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Journal of LGBT Health Research

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General and Minority Stress in an LGB Population in Flanders

Nele Cox a; Wim Vanden Berghe a; Alexis Dewaele b; John Vinke a
a
Department of Sociology, Ghent University, Belgium b Policy Research Centre on Equal Opportunities,
Belgium

Online Publication Date: 01 January 2008

To cite this Article Cox, Nele, Berghe, Wim Vanden, Dewaele, Alexis and Vinke, John(2008)'General and Minority Stress in an LGB
Population in Flanders',Journal of LGBT Health Research,4:4,181 — 194
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 General and Minority Stress in an LGB Population
in Flanders
Nele Cox
Wim Vanden Berghe
Alexis Dewaele
John Vinke

ABSTRACT. This article concentrates on the influence of determinants of mental health on a lesbian,
gay, and bisexual (LGB) population in Flanders. Our sample is drawn from the Zzzip survey, and
Downloaded By: [Canadian Research Knowledge Network] At: 18:02 7 October 2009

contains 2,280 LGBs, of whom 1,565 are men and 715 are women. The traditional social stress model
outlines the influence of general stressors on stress (Pearlin, 1989). Meyer (1995) has expanded Pearlin’s
model to include the concept of minority stress.
This study focuses on aspects of personal characteristics and social structural arrangements. Our
study confirms the importance of age and education as relevant determinants for mental health. Ad-
ditionally, although most research establishes sex differences in depression, this study does not find
significant differences in depression between men and women. In women, sexual identity is a significant
determinant of depressive score, but we do not find the same in men. Finally, both general and minority
stressors, especially the internal stressors, are found to have an important effect on depressive outcomes.

KEYWORDS. Social stress model, minority stress, sexual identity, mental health

THE SOCIAL STRESS MODEL (lesbians, gays, and bisexuals; Sandfort, De

Since the removal of homosexuality in 1973
from the list of mental disorders, research has
shifted from the study homosexuality as a men-
tal illness to the study of the influence of so-
cial stressors on the mental health of LGBs
Graaf, Van Bijl, & Schnabel, 2001). This study
domain became the dominant theoretical per-
spective for understanding variation in health
and well-being (Thoits, 1999). The social stress
model identifies and details the interrelationship
among personal and social experiences, which

We dedicate this article to our beloved friend and colleague, Professor John Vincke. We will remember
him as a passionate researcher and a truly exceptional human being.
Nele Cox, MA, is affiliated with Ghent University, Department of Sociology, Belgium, has a master’s in
sociology, and works as a PhD student at the Department of Sociology, Ghent University; her main research
interests are sexuality, identity formation and social stress. Wim Vanden Berghe, MA, is affiliated with Ghent
University, Department of Sociology, Belgium, has a master’s in sociology, and works as a PhD student at the
Department of Sociology, Ghent University; his main research interests are sexuality and HIV/AIDS studies.
Alexis Dewaele, PhD, works as a researcher at the Policy Research Centre on Equal Opportunities, Belgium,
and has both a Master’s in psychology and has a PhD in sociology; his main research interests are personal
social networks and equal opportunities in the life of LGBs (lesbian, gay and bisexual people). John Vincke
was professor of sociology and chair of the Department of Sociology, Ghent University. His main research
interests were within the realm of HIV prevention.
Address correspondence to: Nele Cox, MA, Department of Sociology - Korte Meer 5 – 9000 Gent –
Belgium (E-mail: Nele.Cox@UGent.be).

