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    Israeletal.2021-DevelopmentandEfficacyofanOnlineInterventionTargetingLesbianInternalizedHomonegativity

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    Israeletal 2021-DevelopmentandEfficacyofanOnlineInterventionTargetingLesbianInternalizedHomonegativity

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    Magda Rossato

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    Pari Se moose Professional Psychology: Research and Practice Development and Efficacy of an Online Intervention Targeting Lesbian Internalized Homonegativity ‘Tania Israel', Joshua A. Goodman, Krishna G. Kary', Em Matsuno’, Andrew Young Choi', Yen-Jui Lin’, and Caitlin R. S. Merrill? "Department of Counseling, Clinical, and School Psyehology, Gevirt: Graduate School of Education, University of California, Sana Barbra * Counseling and Psychological Services, Univesity of San Francisco Internlized omonepativity (1H) serves as a key predictor of mental health dspasts such ax depesion, tmx, and substance abuse in minociy sues theory (Meyer, 2003). We adapted an efficacious intervention to seduce TH in sexual minority men to address the specie experiences of cisgender lesbian ‘women. The intervention, based on principles of the Releasing Interaize Stigma for Empowermest (RISE) model (Line al, 2019), contains four iterative modules that were wiloeed towazd the speci experiences of lesbians Combating stereotypes, identifying and réjectng negative messages, reinforcing the rejection of negaive messages, and enhancing afimation. Five hundred thy te parcpans, recruited from Amazon Mechanical Turk, suocesflly completed covariate measures of se-estets and identity concealmeat, RISE (n = 274)orasuess- management conto condition (x = 259) andthe Lesbian Imtenlized Homophobia Scale (LIHS) at potest. We found that RISE panicipants had lower levels of pesonal homonepativity at postest compared with contol paricpant, and tere were no diferencia tudes toward othe lesbias. Our results suggest that IH in lesbians canbe ares, and we provide 5 suggestions fr how therapists may use RISE to augment therapy or implement specie componens ofthe intervention int ther prvtice wit lesbians who expecence I Joshua A. Goodman © hipsorcd og0000-0002-6467-3816 Em Matsuno © tapsforidor/0000-0002-6333-7984 Andrew Young Choi © tpn og/0000-0002-9560 1022 “Tas ea olds a PAD i Counseling Psychology fom Arizona tate Univenity. She isa Professor inthe Deparment of Counseling, lial and School Psychology athe University of California, Sania Barbara, Her Scholarship focuses on interveations to support the mental heath and Wellbeing of sexual and ender minors, bisexuality, seal justice, and logue across poll diferences, ‘esmn A. Goopsiy received his PHD in Counseling, Clinical and School Psychology fom the University of Califia, Suna Barbara Hes eurenty an Assistant Profesor of Psychology at Rhodes College, His research imerests include family support fr sexual and gender minaty youth and interventions thi tito improve mental health ad far suport for seul and gender minority individuals and commas. Kiss G. Katy received their PD i Counseling, Clini, and School Psychology fom the University of California Santa Barbara They ae ‘eerily a sal psyehologist in the Adal Payeitry department at Kaiser Permanente in Mountain View, California Their aeas of interest inelude sexual and gender identiy concer, sexual functioning, mica supervision and waining, and program development iy Marsono received their PAD in Counseling, Clinical, and School Psychology (counseling emphasis from the Universi of Calfoia, Sana, Bathura. They are curently a research posioctral fellow at Palo Alto University. Masuno's research interest include tans and nonbiary meatal heal, minosty sites and revence, and intervention research. [Avoxrw Yous Coo cared his PRD in Covaseing, Clinical, and School Psychology from the University of California, Sana Barbara Hes ow at the Counseling and Student Development Cener of the University of Hawai at Migoa. His scholarly intrest inelade idenity formation, imersectionality, and mental health stpong Asian Americans and sexual rminociy people of colo, and te psychology of racism, oppression, and lierton. Yell) Li received his PRD in Counseling, Clini, and) School Psychology fom the University of Califomia, Santa Barbara. He euzenly works in administration atthe Las Angeles County Department of Mental Heal He is interested in igtmalzed stigma, LGBT isues, and ross cult cownscing ‘Cams RS. Menaas received her MA in Counseling Psychology fom the University of Calfomin, Santa Barbar, Shes cet PAD Candiate a