The Mental Health Consequences of Life Course-Varying Exposure to Structural Sexual Minority Stigma: Advancing Causal Inference Using Longitudinal Models Moderated by Sexual Orientation

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PROJECT SUMMARY Sexual minorities (i.e., individuals who do not identify as heterosexual, or who are attracted to, have romantic relationships with, or have sexual contact with, people of the same or diverse genders) in the US are at a two to seven-fold increased risk for lifetime report of suicide attempts and a near three-fold increased odds for depression. Sexual minority stigma exposure, in its various forms, has been purported as a cause underlying and driving these sexual orientation-based disparities in mental health. While structural forms of sexual minority stigma, including discriminatory laws, inequitable policies, and negative population attitudes, have been associated with adverse sexual minority mental health in cross-sectional designs, no longitudinal studies to date have examined three key elements needed to establish causality, including 1) temporality with the exposure preceding the effect, 2) dose-response gradient comprehensively assessed across the life course, and 3) specificity of results with the exposure explaining an observed disparity in outcomes. With data collected during a transformational period for sexual minorities in the US (from 2001 to 2018 with, e.g., changes in population attitudes and the step-wise introduction of same-gender marriage), the National Longitudinal Study of Adolescent to Adult Health (Add Health) provides a unique and timely opportunity to longitudinally examine the effect of life-course structural stigma exposure on sexual minorities’ mental health and the three missing causality requirements. Therefore, this proposed study will 1) quantify the level of structural sexual minority stigma for each US state between 2001 and 2018 and calculate individuals’ exposure over time, 2) examine the associations between structural sexual minority stigma and suicidal ideation, suicide attempts, and depressive symptoms in longitudinal models, and 3) examine if the associations between structural sexual minority stigma and mental health outcomes in longitudinal models vary by sexual orientation. The proposed study will employ advanced three-level multi-membership longitudinal models to account for lifetime-varying exposure and between-state migration. Findings from the proposed study may have direct theoretical and applied implications as it addresses important causality issues on how structural sexual minority stigma shapes sexual minorities’ mental health. Results may further contribute to health equity by facilitating targeted advocacy to improve structural climates for sexual minorities, not only in the US, but similarly across the globe.