Journal of LGBT Health Research, Vol. 4(4) 2008

Copyright
C Taylor & Francis Group, LLC
doi: 10.1080/15574090802657168 181
 182 JOURNAL OF LGBT HEALTH RESEARCH
are hypothesized as relevant to mental health
risk. Pearlin’s (1989) traditional social stress
model outlines the influence of personal and so-
cial life events and daily hassles on stress, me-
diated by social support and coping strategies.
Empirical evidence suggests that psychosocial
resources are beneficial to mental health. For ex-
ample, symptoms of depression and anxiety tend
to decrease as social support increases (Wething-
ton & Kessler, 1986). The evidence with re-
gard to coping is equivocal because the effec-
tiveness of various coping strategies appears to
be situation specific: What works with regard to
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one stressful situation may actually cause prob-
lems in another (Pearlin, 1989). The response to
stress is a combination of individual and contex-
tual conditions. Most people will react to stress
without negative stress outcomes, but some will
translate stress into distress. As an experience
becomes personalized, the definition of a situa-
tion as stressful will depend on the individual’s
perception of both the situation and his or her
ability to respond to it. The systematic investi-
gation of social stress and its effects, however,
requires researchers to focus on commonalities
in experience that exist across situations and
across individuals. Commonalities in reactions
to stress have been sought in personal character-
istics and in structural arrangements of society,
which include socioeconomic and demographic
risk factors (Aneshensel, 1991; Large & Mar-
cussen, 2000). Our study focuses on the aspects
of personal characteristics and social structural
arrangements. First, we start with the individ-
ual features, namely demographic background
characteristics and sexual identity. Second, situ-
ational risk factors such as general and minority
stressors are taken into consideration.
STRESS OUTCOMES ACROSS
INDIVIDUALS: BACKGROUND AND
SEXUAL IDENTITY
Sex, Age, and Education
Sex differences in the prevalence of mental
disorders are one of the most consistent findings
in mental health research and are the main fo-
cus in many general stress studies (Rosenfield,
1980; Thoits, 1999). Women report greater in-
ternalized distress than men do; this is expressed
in higher average levels of depression and anx-
iety (Mirowsky & Ross, 1995, Wilson, 1987).
Research also indicates that women of all sex-
ual orientation groups are more likely to report
that they have been in therapy than their male
counterparts are. Theories about gender-based
exposure to social stressors explain women’s el-
evated distress as the consequence of inequality
and disadvantage (Mirowsky & Ross, 1995). We
use these findings as input for Hypothesis 1.
With regard to the relationship between age
and depression, research shows that depression
is lowest among the middle-aged, higher among
younger and older adults, and highest among
the oldest. Depression reaches its lowest level
around age 45. Explanations about this U-shaped
relationship are found in the adult life cycle; cer-
tainty about marital, employment, and economic
status flattens out the age-related curve of de-
pression found at middle adult age (Mirowsky
& Ross, 1992). In LGB research, young LGBs
seem to be at greatest risk for mental health
problems, which are expressed in suicidal be-
havior, multiple disorders, and depressive symp-
toms (Fergusson, Horwood, & Geautrais, 1999).
This can be explained by the fact that an LGB
identity usually develops during this age period
and causes considerable distress (Blake, Led-
sky, Goodenow, Sawyer, & Hack, 2001; Durant,
Krowchuk, & Sinal, 1998; Garofalo & Katz,
2001; Harrison, 2003; Lock & Steiner, 1999;
Scheer et al., 2002). In this study, age differ-
ences form the basis for Hypothesis 2.
Finally, the educational level is taken into ac-
count. The negative relationship between educa-
tion and psychological distress is one of the most
firmly established associations in epidemiology
(Kessler, 1982). Research indicates that the well-
educated have lower levels of emotional distress
and physical distress. Poorly educated persons
have higher levels of depression, anxiety, and
pain (C. E. Ross & Van Willigen, 1997). These
general population findings serve as the back-
ground for our third hypothesis.
Sexual Identity
Identity, or self-concept, can be described
as the mental image people have of them-
selves. One of the many identities included in a
 Cox et al.
person’s self-concept is that of sexual identity.
Sexual identity refers to the self-concept an in-
dividual organizes around that person’s sexual
orientation (Diamond, 2000, 2003). The devel-
opment of a sexual identity is a process of engag-
ing in sexual behavior; forming attitudes about
sexual experiences and sexuality; and navigat-
ing the social, emotional, and physical chal-
lenges of sexual behavior (Graber & Archibald,
2001). When an individual has a perception of
self as LGB in relation to romantic or sexual
situations, it is called an LGB identity (Troiden,
1989). Because of the heteronormativity of mod-
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ern society, heterosexuality is the assumed sex-
ual identity until the opposite is proven. As a
consequence, young people grow up with the
presumption of heterosexuality. As a conse-
quence, being LGB is experienced as a deviant
state of sexual identity, which can cause stress
(D’Augelli, 1996; Herdt, 1989).
In addition to a lesbian or gay identity, indi-
viduals can also identify themselves as bisex-
ual, meaning that they are sexually oriented to-
ward both men and women. All types of sexual
identity that fall between exclusively homosex-
