social and economic determinants play in the health of the LGB population. Until recently, reliable population level data on LGBs were nearly impossible to get, making socioeconomic comparisons difficult. In response to the HIV/AIDS epidemic, ques- tions on sexual behavior and orientation were added to some large-scale national studies, but they were more often added for men and often resulted in small samples of homosexually active respondents, thus pro- viding little statistical power to detect effects (Cochran & Mays, 2000).
Issues related to definition hinder comparisons further. Some studies use a behavioral history of same-sex partners to identify gay/bisexual populations, whereas others use self-reported identity measures (e.g., gay, lesbian, bisexual, queer). Although most men who self-identify as gay or bisexual are “captured” by screening techniques based on sexual behavior history, the reverse is not true. That is, slightly less than half of the men who report at least some adult same-sex behavior self-identify as gay, homosexual, or bisexual (Cochran & Mays, 2000). Nonetheless, several studies, both population-based and those with convenience samples, show a consistent, if directional tendency for higher education and lower income among gay-identified men compared to the national population (Herek & Glunt, 1995; Cochran & Mays, 2000; Gilman et al., 2001; Cochran et al., 2003).
The visibility of openly gay men in Hollywood and more broadly in the arts may have contributed to a popular perception of the gay com- munity as affluent. Badgett (2000), in her analysis of marketing and promotional efforts that characterized the gay community as an untapped affluent market, has shown that the data profiles packaged by Simmons Market Research Bureau and other marketing research companies were based on convenience samples from such outlets as gay-targeted media, gay political organizations, mail order companies, and credit card companies. By contrast, Badgett’s (1995) analysis of a random sample of behaviorally LGB men and women from the 1989–1991 General Social Survey conducted by the University of Chicago’s National Opinion Research Center showed that LGBs who worked full time had comparable education but lower income than their heterosexual counterparts. More importantly, she found that gay/bisexual status was a significant and negative determinant of income among the men, such that gay and bisexual men who worked earned from 11% to 27% less than their heterosexual counterparts with the same experience, education, occupation, marital status, and regional residence. Although Badgett did not find a consistently statis- tically significant effect for lesbian/bisexual status among the women, we might speculate, given the 65% gender wage gap, that coupled lesbian households would have lower income than married or coupled heterosexual households. Because these effects were based on behav- ioral definitions and not workplace disclosure or identity, Badgett argues that they underestimate labor discrimination effects.
Reliable data on Black LGB populations are even more rare. Battle et al. (2002) conducted one of the largest, though venue-based, studies
of Black LGBs in the country. Interviewing more than 2000 Black LGBs in nine cities at LGB-related events, Battle and his colleagues profiled a highly educated but relatively low-income Black LGB population.
Compared to the national Black population, for example, Black LGBs in this study were three times more likely to have a college degree.
Although this higher educational achievement did seem to result in lower poverty rates, it did not translate into higher income. That is, compared to the national Black population, Black LGBs were much less likely to be earning less than $15,000 annually; yet only 10% earned more than $75,000 annually, compared to 13% of the Black population at large. In the case of Battle et al.’s work, the explanation for higher education and lower income may be a result of sampling a younger population in urban areas.
Black LGBs are likely to be affected by socioeconomic determinants affecting both Black and LGB communities, but we do not understand enough about the socioeconomic determinants of health in the LGB community to even speculate on the implications of the structural
“intersection” of race and sexual orientation. Furthermore, work on structural pathways has tended to focus almost exclusively on socio- economic factors and on differential access to material conditions. As Jones (2000) has conceptualized institutionalized racism, health dis- parities can also flow from differential access to power, including a
“voice” in voting, governmental representation, the media, and indeed one’s own history. How the lack of visibility and representation of Black LGBs in the public sphere (e.g., government and mainstream media) might affect the health and well-being of Black LGBs is com- pletely uncharted territory.
2.2 Psychosocial Pathways
The other broad category of pathways leading from stigma to ill health is psychosocial processes involving stigma-related stressors and individual-level responses to them. These psychosocial processes—
including both perceived discrimination and internalization of stigma—
are generally seen as distinct from the more structural pathways just discussed. In the psychosocial stress paradigm, coping processes, such as social support and social identity, are often theorized as “buffers” that intervene between stigma-related stressors and their negative health effects. Crocker and Major (1989) and Miller and Kaiser (2001) have pro- vided important elaborations of coping mechanisms. Miller and Kaiser, in particular, provide a schematic of possible voluntary and involuntary coping responses to stigma-related stressors, differentiating between health-inducing and health-reducing coping strategies.