the Univesity of Calfonia, Santa Barbara and 2 Doctoral lnen a the University of California, Los Angels. Her areas of profesional interest inslude LGBTQ+ ments health and icrvenion, with « oous on the transgendevinonbinary population, Dats collection fortis atile was nanilly supported in pat by the University of Clfomia, Sana Barbara Academe Serate Grant awarded 10 “Tuna sae. Findings rom hs article were previously presented atthe 124%, Annual Convention ofthe Amencan Psychological Association in Denver, CO in August 2016 Correspondence concerning this ancle should te addressed to Tania Isral, Department of Counseling, Clinical, and Schoo! Psychology, Gevirtr Graduate School of Bdscation, University of California, Santa Barbara, CA 931069490, United States. Email: tstul@ usb eda 2 ISRAFL ET AL. Public Significance Statement ‘We tested an internet-based psychological resource to help lesbian women address negatives: stitudes abou heir sexual osentaton ad found that parcpuns who used this rexouree eld more postive ates about tei lesbian idensty compared with a cont! group who completed sues ‘managemeat activities. Because negative selFatiudes ar associate with mental beat challenges, his resource shows promise in addressing common source of psychological dress for lesbian women, ‘Keywords: internalized homoncputvty, lesbian, LGBT, online intervention, semua minority women ‘A substantial body of research has established that lesbians ‘experience mental and physical health disparities relative to their heterosexual peers. Specifically, lesbians are at elevated risk for mood or anxiety disorders and suicidality (Blosnich etal, 2016; Bostwick etal, 2010). They are also more likely than thee etero- sexual peers to engage in health risk behaviors, including alcohol abuse, smoking, and substance use (Hequembourg etal, 2020; Mereish & Bradford, 2014), and experience worse physical health ‘outcomes both globally, and in tems of specific outcomes such as ‘obesity and cardiovascular disease (Simoni etal, 2017). Models of mental and physical health for sexual minority popula- tions suggest tht minority stress processes explain health disparities between lesbians and their heterosexual peers (Hatzenbucle, 2009; Meyer, 2003). Such models distinguish between distal stressors, which aze exlemally experienced events such as prejudiced mes” sages, discrimination, and violence based upon one’s sexual orien- tation, and proximal stressors, which are intemal experiences such as expectations of rejection du to sexual orientation, concealment ‘of sexual orientation, and internalized homonegativity (IH). A. ‘minority stress framework has been used to conceptualize health disparities atthe intersection of multiple marginalized identities, such as the mental health of Black lesbian women (Calabrese tal, 2015), A particular focus of minority sess research has been TH (also referred to 2s intemalized homophobia or heterosexit), which i sexual minority person's adoption of societal stigma about their sexual orientation. A lage body of research has identified significant associations between TH and adverse mental health outcomes (Szymanski etal, 2008), Research about TH in lesbians, speci cally, has established its role asa predictor of psychological distress (Szymanski & Kashubeck-West, 2008), including signiticant asso- Cations between IH and depression (Piggot, 2004; Rubino etal 2018), alcohol and substance use (Lehavot & Simoni, 2011), low self-esteem (Szymanski etal, 2008), and distress about sex (Cohen & Byers, 2015). Likewise, IH is associated with lower social suppor, a key protective factor against the negative impacts of minority stress (Szymanski & Kashubock-West, 2008). ‘Although IE has similar impacts on women and men, there are important differences in the manifestation of TH based upon gender Most notably, TH is intetwined with gender role socialization, ‘which for people socialized as women includes the devaluing of female sexual desire, emphasis on interdependence over indepen- dence, and emphasis on mothethood (Szymanski & Chung, 2003). CCisgender sexual minority women are exposed to and may inter- nalize messages that are rooted in sexism, including the denigration ‘of “butch” gender expression, the perception that lesbians are aggressive, and the notion that fulfillment requires: marrying. & ‘man and raising children (Szymanski & Chung, 2001; Szymanski & Henrichs-Beck, 2014). These findings highlight the importance of targeting gender-speciic manifestations of I, Interventions to Reduce 1H ‘The well established link between TH and adverse mental and ‘behavioral health outcomes has le to calls for interventions