ual and exclusively heterosexual orientation are
labeled as bisexual, although a whole range of
bisexual types exist, and the bisexual label can
mean very different things to different people.
Individuals that are oriented toward one sex,
monosexuals, often resist being labeled as bi-
sexual. And many gay men and lesbians be-
lieve that bisexuals fear the stigma attached
to being defined as gay or lesbian (Weinberg,
Williams, & Pryor, 1994). The belief that bisex-
uals are confused about their sexual identity is
also widespread (Van Wyk & Geist, 1995). Con-
sequently, more stressful outcomes for bisexuals
versus monosexuals could be expected as a result
of denial, or the expected stigma associated with
their sexual identity. This comprises our fourth
hypothesis.
Reported and expressed sexual identities are
both influenced by psychological and societal
factors. Although men are more likely to la-
bel themselves as gay, young women tend to
report more uncertainty about sexual orienta-
tion and direction of attraction. They are more
likely to consider themselves as bisexual, expe-
rience more same-sex attraction, and act on it at a
183
later age. Women also report more heterosexual
activity (Dempsey, Hillier, & Harrison, 2001).
Therefore, young women are more likely than
young men to be attracted to both sexes, to iden-
tify themselves as bisexual and to be unsure of
their sexual identity (Dempsey, Hillier, & Harri-
son, 2001; Diamond & Savin-Williams, 2000).
Given these sex differences in the light of sex-
uality, sexual identity, and identity formation, it
is possible that sexuality has a different impact
on women versus men in the domain of mental
health issues. We consider this in Hypothesis 5.
STRESS OUTCOMES ACROSS
EXPERIENCES: GENERAL AND
MINORITY EXPERIENCES
Besides the stressful impact of individual fea-
tures, stressful experiences also affect people
(Meyer, 1995; Pearlin, 1989). Individual stress-
ful experiences are defined as events and condi-
tions that cause change and require the individual
to adapt to a new situation or life circumstance.
Experiencing those daily hassles or life events
can cause mental health problems (Aneshensel,
1991; Pearlin, 1989; Thoits, 1999). It is es-
pecially important to recognize the difference
in impact of general versus minority stressors.
Therefore, Hypothesis 6 considers the impact of
the former.
Social stressors are conditions in the social
surroundings that can cause stress and that often
stem from holding a minority position in society
(Pearlin, 1989). This leads us to the concept of
minority stress in which individuals from stig-
matized social categories are exposed to stress to
as a result of victimization, stigmatization, and
discrimination experienced due to their particu-
lar social position (Brooks, 1981; Meyer, 2003).
The concept of LGB minority stress is based on
the premise that LGB people in a heterosexist
society are subjected to chronic stress related to
stigmatization. Minority stress is an additive to
the general stressors that are experienced by all
people. It is also chronic because it is related to
relatively stable underlying social and cultural
structures; it derives from social processes, in-
stitutions, and structures beyond the individual
(Meyer, 2003).
 184 JOURNAL OF LGBT HEALTH RESEARCH
Diplacido (1998) has reviewed the existing
literature on stress among LGBs and has identi-
fied two types of LGB minority stress. External
stressors are negative events and daily hassles
resulting from the social status of an individual,
such as experiences of discrimination or nega-
tive treatment in society. Rosser and Ross (1989)
found that the relationship between life events
and emotional distress is stronger for gay than
for heterosexual men. Research on LGB youth
has shown that discrimination and experiences
of negative treatment relate to greater mental
health problems in gay men (Diplacido, 1998;
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Meyer, 1995). We use these findings as input for
Hypothesis 7.
Besides these two external stressors,
Diplacido (1998) identified a second type of mi-
nority stressors, namely internal stressors. These
are stressors manifested within the individual
based on social conditions. They often represent
more chronic strains, such as internalization
of cultural stereotypes about homosexuality.
Two main internal stressors are explored. First
of all, LGBs have to deal with internalized
homonegativity. LGBs, just like heterosexuals,
are raised in a heterodominant society with
antihomosexual biases. They may internalize
these negative attitudes towards homosexuality
in other persons, and may also internalize
negative attitudes towards homosexual features
in themselves (Shidlo, 1994). So these biases
set in motion other psychological processes that
extend beyond the development of prejudice.
Internalized homonegativity can be overt, for
example, individuals may accuse themselves of
being bad or inferior because of their homosexu-
ality. This can lead to self-destructive or abusive
behaviors and is extremely psychologically
painful and destabilizing. The covert types of
homonegativity are more prevalent. Here the
affected individuals seem to accept themselves,
yet sabotage their own efforts in a variety of
subtle ways, e.g., they use their sexuality as an
excuse to run away from specific objectives, or
they tolerate discriminatory or abusive treatment
from others. Covert internalized homonegativity
also operates on a community level. Some
LGBs hold themselves to an unrealistic standard
of conduct and can be very negative and critical
toward others who do not meet their expecta-
tions. Or, some LGBs are extremely critical of
other LGBs, reflecting their own discomfort.
So these negative attitudes about homosexuality
have a direct influence on their personal life,