This “social stress” framework has tended to generate research emphasizing psychiatric morbidity as an outcome. For example, the literature clearly indicates that stigma-related stressors, including perceived unfair treatment or discrimination, are risk factors for psychiatric morbidity among LGBs (Meyer, 1995; Mays & Cochran, 2001). Meyer (1995) found that gay-related stressors such as inter- nalized homophobia, stigma, and gay-related discrimination were
associated with a two- to threefold increase in risk for high levels of psychological distress among gay men. Mays and Cochran (2001) found a positive association between perceived discrimination and psychiatric morbidity and a negative association between perceived discrimination and quality of life in the population at large, with a homosexual or bisexual orientation more than doubling the risk of per- ceiving day-to-day discriminatory behaviors, such as perceiving that others think you are inferior, being treated with less respect or cour- tesy, or being insulted, threatened, or harassed. These stigma-related stressors are thought to help explain the higher prevalence of psychi- atric morbidity in the LGB population, as sexual orientation continues to predict morbidity even after controlling for other demographic char- acteristics (Cochran & Mays, 2000; Cochran, 2001; Gilman et al., 2001;
Cochran et al., 2003).2
Meyer (2003) conducted a meta-analysis to document the excess prevalence of psychiatric morbidity among LGBs and elaborated a minority stress model to help explain it. The model describes how pre- judice and discrimination create a hostile social environment, leading to stigma-related stressors such as experience of prejudice events, inter- nalized homophobia, hiding and concealing, and expectations of rejec- tion, which then manifest in reduced mental health. His conceptual framework also includes minority identity characteristics as an inter- vening variable in the minority stressors/mental health outcomes pathway.
The picture is more complicated with respect to stigma-related stres- sors and psychiatric morbidity in the Black population. Some studies have found a link between perceived discrimination or a generalized perception of racism and psychological distress. Jackson et al. (1996), for example, found an association between a negative perception of Whites’ intentions and psychological distress among a national sample of Black Americans. Landrine and Klonoff (1996) found associations between perceived racism and psychiatric distress among Black uni- versity-based populations. Williams et al. (1997) found a relation between discrimination and psychological distress among Black adults in Detroit, and Sellers et al. (2003) found direct and indirect links between perceived discrimination and psychological distress in a lon- gitudinal study of Black “at-risk” youth in Michigan. Yet, by and large, population level studies have not shown excess risk of psychiatric dis- orders or psychological distress among Black Americans once other factors, including socioeconomic status, are controlled for (Vega &
Rumbaut, 1991; CDC, 2004).
Why have these links between perceived discrimination and psy- chological distress not manifested in population-level disparities in psychiatric morbidity? One possible explanation, discussed more fully
2Studies consistently show higher risk for psychiatric morbidity among LGBs, although specific patterns vary by sex and there are some inconsistencies in terms of specific disorders. For a review of this research, see Susan Cochran’s address at the 2001 APA annual convention, published in the November 2001 issue of American Psychologist.
in the section on identity, is that identity-related coping resources may moderate the effects of stigma-related stressors. Although the mecha- nisms were relatively unexplored, Schultz and colleagues (2000) found that being Black was actually a protective factor for psychological dis- tress among Detroit residents living in high poverty areas once such factors as everyday and acute unfair treatment, acute life events, and role-related and financial stress were accounted for. Among residents of less impoverished communities, race was not a significant predictor of psychological distress.
Another possible explanation lies in the relative size of the “within group” segments driving the group rates of psychiatric morbidity. For example, Williams (2003) argues that middle class Black men have more exposure to individually directed discrimination than lower class Black men. He cites sources of evidence that show positive associations between perceived discrimination and education (Forman et al., 1997), between stress and socioeconomic status (James et al., 1992; Strogatz et al., 1997), and between suicide and socioeconomic status (Lester, 1998;
Stack, 1998; Fernquist, 2001) among Black men. Some of these associa- tions are the opposite of what is found among Black women or among Whites. If the stress–mental health relation worked similarly for both Blacks and Whites and was most evident among lower income house- holds, we would definitely expect to see a higher level of psychiatric morbidity in the Black population to the extent that stress is causally related.3 However, the different patterns of stress among Blacks (particularly males) combined with the different distribution of socioe- conomic status characteristics could effectively “wash out” any differ- ential effects. Another theory to consider, though not yet published, has been put forth by James Jackson at the University of Michigan. In short, he argues that some Black people, compared to their White counter- parts, have purchased good mental health with bad physical health. In other words, given all of the pressures of life and poverty, “I’m going to find joy even in the midst of the storm.”