that aim to reduce IH (Berg etal, 2016; Szymanski ct al, 2008). Novably, whereas other proximal stressors in minority stress theory can sometimes be adeptive—for example, concealing one’s sexual orientation for reasons of safety or expeciations of rejection that mentally prepare a person fora discriminatory environment—there is no known bene to I, ‘A recent systematic review ofthe Ierature identified 201 studies bout IH, of which four (2%) were intervention studies (Berg eta, 2016); a small number of addtional intervention studies have been published in recent years (eg, Pachankis eta, 2015; Smith eta. 2017), A majority of interventions with & goal of reducing TH were designed for sexual minority men (Lin & Isracl, 2012; Pachankis etal, 2015; Smith etal, 2017; Vega etal, 2011). Two studies in the review included women: A modified cognitive behavioral group, therapy protocol (Ross et al, 2007) and acceptance and commit ‘ment therapy with a sample of five sexual minority adults (Yadavaia & Hayes, 2012), although neither significantly reduced IH. ‘Two interventions have shown promise for reducing IH. An eightsession cognitive behavioral group with gay and bisexual ‘young adults demonstrated a smal effect sire between 1H at pretest land both posttest and a 3 month follow-up (Smith etal, 2017) Releasing Interalized Stigma for Empowerment (RISE), 2 30-min ‘online intervention for same-sex attracted men based upon social psychological principles of atitade change, yielded significantly lower IH at posttest relative toa contol group (Lin & Israel, 2012). Adaptations of RISE tilored for eisgender gay men dsrael, Goodman, etal, 2020), bisexual people (srael etal, 2019), and sransgender people (Israel, Matsuno et a, 2020) have also been cicacious, Online Interventions Online intrventions—websites and mobile applications that contain self-guided psychological activities and resources —ae a promising tol for addressing mental and behavioral conceras, and hhave been used for such purposes as addressing depression, anxity, alcohol and substance use, and det and exercise goals (Krebs etal 2010; Leeman et al, 2015; Livin etal, 2013; Saddichna etal, 2014). The vast majority of the United States population within LESBIAN INTERNALIZED HOMONEGATIVITY INTERVENTION 3 ‘every demographic group regularly uses the intemet, including 91% ‘of women (Pew Research Center, 2019). A range af computerized health-care interventions has typically had small to medium effect sizes (Finh etal, 2017; Heber et al, 2017; Portnoy et al, 2008). Although there is litle w no online psychological intervention research focused on cisgender lesbians there are reasons to believe ‘that interventions may hold promise with this population. First, the ‘vast majority of sexual minority individual tun to the interme for ‘health-care information Gabson etal, 2017), and lesbian and bisexual women seek sexual minority-speciic spaces for health ‘care related information (Ruppel et al, 2017). Second, people are ‘more likely o share vulnerable information, potentially including internalized negative self atitudes, ia an anoaymous online space ‘than in-person (Coyle etal, 2007). Thied, whereas lesbian, gay, bisexual, transgender, and queer (LGBTQ) people face barriers in accessing health-care services (Alencar Albuquerque et al, 2016), ‘online interventions have the potential to reach cisgender lesbians who lack access to affirming in-person psychological resources, incuding duc to distance (€.. in rutal areas), cost, stigma, and health or mobility concerns Present Study Given the dearth of IH intervention research for lesbian women, wwe sought to develop and test the efficacy of an intervention to reduce IH in this population. We adapted Lin and Israel's (2012) efficacious RISE intervention for sexual minority men—a set guided internet resource based upon research about atitude cchange—to be specific to experiences and messages that were salient to cisgender lesbians, (Bisexual women and transgender lesbians were directed toward versions of RISE that were tailored toward bisexual and transgender people, respectively, Matsuno etal, 2020). Targeting IH in cisgender lesbians, responds 0 recommendations for research ual is tailored toward LGBTQ subpopulations (Balsam & Mohr, 2007) and the IH experiences ‘of lesbians, specifically (Szymanski & Chung, 2003). We hypothe- sized that, relative to @ control, participants who completed the auapted intervention would have significantly lower levels of IH at posttest. In adalition 0 testing the efficacy of RISE, we sought to assure that this psychological intervention containing potentially emotion- ally challenging content