their attitudes towards same-sex sexual and
emotional attraction, same-sex sexual behavior,
and same-sex intimate relationships. No wonder
internalized homonegativity appears to relate
to depression, self-esteem issues, and general
psychological distress (Diplacido, 1998; Lewis,
2001; Meyer, 1995; Shidlo, 1994). This is
considered in our eighth hypothesis.
Next to internalized homonegativity, LGBs
can suffer from stigma consciousness. There are
two aspects to the stigma perspective: stigma-
tized individuals can assume that their abnor-
mality is known or is an evident feature of their
appearance, or, in contrast, they can assume that
it is neither known about by those present nor
immediately visible to them. In all of the var-
ious instances of stigma, the same sociological
feature is found: The stigmatized individual pos-
sesses a stigma, an undesirable difference from
what the environment expects (Goffman, 1986).
What makes the relationship between LGBs
and stigma a special case, is in the first place,
that LGBs are not born as minorities. They grow
up like anyone else, like heterosexuals. It is only
when they develop their LGB identity and come
out as LGB that they attain a minority status.
Second, sexual identity is seen as a concealable
stigma, meaning that they can hide their stigma.
This possibility to hide one’s membership of the
minority group can prevent prejudice and dis-
crimination. On the other side, however, the am-
biguity of social situation and the fear of po-
tential discovery can cause a range of cognitive,
affective, and behavioral problems (Pachankis,
2007).
In addition to stigmatization and minority
status, there is an even more powerful inter-
nal stressor—stigma consciousness. Stigma con-
sciousness refers to the extent to which people
expect to be stereotyped by others. High lev-
els of stigma consciousness reflect an expecta-
tion that one will be stereotyped, irrespective of
one’s actual behavior (Pinel, 1999). This con-
cept helps to explain the stress-enhancing effect
of stigma. The more someone perceives them-
selves as stigmatized, irrespective of the fact
 Cox et al.
that stigmatization arises from firsthand expe-
rience; the greater the need is to anticipate such
stereotyping. This anticipation of stereotyping
can have negative effects on health and psycho-
logical and social functioning (Cohen & Garcia,
2005; Meyer, 2003). M. W. Ross (1985) found
that anticipated social rejection better predicts
psychological distress than does actual nega-
tive experiences. Therefore, it is expected that
stigma consciousness is significantly associated
with depressive symptoms, which brings us to
our last, and ninth, hypothesis (Lewis, Derlega,
Griffin, & Krowinski, 2003; Meyer, 2003).
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METHOD
Research Questions
We investigate how and to what extent general
and minority stressors are related to mental well
being. We also focus on the role of sexual iden-
tity within this social stress process. In Figure 1
the conceptual model is presented. Based on the
theoretical part of the study, nine hypotheses are
tested.
HYPOTHESIS 1: Lesbian and bisexual women
score higher on depressive outcomes
than gay and bisexual men.
HYPOTHESIS 2: Age has a negative impact on
depressive outcomes.
HYPOTHESIS 3: LGBs with less education
have higher average scores on depres-
sive outcomes than higher educated
LGBs.
HYPOTHESIS 4: Bisexuals have higher aver-
age levels of depressive outcomes than
lesbian or gay respondents.
HYPOTHESIS 5: The impact of sexual identity
on depressive outcomes is different in
women versus men.
HYPOTHESIS 6: Experiencing general stres-
sors increases the probability of depres-
sive outcomes.
HYPOTHESIS 7: Experiencing external minor-
ity stressors increases the probability of
depressive outcomes.
185
HYPOTHESIS 8: Internalized homonegativity
has a negative impact on depressive out-
comes.
HYPOTHESIS 9: Stigma consciousness has a
negative impact on depressive out-
comes.
Study Sample
This data set comes from the Zzzip survey,
which was set up in October 2004 and adminis-
trated by February 2005. Zzzip is a wide-ranging
exploration of the conditions of LGB life in
Flanders. Only men and women were invited
to participate, which excludes transgender in-
dividuals. Our original sample contained 1,940
men and 977 women between 14 and 84 years
of age, with an average age of 31.8. Because
of the work-related topics in one of our vari-
ables, we limit our study sample to respondents
with work-related experiences. This reduces the
dataset to 2,280 cases, of which 1,565 are men
and 715 are women. The average age is 34.8
(SE = 11.2); 28% are younger than 26; 18%
of the respondents are older than 45. All educa-
tional levels are represented; however, the ma-
jority (70.8%) has done additional studies after
high school. Ninety-three percent of the respon-
dents of Zzzip have a Belgian origin, 6% a West-
ern origin, and only 1% of the respondents are
from non-Western countries (Vincke, Cox, Van-
den Berghe, & Dewaele, 2006). Because of the
limited ethnic diversity reached in Zzzip, we de-
cided not to take into account ethnicity, although
it is an important demographic factor in mental
health research.
Research Design
Homosexuality is not a straightforward phe-
nomenon to define or measure. The division of
a population based on sex between two same-
sex persons is one possible approach, but not
all such individuals define themselves as being
LGB. In this study, our aim was to address not
only those who have come out as gay, lesbian,
or bisexual, but also the invisible, in the closet,
part of the LGB population. The representative-
ness and purposiveness of this sample within
a hidden population is realized by a diversity
 Downloaded By: [Canadian Research Knowledge Network] At: 18:02 7 October 2009