More recently, studies on discrimination effects have begun to explore the link between perceived discrimination and physical health using the chronic stress model postulated in the medical literature (Sapolsky, 1994; McEwen, 1998; Solarz, 1999). According to this para- digm, stress evokes the “fight or flight” response that involves release of additional hormones. Pulse acceleration, respiratory increases, and slowing of the digestive process are all physical responses to the higher hormone levels. These changes can be adaptive when facing short-lived but immediate danger. However, chronic stress can lead to overexpo- sure to stress hormones, resulting in high blood pressure/hypertension, accelerated arteriosclerosis, calcium loss from bone (among those with depression), and cognitive impairment (McEwen, 1998). The health effects of stress are thought to be so pervasive that some scholars argue that stress is causally implicated in virtually all chronic illness, including diabetes, HIV/AIDS, and asthma (Sapolsky, 1994).
3About 43% of Black households earn less than $25,000 annually compared to 26% of White households (U.S. Census Bureau, 1998).
Using this paradigm, a number of researchers have found associa- tions between perceived discrimination (stigma-related stressors) and physical health. Pavalko and colleagues (2003), for example, recently established that women at midlife who perceived themselves to be the object of job discrimination were 50% more likely to develop physical limitations several years down the road. Their research was longitudi- nal to rule out the possibility that the limitations were actually causing the perceived discrimination.
Kreiger and Sidney (1996) found that systolic blood pressure was independently associated with both self-reported racial discrimination and coping strategies among Black young adults. In an earlier study, Kreiger (1990) found a similar relation between self-reported discrim- ination and self-reported hypertension among Black adults in Oakland, California.
Given the positive association between education and perceived discrimination among Black Americans and the positive association between socioeconomic status and stress among Black men, stigma- related stress could explain the reversal of the socioeconomic gradient on the health of Black men compared to broader population studies (Adler & Boyce, 1994; Williams, 2003). Williams (2003) has shown that middle class Black men are an anomaly in that they do not show the expected advantages in health status that middle class White men show vis-à-vis their lower socioeconomic counterparts. Black men with a college degree, for example, have higher levels of hypertension than those with only some college education (Hypertension Detection and Follow Up Program, 1977). Although income is inversely associated with hypertension among Black women, there is no association between income and hypertension among Black men (Pamuk et al., 1998) despite findings that suggest that college-educated Black men have lower hypertension behavioral risk factors (cigarette smoking, physical inac- tivity, excess weight) compared to Black men with only a high school degree (Diez-Roux et al., 1999). Suburban residence is associated with higher mortality risks for Black men but lower mortality risks for White men and women (House et al., 2000). In his review of these data, Williams (2003) identified three potential sources of stress that may help explain the excess health burden of higher socioeconomic status Black men: their increased exposure to racial discrimination, the “recent, tenuous and marginal” nature of middle class status, and unfilled expectations due to the lower-than-expected socioeconomic status
“returns” they receive for their educational investment (p. 725).
To our knowledge, no work has been done on the relation between physical morbidity and perceived discrimination among the LGB or the Black LGB population. In fact, there is little research even document- ing the extent and type of health disparities affecting Black LGBs. In one of the few studies to compare health between a Black homosexu- ally active population and the Black population at large, Mays et al.
(2002) found that Black lesbians in Los Angeles county were more likely to rate their health as poor or fair, to be overweight or obese, or to smoke or be heavy drinkers than a racially and demographically matched sample of women in the same area. They were also less likely
to be insured, to have a regular source of health care, and to have been checked for high cholesterol (past 5 years) or had a Pap test (past 2 years) or a clinical breast examination (past 2 years). On the other hand, there were no statistically significant differences in prevalence rates for hypertension, asthma, arthritis, cardiovascular problems, or diabetes (though these conditions may be more likely to go undiagnosed among the uninsured). The lesbians were more likely to have had their blood pressure checked during the past year and to be taking medication if they had hypertension. Thus, despite higher risk factors and lower access to care, Black lesbians did not seem to be in appreciably worse health, suggesting the possibility of protective mechanisms. This pos- sibility is worth investigation. However, if indeed Black lesbians, on average, have learned to navigate oppression more successfully, this should in no way displace efforts to challenge the structures that oppress Black lesbians and others in the first place.
Thus, it seems clear that perceived discrimination among both LGBs and Blacks has negative health consequences. Black lesbians face the additional challenge of coping with gender-related discrimination and stress. This leads to a number of research questions. Does multiple mar- ginalization have a multiplicative effect on experiencing stigma-related stress? Do multiple “sources” of stigma-related stressors lead to com- promised mental or physical health faster or with more intensity?