was not inadverienly harmful to par pants. Tis was a priority due to te absence ofa relationship with 2 ‘mental health professional in the asynchronous environment and in ‘rdr to assess the appropriateness of potentially offering RISE to youth inthe future. We hyposhesized that RISE participants would not express different postntervention level of positive and negative affect compared with participants in the control condition. Method Participants A total of 661 participants provided informed consent and ‘completed a screening. Of those who began the study, 63 dropped ‘out, 64 were disqualified (e.., non-US. location, failed validity test, completed the study in under 15 min), and one was not analyzed due to technical issues with the data, yielding a final sample of 533 participants. Most participants sel-identiied as & lesbian (04%, m= 502) oF gay (2%%, n= 12); others reported exclusively same-sex attractions and identified as heterosexual (1%, m =4), another response option (e-., queer, questioning, unlabeled; 2%, x =9), or did not list a sexual orientation. The ‘mean age was 31 (SD = 9.80) and ranged 18-~68-years-old. Pat cipants identified their race/ethnicity ina cheek: all-that-apply for ‘mat as White/Cancasian (16%, n = 406), Black/African American (13%, n = 68), Latina (8%, n = 44), Asian/Pacific Islander (4%, n= 21), Native Ametican/Alaska Native (2%, n = 10), Middle Exstem (1%, n= 4), or another race or ethnicity (1%, » = 5), "The modal participant was middle class on a subjective measure of socioeconomic status; SES (Adler etal, 2000) asking partici- pans fo rate their social class on a ladder ranging from the frst (west) to ninth (highest step (M'= 4.45 SD = 1.75), and about ‘one-third of participants had Bachelor's degree or bigher (32%, n= 172), Most paticipants were politically liberal or very liberal (66%, m= 353) with fewer identifying as conservative or very conservative (9%, n= 48) of neither liberal nor conservative (242%, n = 127), Patcipantsdeseribed their location as suburban (4296, n = 223), urban (36%, m = 193) oF rural (20%, = 105), Intervention ‘The RISE intervention consisted of four modules, adapted from Li and Israel (2012) and grounded in social psychology principles of attude change, with IH framed as an atiude toward the self (Lin (al, 2019), As Lin and Israels (2012) intervention was designed for men, we modified the content 10 reflect cisgender lesbian ‘women's intemalized homonegativity, as described below. A draft of the modified intervention was reviewed by a panel of psychol- ‘ogists and other researchers with expertise in lesbian women’s TH as well as lesbian community members. In che present study, the finalized RISE intervention took approximately one half-hour to complete (Mdn = 30 min; M = 32 min, excepting a small number of outliers), although times registered in Qualtries, excluding out- lies, ranged from 15 min (the minimum tobe included in analyses) to 25.5 hr, Although the RISE intervention is self-guided, the modules were designed to build upon each other, and participants ‘were required to complete the modules in order. An overview of cach of the four madules is below. ‘Module 1: Combat Stereotypes ‘This module was designed to modify participants’ maladaptive beliefs about lesbians (eg. lack of sexual satisfaction in relation- ships) by presenting evidence to counter common stereotypes (Adams et al, 2007). Offering credible information in 2 neutral ‘manner may reduce belief perseverance and facilitate change in erroneous convictions (Lin etal, 2019). The participant was pre- sented with cight statements and asked to decide whether each was true, mostly tre, nether ue nor false, mostly fale, or false. These response options were used to reflec he fac tha certain stereotypes (cg, lesbians ae masculine) ate not universally tre noe alse. Aer the participant solected an answer, immediate feedback was pro vided about the acuraey of their answer, along with an elabortive explanation in accessible language with colorful graphics. At the end ofthe module, participants completed a four-item quiz to assess their attention and retention ofthe evidence presente. 4 ISRAFL ET AL. Module 2: Identify and Reject Negative Messages In the second module, participants relected on the negative messages about lesbians to whieh they had been exposed. Consistent with atribution theory, this approach was designed to help part- -ipants weaken the impact of stigma by recognizing extemal origins of internalized messages (Lin etal, 2019) in contrast to uncon- sciously accepting a negative self-image (Szymanski, 2005). Pat

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