186
FIGURE 1. Conceptual Model.
 Cox et al.
of techniques. Through a large-scale marketing
campaign set up by a LGB marketing agency, we
have tried to sell our social product (our ques-
tionnaire) to the customer (persons who feel at-
tracted to same-sex individuals). Zzzip stands for
“to unzip yourself,” to show who one is and what
one stands for, to expose one’s self. The respon-
dents were invited in several ways to the Web site
www.Zzzip.be to fill out our extensive and inten-
sive questionnaire. During the process of data
gathering, we evaluated the sample composition
based on age and sex so that we could address the
under-representation of particular groups by use
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of a second method—paper and pencil question-
naires. This seemed necessary to accommodate
women and elderly LGBs. In LGB research there
is always a problem of finding women and older
LGBs. An online survey covers these under-
representation partly, but younger men stays the
most available group (Vincke et al., 2006).
Measures
Dependent variable. In measuring depression
as one specific indicator of mental health, we
used Radloff’s (1977) Center of Epidemiologic
Studies Depression scale (alpha = 0.95). This
scale is used in a great deal of sociological re-
search on mental well-being because of its non-
clinical character. The scale contains 20 items,
with a minimum score of 0 and a maximum score
of 60.
TABLE 1. Components of External Stress Indexes (Frequencies)
General Stressors (Health, % Experienced
Work, Relationship) This Situation
Subjective health status 14.8% (bad health status)
Physical pain during last 11.2%
month
Unemployment 6.7%
End of a relationship 3.7%
Index general stress (sum) 26.4% experienced at least
one of these situations
187
Independent variables. To measure sexual
identity, we asked the respondents to indicate
how they would describe their own sexuality on
the Kinsey scale. The scale goes from 0 (ex-
clusively heterosexual) to 6 (exclusively lesbian
or gay). The respondents that answered 0 were
excluded from further questions. A score of 7
indicated that respondents did not know how to
identify themselves. Although it is an interest-
ing subgroup, for this study these respondents
(54) are seen as missing and will be removed
from further analyses. The fact that 84.4% of
the respondents identified themselves as almost
exclusively lesbian or gay results in a highly
skewed distribution. The mean score is 5.5, with
a standard deviation of 0.9. Most respondents
scored higher than 3 on the Kinsey scale.
General stressors were measured by means
of several general event items in the spheres of
work (unemployment), health (physical pain and
state of health), and relationship (termination
of a romantic relationship). We rescored these
items to 0 (not experienced) and 1 (experienced).
Next, these items were totaled so that a high
score indicated the experience of more stressors
(see Table 1).
External minority stressors were limited to
discrimination at work. Similarly, we opera-
tionalized the external LGB-specific stressors
with regard to external general stressors (Rosser
& Ross, 1989). The items in the scale cov-
ered discrimination at work and included being
Minority Stressors % Experienced
(Discrimination at Work) This Situation
Ever not been accepted for 11.7%
a job due to your sexual
orientation
Ever been maltreated at 9.4%
work due to your sexual
orientation
Ever been dismissed due 9.0%
to your sexual
orientation
Co-workers been negative 22.4%
about your sexual
orientation
Index external minority 35.4% experienced at least
stress (sum) one of the situations
 188 JOURNAL OF LGBT HEALTH RESEARCH
discharged, being denied a job, being denied a
promotion, and experiencing negative attitudes
of colleagues (see Table 4).
Finally, two scales of internal minority stress
were used. To measure stigma consciousness,
we used Pinel’s (1999) Stigma Consciousness
Scale. The reliability analysis revealed a Cron-
bach’s alpha of 0.75. We measured internalized
homonegativity using Mayfield’s (2001) inter-
nalized homonegativity inventory (IHNI) for gay
men. We adapted the scale to relieve the contents
of its male perspective and based on the results
in the pre-test we curtailed the measure to 10
items (alpha = 0.80).
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RESULTS
Procedure
To study the effect of sex, age, and education
we performed a univariate analysis of variance
(ANOVA). Correction for multiple comparisons
was made by applying the Bonferroni correction
(see Table 2).
To test the hypotheses, a hierarchical step-
wise regression technique was used, based on
Pearson’s correlations (see Table 3) with CES-
D (Center of Epidemiologic Studies Depression
scale) as the dependent variable (see Table 4).
We constructed our analysis model in different
steps to examine the contribution of change in
the independent variables to change in CES-D.
As the direction of effects had been predicted,
we used one-tailed significance tests to assess
the hypothesized relationships. In Step 1, the
background variables sex, age, and education
were entered to control for their effects. We in-
cluded sexual identity in the second block. Our
external stress indicators were added in the third
step and the internal minority stressors were
added in Step 4. We then included some inter-
action terms to verify the impact of sex on the
relation between sexual identity and depression.
For this step, we standardized our interaction
variables and did a separate regression analyses.
Descriptive Statistics, Univariate Analyses
of Variance, and Bivariate Correlations
Mean depression score was 13.9, with a stan-
dard deviation of 11.8 and a skewness of 0.8.
To overcome this asymmetric form, we used the
squared CES-D in a linear regression (M = 3.4;
SE = 1.8). In the past, a threshold was deter-
mined by which individuals who scored higher
than 16 had more risk of distress and depres-
sion. Scores above 21 were seen as a clear indi-
cation of depression (Bouma, Ranchor, Sander-
man, & van Sonderen, 1995). Univariate analy-
sis of variance and t-tests showed that women
(M CES-D = 15.4) scored slightly higher on
CES-D than men (M = 14.2; M difference =
1.2 , p < 0.05), respondents with less educa-
tion (M = 16.7) scored significantly higher than
more highly educated respondents (M = 13.7;
M difference = 2.9, p < 0.001), and LGBs un-
der 26 years old (M = 16.4) scored significantly
higher than LGBs between 27 and 45 years old
(M = 13.9; M difference = 2.5, p < 0.001) and
older than 45 years old (M = 14.2; M differ-
ence = 2.2, p < 0.05).
Interesting differences in sex, age, and edu-
cation come up regarding sexual identity, Al-
though the means of all groups are extremely
homosexual leaning, women (M = 5.3) score
significantly lower on the Kinsey scale than men
(M = 5.6, M difference = 0.3 , p < 0.001).
The youngest age group (M = 5.4) scores more
bisexual than the middle age group (M = 5.5;
Mean difference = 0.1 , p < 0.05) and much
more bisexual than the +45-year-olds (M = 5.6;
M difference = 0.2 , p < 0.001). As far as ed-
ucation, t−tests show slightly higher scores for
low education respondents (Mean = 5.5) than
for the higher educated respondents (M = 5.4;
M difference = 0.1, p < 0.05).
When we focused on the experiences of stress,
we found that many respondents had not expe-
rienced any of the events we asked about within
the given time period (73.6%). With regard to
experiencing minority stressors, 64.6% of the
respondents said they had not experienced any
discrimination at work. Table 4 gives a short
overview of the components of general and mi-
nority stress, including the frequency with which
respondents did experience those hassles. Lower
educated respondents scored significantly higher
on general stress experience (M = 0.5; M differ-
ence = 0.2, p < 0.001) as well as on external mi-
nority stressors (M = 0.6; M difference = 0.1,
p < 0.001). Bivariate correlations show a signif-
icant association between external general stress
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TABLE 2. Descriptive Statistics and Univariate Analysis of Variance