Or, do multiple forms of marginalization bring additional coping mechanisms that can be adapted to deal with different types of stigma?
Kreiger (2000a) notes that studies on discrimination and health need to address a number of persistent methodologic problems. Such prob- lems include the lack of a standardized, validated instrument for measuring discrimination (which she argues should include the time period, domain, intensity, and frequency of exposure), measurement issues related to susceptibility, and investigation of likely effect modi- fications (Kreiger, 2000a).
Internalization of stigma has not necessarily worked in the ways that social psychologists originally envisioned, and here Goffman’s (1963) distinctions between the “discredited” (those whose stigma is observ- able) and the “discreditable” (those whose stigma is not immediately apparent) may be germane. For those with discreditable stigma (same- sex sexual preferences, for example), the task of managing stigma, according to Goffman, is one of managing information. Thus, “hiding”
an LGB identity, in this framework, is a strategy for managing the homosexual stigma. For the discredited (race), the task is managing tension in social interactions. For example, a casually dressed Black man may feel compelled to “prove” he is not a threat when entering a predominantly White environment, or a professional Black woman might feel she needs to manage others’ embarrassment or discomfort when they realize that she is the attorney, not the secretary they assumed.
These differences may affect stress, coping ability, and the likelihood of internalizing the stigma. For decades, social psychologists chased the holy grail of “proving” that the stigmatized suffered from lower self- esteem. Taking their cue from symbolic interactionists (Mead, 1934;
Cooley, 1956), they argued that members of stigmatized groups must have lower self-esteem because their sense of identity was at least in part constructed from their perspective of how the “generalized other”
evaluated them. Erikson (1956) and Allport (1954/1979) argued that through internalization of stereotypes the stigmatized were plagued with feelings of worthlessness and self-hate. In their review of studies on self-esteem and stigma, however, Crocker and Major (1989) found that prejudice does not generally lead to lower self-esteem among those from stigmatized groups. Their review covered more than 20 years of research and a wide range of stigmatized groups. With respect to Blacks, they found that levels of self-esteem were equal to and in some cases higher than levels of self-esteem among Whites.4Studies among homosexuals showed that self-esteem was “not consistently lower”
(Crocker & Major, 1989, p. 611).
Although stigma may not result in lower global self-esteem among Black Americans, the protective mechanisms through which they main- tain their self-esteem in the face of persistent discrimination appear to have their own costs. For example, Crocker et al. (1998a) theorized that Black students “disengage” their self-esteem from achievement in a particular domain if they suspect that the domain is “biased.” Major and colleagues (1998) were able to show in a series of studies that when Black students perceived that intellectual tests might be biased their self-esteem was “immune” to test performance feedback, compared to White students, whose self-esteem fluctuated with feedback on their test performance. Crocker et al. (1998) call the short-term severing of self-esteem and achievement in a particular domain “disengagement.”
Over time it can lead to “disidentification” or a longer-term adaptation of removing a particular domain from their personal identity. They point out that disidentification in a particular domain suppresses moti- vation, regardless of talent, and leads to “systematic group differences in aspirations, skills and achievements, even when individual capabil- ities do not warrant these differences” (p. 530).
In another study, Steele and Aronson (1995) demonstrated the per- nicious effects of a stigma stressor they call “stereotype threat.” When given an intellectual test that both Black and White students were told was “just a laboratory exercise,” Black and White students scored equally well (controlling for other factors such as socioeconomic status). Black students performed lower than White students, however, when given the same test and told that the test measured intellectual ability. Steele and Aronson argue that Blacks know they are stereotyped in the domain of intellectual achievement and that the threat of being evaluated stereotypically or of having their own behavior reinforce the stereotype was enough, in the absence of any overt discrimination, to raise self-doubt and jeopardize academic performance. The process
4Marketers are beginning to ponder the implications of differential self-esteem among youth. The Wall Street Journal recently reported on a large-scale study, released by Viacom, Inc.’s Nickelodeon, in which researchers found that Black children had the highest levels of self-esteem and perceived efficacy of the ethnic groups studied. (Wall Street Journal, Marketplace page, June 18, 2004.)
through which their performance was jeopardized was elucidated through part of the experiment. Students completed word fragments and were asked to indicate their race on an optional questionnaire.