Agea (Mean Subscores) Education (Mean Subscores)

Sex (Mean Subscores)
26–45 No College/University College/University
Valid N M SD M (68.7%) F (31.3%) −26 (27.5%) (54.7%) 45+ (17.8%) Degree (29.3%) Degree (70.8%)

Sexb 2280
Agec 2267 34.830 11.218
Educationd 2277 2.950 0.837
Sexual identitye 2226 5.460 0.939 5.550*** 5.260*** 5.350 5.480 5.590 5.530* 5.430*
General stressorsf 2280 0.362 0.673 0.344 0.402 0.378 0.323 0.458 0.494*** 0.307***
Exterior minority stressorsg 2277 0.524 0.848 0.539 0.492 0.506 0.521 0.561 0.624*** 0.484***
Stigmah 2280 25.980 9.882 26.120 25.660 26.620 25.680 26.000 25.810 26.060
Internalized homonegativityi 2280 11.070 7.232 11.320* 10.530* 11.760 10.870 10.620 10.570* 11.280*
CES-Dj 2279 13.870 11.804 14.232* 15.405* 16.372 13.848 14.211 16.692*** 13.748***

Notes. Bonferronni correction—IHNI by age: −26 > 26–45*, −26 > 45+*; CES-D by age: −26 > 26–45***, −26 > 45+*; Sexual identity by age: −26 < 26–45*, −26 < 45+***. a Post-hoc tests for
general stress by age: 26-45 < 45+**. b 0 = men, 1 = women. c Minimum age = 15, maximum age = 84. d Highest educational degree (1 = elementary/lower high school, 2 = higher high school, 3 =
college, 4 = university). e1 = almost exclusively heterosexual to 6 = exclusively gay or lesbian. f Low scores = little experience of general stressors. g Low scores = little experience of external minority
stressors. h Stigma consciousness (low scores = low degree of stigma consciousness). i Low scores = low degree of internalized homonegativity. j CES-D: Depressive outcomes (low scores = low degree
of depression).
*p < 0.05. **p < 0.01. ***p < 0.001.

189
 190 JOURNAL OF LGBT HEALTH RESEARCH

TABLE 3. Correlation Matrix (Pearson’s Correlation)

Sexual General Minority

Sex Age Education Identity Stressors Stressors Stigma IHNI CES-D

Sex 1
Age −0.060** 1
Education 0.019 −0.081** 1
Sexual Identity 0.142** 0.094** −0.073** 1
General Stressors 0.040 0.018 −0.169** 0.024 1
Minority Stressors −0.026 0.010 −0.071** 0.068** 0.174** 1
Stigma −0.021 −0.032 0.033 0.006 0.116** 0.337** 1
IHNI −0.050* −0.058** 0.051* −0.183** 0.051* 0.057* 0.357** 1
CES-D 0.044* −0.068** −0.125** 0.043* 0.342** 0.239** 0.304** 0.295** 1

*p < 0.05. **p < 0.01.

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and depressive outcomes (rgenstr = 0.34; p < Multivariate Analysis

0.01) and between external minority stress and
depressive outcomes (rminstr = 0.24; p < 0.01).
The internal minority stressors—stigma con-
sciousness (Mean = 26.0; SD = 9.9) and in-
ternalized homonegativity (Mean = 11.1; SD =
7.2)—are normally distributed. Univariate anal-
ysis of variance shows that stigma conscious-
ness and internalized homonegativity appeared
equally across sex, age, and educational level.
Both variables are positively correlated with the
dependent variable CES-D (rstigma = 0.30; p <
0.01; rIHNI = 0.30; p < 0.01). So a high ex-
tent of internal minority stress is associated with
higher scores on depression.
Our complete model explained 23.4% of the
total variance of depression (see Table 3). First,
possible stress outcomes—namely background
variables and sexual identity—were scrutinized
across individuals. Age (β age = –0.07; p <
0.001) and education (β educ = –0.11; p <
0.001) both had a negative impact on depressive
outcomes: Young respondents scored higher on
CES-D, as did the lower educated respondents.
Surprisingly, no sex differences were revealed
within the analyses (p > 0.05). This means a re-
jection of the first hypothesis and a confirmation
of the second and third one.