Black students who were told the test was diagnostic completed a higher number of word fragments with race-related and self-doubt related words than Black students in the nondiagnostic and control groups. They also were less likely to volunteer race information. White students’ responses were unaffected by the test description. Thus, although stigma may not result in reduced global self-esteem, it is clear that it can affect self-doubt and efficacy in specific contexts. Further- more, the costs of maintaining self-esteem are high. In commenting on Steele and Aronson’s work, Link and Phelan (2001) noted how the psy- chosocial process of stereotype threat contributes to structural dis- crimination. They argued that the mere existence of a stereotype calls into question the “objective” nature of the test. Because a perceived stereotype undermines the validity of the test results for Black students, use of the test as “objective” in fact systematically discriminates against Black students.
How these dynamics affect the Black LGB population is an area for investigation. For example, Black LGBs may have race identity strategies that prevent the harmful internalization of race-related stigma, although, as we have seen, this can be a double-edged sword, as strategies that offer strong psychic benefits in one domain can, through stereotype threat, “bleed over” into structural disadvantage.
As same-gender-loving people, have Black lesbians and gay men learned these same “protective identity strategies”? Or, does racism in the gay/lesbian community prevent them from drawing upon that community’s social support? At the same time, are they more likely to internalize the stigma of homosexuality and “hide” their identity to prevent alienating themselves from the Black community? We now consider how identity management among Black LGBs helps or hinders their health and well-being.
3 Stigma, Identity, and Black LGB Well-Being
“Identity” is conceptualized as an important “buffer” that can mitigate the negative consequences flowing from stigmatization. Whereas in modern societies identities generally serve important functions in people’s self-definition, self-expression, social affiliations, and sense of well-being (Lewin, 1948; Tajfel & Turner, 1979; Howard, 2000), strong identities are theorized to be especially important for members of stigmatized groups, serving as psychological, social, and political resources for coping with the stresses related to their stigmatized social status (Cass, 1979; Troiden, 1989; Icard, 1996; Lemert, 1997; Cross et al., 1998; Sellers et al., 1998b). Most of this literature focuses on psychoso- cial rather than structural pathways. Despite “self-acceptance” and
“commitment” to the stigmatized group being frequently conceptual- ized as one of the highest stages of minority (race or sexual orientation) identity development, the relation between strong identities, social change, and structural discrimination is largely unexplored territory.
Although strong identities are seen as an asset, their salubrious effect is interfering with and “neutralizing” an otherwise negative process.
In recent research, Ryff et al. (2003) found that minority status (race and ethnicity) was associated with stronger existential aspects of well- being, including the struggle for meaning and purpose in life and a sense of personal growth, autonomy, and mastery, thus establishing a positive and independent realm of mental health that is seemingly more available to members of stigmatized racial/ethnic communities than to those of White/majority status. Sexual orientation was not explored in this study.
How do these streams of research on stigma, discrimination, and identity management inform our understanding of the Black LGB community? Unfortunately, not as well as they should.
Research on identity management has also focused on one “identity”
element at a time, failing to explore how those with multiple minority statuses manage to integrate elements of their various stigmatized identities. Thus, research on identity has been conducted on largely heterosexual Black populations and largely White gay populations, with only a handful of studies looking at the intersection of the two.
Those who have written about the stresses associated with managing multiple stigmatized identities have done so largely from experience as clinicians or in qualitative research (Icard, 1986, 1996; Loiacano, 1989;
Greene, 1994, 2000; Wilson & Miller, 2002). A number of themes have surfaced, including the experiencing of ethnic communities as hetero- sexist and of gay/lesbian communities as racist. Some have highlighted the pressure Black LGBs experience to “choose” between their identi- ties and to negotiate different identities based on social context. Other themes are the conflict they encounter with their families and churches, the guilt they sometimes harbor due to normative judgments about homosexuality being a “White problem,” and the historical, political, and cultural context for the Black community’s marginalization of its own gay and lesbian members.
The omission of Black LGBs from the larger literature on identity and on stigma leaves a number of questions unexplored. To what extent, for example, do Black LGBs employ similar or different strategies for coping with racism and with heterosexism? If discrimination’s effect is physically “embodied” in its victims, can strong identities provide pro- tection from physical disease, even while larger efforts to eradicate dis- crimination continue? If being gay, lesbian, or bisexual and Black puts one in double jeopardy, is it possible that developing a strong “inte- grated” identity can be especially beneficial, providing individuals with a stronger sense of purpose and meaning in life? If so, what can the Black LGB community as well as the larger society learn from that experience?
3.1 Identity Management Among Black Americans
There are numerous identity models for race/ethnicity (see reviews by Phinney, 1990; Cross et al., 1991; Sellers et al., 1998b). W.E.B. Du Bois recognized as early as 1903, in the Souls of Black Folk, that Blacks could and did draw upon uniquely Black American cultural strengths to
reconcile the “double consciousness” born of being Black in a White society that preaches freedom and practices slavery. One of the earliest racial/ethnic identity models (conceptualized as such) was Cross’s Nigrescence model (1971). According to this model, the individual begins with low race salience. Then, as a result of some type of
“encounter,” the individual confronts the stigmatized nature of his/her race and begins to reevaluate his/her racial identity. During the immer- sion/emersion phase that follows the encounter phase, race identity is typically heightened, and out-group (White) evaluations tend to be negative. The final stage in Cross’s Nigrescence model, called inter- nalization/commitment, is a synthesized identity in which race is inte- grated with other aspects of an individual’s identity, such as family, religious affiliation, profession, and avocation, among others (Cross, 2001).
Cross and others have asserted that there is a direct relation between an internalized Black identity and psychological health among Blacks (Parham, 1989; White & Parham, 1996; Cross et al., 1998). Empirical research using the Racial Identity Attitudes Scale (RIAS) has provided some support for this hypothesized link (Parham & Helms, 1985; Pyant
& Yanico, 1991; Munford, 1994). Munford (1994), for example, found a relationship between “stage” variables and depressive symptoms, with internalization scores inversely correlated to depressive symptoms and earlier stages (preencounter, encounter, immersion-emersion) associ- ated with elevated depressive symptoms.
The Cross model has been critiqued, however, for failing to explicate the pathway through which the link between identity and psycholog- ical functioning occurs and for the analytic inflexibility of a model that assumes a uniformity of attitudes in development stages and thus hampers the ability to explore such potential pathways (Caldwell et al., 2002). For example, as evidence of an inverse relation between stress and mental health mounted, researchers began to conceptualize dis- crimination as a type of stress and hypothesized how various coping mechanisms could mediate the relation between stress and psycholog- ical distress (Landrine & Klonoff, 1996; Miller & Kaiser, 2001; Sellers et al., 2001). Much of this work relied on the conceptual “stress and coping” framework provided earlier by Lazarus and Folkman (1984).
As this framework was contextual rather than developmental, new and developmentally fluid models of racial identity emerged in which iden- tity was conceptualized as multidimensional rather than progressive (Phinney, 1992; Sellers et al., 1998b). Sellers and his colleagues (1997, 1998b) proposed The Multidimensional Model of Racial Identity (MMRI), comprised of four dimensions, to explain the personal signif- icance and meaning of being Black. In developing this model, Sellers drew upon two traditions of racial identity models: the mainstream tradition, which focuses primarily on the universal aspects of group identity, and the underground tradition, which focuses on the unique oppression and cultural experiences of Black Americans (Sellers et al., 1998b). The model’s dimensions are race salience, centrality, regard, and ideology. Some of these dimensions are conceived as more endur- ing (e.g., ideology), whereas others are conceived as contextual (e.g.,
race centrality) (Shelton & Sellers, 2000). “Regard” incorporates both a sense of collective self-esteem, or how the individual evaluates his or her own race (private regard) as well as the “generalized other” per- spective from the symbolic interactionist tradition; that is, how one thinks others regard one’s race (public regard).
With the more flexible MMRI, researchers began to test the relation between specific dimensions of racial identity and mental health and the role of perceived stress as a potential mediator. In samples of Black high school and college students, for example, Rowley et al. (1998) found that high private regard was associated with high self-esteem, mediated by race centrality. That is, among those who had high race centrality there was an association between private regard and self- esteem, but no such association existed when race centrality was low.
Caldwell et al. (2002) found that private regard and race centrality both influenced anxiety and depression among Black adolescents but indi- rectly through perceived stress. In their research, private regard was inversely related to perceived stress, as one might expect, but race cen- trality was positively related to perceived stress. Thus, the more central race was to the adolescent’s identity, the more stress he or she per- ceived. Caldwell and her colleagues also found a positive relation between maternal support—the extent to which adolescents perceived that their mothers provided emotional, problem-solving, and moral support—and centrality and private regard. This finding led the authors to hypothesize that “an important part of African American mothers’ social support relationships with their children implicitly [may include] transmissions about the significance and meaning of race, in efforts to enhance self-esteem and other competencies in their children” (p. 1331).