TABLE 4. Multivariate Statistics: Linear Regression Betas

Step

Predictor 1 Beta 2 Beta 3 Beta 4 Beta 5a Beta

Sex (female) 0.015 0.009 −0.001 0.022 0.021

Age −0.069** −0.065* −0.067** −0.054** −0.054**
Education −0.111*** −0.114*** −0.057** −0.082*** −0.081***
Sexual identity −0.047* −0.049* 0.009 −0.015
General stressors 0.276*** 0.253*** 0.251***
Minority stressors 0.18*** 0.107*** 0.107***
Stigma 0.19*** 0.207***
IHNI 0.198*** 0.201***
Sex × Sexual identity −0.052**
Adjusted R2 0.015 0.017 0.137 0.230 0.232
R2 change 0.016*** 0.002* 0.121*** 0.093*** 0.003**

Note. Dependent variable: CES-D depressive outcomes (Square - transformation). The displayed coefficients are standardized beta weights
at each step.
a This is a separate analysis with standardized interaction variable sexual identity.

*p < 0.05. **p < 0.01. ***p < 0.001.

 Cox et al.
Bisexuals scored somewhat higher on depres-
sive symptoms than more homosexually oriented
respondents (β sexid = −0.05, p < 0.05). These
results were repeated in Step 3, but when adding
our internal minority stressors, the effect of sex-
ual identity on depression is mediated (β = 0.01;
p > 0.05). The fourth hypothesis, that bisexual
have higher average levels of depressive out-
comes, is not established in this study.
Focusing on Step 3, positive significant ef-
fects were found for the external stressors on de-
pressive outcomes. Controlled for demographic
background and sexual identity, more general
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stressors generated significantly more depres-
sive outcomes (β general str = 0.28; p < 0.001).
Experiencing more discrimination at work was
also significantly related to more mental health
problems (β minstr = 0.18; p < 0.001). These
results confirm the sixth and seventh hypotheses.
After adding internal minority stressors, we
observed a significantly positive association be-
tween both stressors and depressive symptoms,
confirming the last two hypotheses. Respondents
who felt stigmatized scored significantly higher
on CES-D (β stigma = 0.19; p < 0.001), as
did respondents who experienced more internal-
ized homonegativity (β homoneg = 0.20; p <
0.001).
Finally, we have introduced an interaction ef-
fect in our model to test the hypothesis that the
impact of sexual identity on depressive outcomes
is different between both sexes. The interactional
term between sex and sexual identity indicates
a difference in the impact of sexual identity on
depressive outcomes in women versus men (β =
–0.05; p < 0.01). For women, bisexuality is sig-
nificantly related to depressive outcomes (β =
–0.11, p < 0.01). This effect is not found in
men.
DISCUSSION
Pearlin’s (1989) social stress model, which
includes the effect of individual and social life
events and daily hassles on stress, is one of the
dominant paradigms in the sociological study
of well being. Meyer has expanded this model
and formulated the minority stress paradigms
(Meyer, 1995). Based on these theories, we
191
tested a model that looked at determinants of
mental health issues with a focus both on indi-
vidual and social characteristics of LGBs as a
sexual minority.
Although they are normally dealt with as con-
trol variables, we wanted to know if, and to what
extent, sex, age, and education influence mental
well-being in an LGB population experiencing
minority stress. Generally sex, age, and educa-
tion have a negative impact on depressive out-
comes. In our study, we find this to be only par-
tially true. One remarkable result is that there
was a lack of significant differences between
men and women regarding depressive outcomes.
It is possible that LGB men and women, indeed,
have similar levels of depression, and that the
explanation for the lack of sex differences can
be found in biological factors related to mental
health risks and sexual orientation (Rahman &
Wilson, 2003). Further investigation is needed.
Within youth research, the general youth pop-
ulation is described as being at risk. LGB youth
particularly seem to be at increased risk of men-
tal health problems (D’Augelli & Hershberger,
1993; Fergusson et al., 1999). Based on our re-
sults, it also appears that younger LGBs suf-
fer more from depressive outcomes than older
LGBs. The last background variable considered
was educational level. In our study, education
as a measure of socioeconomic status has a
strong impact on depression; this is fully in line
with past research, which has repeatedly con-
firmed the strong negative relationship between
socioeconomic position and psychological dis-
tress (Kessler, 1982; C. E. Ross & Van Willigen,
1997). Zzzip contains only nonexclusively het-
erosexual men and women, so no remarks are
made about the depressive level of heterosexu-
als versus LGBs. However, by using the Kinsey
scale, we have a range of sexual identities from
not exclusively heterosexual to exclusively gay
or lesbian. Bisexuality is significantly related to
poorer mental health in women, but not in men.
This is another indicator of the different path-
ways of sexual orientation and sexual identity in
men and women. They deal with their sexual-
ity in distinct ways and they also express diffi-
culties differently. However, because the effect
is rather small, the significance could also be
the result of a type-1 error. Conducting separate
 192 JOURNAL OF LGBT HEALTH RESEARCH
analyses for men and women and for younger
and older respondents, the impact of bisexuality
on depressive outcomes is greatest in the middle-
aged women. Further exploration in regard of
this finding is opportune to get more insight in
the explanation and contextualizing of this inter-
action effect.
Although a lot of LGB-specific research on
mental health includes internal stressors, it does
so without giving attention to the additional
effect of minority status. Also, in addition to
minority stress, LGBs remain exposed to gen-
eral stressors. Our hypotheses, which focus on
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the impact of stressful experiences and minority
stressors on mental health outcomes, have been
confirmed. Although experiences of general and
minority-status life events and daily hassles re-
sult in higher levels of depression, the general
negative experiences (poor health, unemploy-
ment, the end of a relationship, etc.), especially,
cause a significantly higher depression level.
Besides external minority stressors, LGBs can
suffer from internal minority stressors. Previous
research shows that both stigma consciousness
and internalized homonegativity have a posi-
tive impact on depressive outcomes (Cohen &
Garcia, 2005; Diplacido, 1998; Lewis, Derlega,
Berndt, Morris, & Rose, 2001; Lewis, Derlega,
Griffin, Krowinski, 2003; Meyer, 1995, 2003;
M. W. Ross, 1985; Shidlo, 1994). Respondents
who feel stigmatized score significantly higher
on CES-D. LGBs with a high stigma conscious-
ness tend to interpret interactions in light of this
stigma and are very aware of their difference.
Consequently, they will anticipate this stigma,
which can cause a great deal of stress, translated
into higher degrees of depression. Also, LGBs
that have internalized the negative attitudes to-
wards homosexuality in other persons and to-
wards homosexual features in themselves score
significantly higher on the depression scale.
These findings about external and internal mi-
nority stressors say something about the values
and norms in Flemish society. During the last
decade, much has changed for LGBs in Flanders.
Belgium has reached a fully juridical recognition
of homosexuality since the legislation of mar-
riage between persons of the same sex and adop-
tion by same-sex partners (Waaldijk, 2006). This
makes Belgium, together with the Netherlands
and Spain, the country with the most extensive
LGB rights in Europe. As a result of antidiscrim-
ination legislation in Belgium, which states by
law that individuals may not be discriminated
by their sexual orientation, external LGB dis-
crimination is under attack. Those engaging in
overt LGB discrimination at work, for exam-
ple, can be sued. This reduces the overt forms
of discrimination. Although most of the Flem-
ish population tends to be accepting of homo-
sexuality, one could argue that Flemish society
is still characterized by heteronormativity and
aversive prejudice (Dovidio & Gaertner, 1986;
Pickery & Noppe, 2007). This means that there
is still a difference between what people say and
how they actually behave. Most people have a
positive attitude toward homosexuality, but they
tend to behave in a stereotypically heterodomi-
nant way (Crocker, 2005). Internal stressors are
much more difficult to handle because they are
based on subtle processes inherent to the so-
cialization process. Internal minority stressors
remain very important sources of stress. As long
as societies are heteronormative, stressors such
as internalized homonegativity and stigma con-
sciousness will remain significant predictors of
stress outcomes, including depression.
The results of this study should be inter-
preted in light of the following limitations and
strengths. Zzzip is based on cross-sectional data,
which makes longitudinal or lifespan research
impossible. Furthermore, we had to limit our
model, which meant that we were only able to
explore a subpart of the whole picture. The fo-
cus was on depressive outcomes as an indicator
of mental health, which gives a one-sided vi-
sion of stress outcomes. In the next Zzzip sur-
vey, not only internalized stress outcomes—such
as depression, feelings of loneliness and self-
esteem—but also externalized stress outcomes
like deviant behavior (at school, towards alcohol,
criminality, etc.) are includes to get the broader
picture.
Additionally, although general and minority
stressors were compared, they covered different
areas of life. General external stressors consisted
of events that happened in the spheres of work,
health, and relationships, whereas the minority
stressor variable was limited to discrimination at
work. To get a more detailed view of the effect
 Cox et al.
of external general and minority stressors, more
complete scales should be used, for example, the
life event scale of Tennant and Andrews (1976)
for general stressors, and SCALES of Rosser
and Ross (1989) for minority daily hassles and
life events.
This study also offers a number of strengths.
First of all, Zzzip is a large and diverse sample.
The sample contains 2,280 respondents, reflect-
ing the variance within the LGB population (men
and women, higher and lower educated respon-
dents; lesbians, gays, and bisexuals; LGBs in and
out of the closet, etc.). Second, our model gives
Downloaded By: [Canadian Research Knowledge Network] At: 18:02 7 October 2009
renewed attention to the specific impact of back-
ground variables in the social stress model, an
impact that is taken for granted in most research.
And finally, our study has focused on both gen-
eral and minority stress, with an emphasis on
the importance of minority stress, an issue that
has been largely ignored in much LGB-specific
research.
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