Finally, Sellers and his colleagues (2003), in one of the most direct tests of the “buffering” effects of identity, found that high race central- ity, although indeed increasing the likelihood of experiencing race discrimination and therefore stress, also reduced the impact that discrimination had on psychological distress among Black youth. In other words, only among those for whom race was a less central part of identity was there a relation between perceived discrimination and psychological distress. Among those with high race centrality, the link between discrimination and distress was attenuated. Thus, the authors concluded that “the moderating effect of centrality can be interpreted as a protective effect in resilience theory,” and that “young adults whose racial identity is central to their self-concept appear to be resilient in the face of risks posed for racial discrimination” (p. 312).
3.2 Sexual Orientation Models of Identity
Many sexual orientation models ignore bisexual identities, either explicitly or implicitly, and bisexuals are included in research incon- sistently. They are more likely to be included in studies using same- gender sexual activity as sampling criteria rather than gay or lesbian identity or labeling. Yet behaviorally oriented samples that do not break out bisexuals from gays and lesbians may mask important
differences in identity that could be insightful in terms of coping strategies.
Gay/lesbian identity models tend to be stage models that move from sexual identity confusion as the individual grapples with conflicting personal feelings, social norms, and internalized homophobia through identification of same-sex feelings/attractions and acceptance (self labeling), to identity pride/commitment for same-sex sexual orienta- tion identity (see Eliason’s review, 1996). Troiden (1993), building on the work of others, conceptualized the final, and presumably healthi- est, stage of a same-sex sexual orientation identity as “committed.” This stage includes disclosure of one’s identity to the public and accepting a gay/lesbian identity as primary. Despite the predominance of the theme that “coming out” is a key process to psychological health and well-being, Cochran (2001) pointed to the lack of an abundance of empirical research to support this hypothesis. Much of the literature on mental health among the LGB population has focused on elevated levels of psychological distress associated with a same-sex sexual iden- tity per se (Rosario et al., 2001; Savin-Williams, 2001; Savin-Williams &
Ream, 2003) and not on associations between mental health and spe- cific “stages” implied in the coming out process. Indeed, the latter research is difficult to operationalize as, assuming the model to be a true reflection of sexual orientation identity development, it would be difficult to obtain reliable samples of those exhibiting a same-sex sexual orientation before they have actually come to claim and have some comfort level with that identity.
Sexual orientation is also multidimensional, incorporating elements of same-sex sexual behavior, same-sex attraction, and gay/lesbian/
bisexual identity and life-style (Sell 1997). Inconsistent operationa- lization of “homosexuality,” particularly with respect to behavioral versus identity-based definitions, and difficulty using probability- based sampling techniques in this population have inhibited research that would lead to a clearer picture of how identity functions with respect to LGB psychological health. In a review of sampling method- ologies used in 152 public health articles that included gay, lesbian, or bisexual populations from 1990 to 1992, Sell and Petrulio (1996) con- cluded that the authors “rarely conceptually defined the population they were sampling, used a variety of inconsistent methods to identify and select subjects, sampled from settings representative of dramati- cally different populations, and rarely used probability sampling”
(p. 32).
3.3 Dual Identity Among Black LGBs
As we have seen, the identity development processes are different for race and for sexual orientation. Race identity begins early and Caldwell et al.’s study (2002) suggests that mothers play a deliberate role in cultivating race centrality and positive private regard, perhaps in intuitive recognition of their psychic benefits. This may help account for the high levels of self-esteem found among Black adolescents (Jordan, 2004) and for the lack of a relation between public regard (how
one thinks others see their group) and mental health among Black youth (Sellers et al., 2003).
By contrast, the LGB population exhibits higher rates of major depression, generalized anxiety disorder, substance abuse/depend- ence, and suicide (see Cochran, 2001, for a review of sexual orientation and LGB mental health). It is unlikely that parents of LGBs deliberately try to instill protective aspects of a homosexual identity in their chil- dren. Indeed, it is unlikely that heterosexual parents envision their chil- dren as anything but hetereosexual until long after individuals have developed a same-sex sexual orientation manifested by attraction, behavior, and/or identity. LGBs, then, are likely to have internalized some of the larger society’s homophobic attitudes, whereas Black parents may work to protect their children from internalizing the larger society’s racist attitudes. Thus, emerging realization of sexual orienta- tion is more likely to be met with shame or at least confusion initially rather than pride, making adolescence a particularly vulnerable time for LGBs (Cochran, 2001). Indeed, members of sexual orientation minorities may not have the same resources vis-à-vis identity forma- tion that enable ethnic minorities to develop higher rates of existential well-being and purpose, as documented by Ryff et al. (2003).
Despite the importance of the “coming out” process in the LGB iden- tity literature, most gay/lesbian models reflect Anglo/White experi- ences. The scant research on Black LGBs suggests that the “coming out”
process for Black gay men is qualitatively different from that of White gay men. In research conducted by Dube and Savin-Williams (1999), for example, older Black gay men generally came to understand and label themselves as gay much later than would be suggested by the theoretical models. Younger Black gay men were more likely to under- stand themselves as gay after having had same-sex sexual encounters, whereas, in contrast, their White and Asian gay counterparts did so before. Furthermore, the young Black gay men were substantially less likely to have disclosed their sexual orientation to their families.
Comparisons of coming-out experiences and sexual practices between Black and White lesbians are even less well researched. Nar- rative literature among Black lesbians, however, emphasizes the impor- tance of coming out and the indivisibility of their identity as Black and as lesbian (Lorde, 1984; Kitzinger, 1987). Catherine McKinley and L.
Joyce Delaney published Afrekete: An Anthology of Black Lesbian Writing in 1995, and Lisa C. Moore began a publishing house, RedBone Press, featuring the work of Black lesbians. She has since edited Does Your Mama Know? An Anthology of Lesbian Coming Out Stories (1997) and published Sharon Bridgforth’s Bull Jean Stories (1998). One Black lesbian, interviewed about the tumultuous decades of the 1960s and 1970s on the PBS special “Out!: Audre Lorde: A Litany for Survival,”
commented on the impact Audre Lorde’s coming out had on her own identity. She said it made her realize that coming out was not just a rebellious reaction but was integral to survival itself.
For many Black LGBs, however, maintaining the “indivisibility” of identity is difficult. Black LGBs often feel the pressure to “choose”
between what are perceived as conflicting identities: their “Black self”
or their “LGB self.” Experiencing gay/lesbian culture as White and hegemonic, ethnic minority gay men and lesbians feel a strong need for continued ties to their cultural communities (Icard 1986; Loiacano, 1989; Morales, 1992; Greene, 1994; Jackson & Brown, 1996). Psycholog- ically, they cannot “afford” the rejection of the homophobic hetero- sexual world that is often posited as a “stage” in LGB identity development (Eliason, 1996) because the “homosexual world” does not deliver the same social and psychological benefits for them as it does to the White gay and lesbian community. This is reflected in a propen- sity for Black lesbians to maintain connections to the heterosexual com- munity (including relationships with men) and to rely more heavily on their families for support than do White lesbians (Bass-Hass, 1968;
Bell & Weinberg, 1978; Mays & Cochran, 1988; Greene, 1994; Jackson
& Brown, 1996). This may also help explain the rejection of the “gay identity” among many Black men (Icard, 1996). Indeed, experiencing the LGB community as racist, gay Black men in particular may
“disengage” from that community (Battle et al., 2003).
Although rarely documented empirically, assertions of racism in the LGB community are supported qualitatively by the experiences of many of the authors as practicing clinicians (Icard, 1986; Greene, 1994), by personal testimonials (Lorde, 1984; Asanti, 1997, 1998, 1999; Burstin, 1999; Herren 2001), and by depth interviews (Lociano, 1989; Mays et al., 1993; Jackson & Brown, 1996). Like racism in the larger culture, racism in gay/lesbian communities takes many forms, including prej- udiced treatment (DeMarco, 1983; Icard 1986); invisibility, lack of acknowledgement, distortion, marginalization, and tokenism (Jackson
& Brown, 1996); White standards of beauty (Loiacano, 1989); and sexual objectification or perceptions of exoticism (Burstin, 1999; Diaz et al., 2001). In one of the few large-scale empirical studies in the literature (Diaz et al., 2001), 62% of gay or bisexual Latino men reported feeling that they had been sexually objectified due to their race or ethnicity, and one in four (26%) reported feeling uncomfortable in spaces primarily attended by White gays.
3.4 Homophobia in Black and Ethnic Communities
The impact of racism in the gay and lesbian community on Black Americans and other ethnic minorities is double-edged because ethnic minority gay men and lesbians also face homophobia in their ethnic communities (Mays & Cochran, 1988, Chan, 1989; Greene, 1994;
Jackson & Brown, 1996; Diaz et al., 2001).
In the Black community, homophobia is attributed to a variety of factors, many of which involve the legacy of slavery. These include a strong Christian heritage, which tends to view homosexuality as a
“sin;” the need for Black women, historically perceived to be “at the bottom of the heap,” to have another group relieve them of this dubious status; heightened need for “normalcy,” as defined by the dominant culture, due to internalization of racist sexual myths and stereotypes; and a reaction to the perceived shortage of marriageable
