Psychoneuroendocrinology 75 (2017) 1–4

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Psychoneuroendocrinology
journal homepage: www.elsevier.com/locate/psyneuen

Short Communication

Cortisol profiles differ by race/ethnicity among young sexual minority

men
Stephanie H. Cook a,c,∗ , Robert-Paul Juster b , Benjamin J. Calebs a , Justin Heinze c ,
Alison L. Miller c
a
Department of Psychology, The University of Michigan, Ann Arbor, MI, United States
b
Department of Psychiatry, Columbia University, New York, NY, United States
c
School of Public Health, Health Behavior Health Education Department, The University of Michigan, Ann Arbor, MI, United States

a r t i c l e i n f o a b s t r a c t

Article history: Much of the extant scientific research examining hypothalamic-pituitary-adrenal (HPA)-axis functioning
Received 21 June 2016 is conducted among White heterosexuals. Very little research examines HPA-axis functioning between
Received in revised form 4 October 2016 different minority groups. Individuals who identify as both sexual and racial minorities may experience
Accepted 11 October 2016
increased stigma and discrimination that can affect HPA-axis functioning. In the current study, we exam-
ined diurnal cortisol rhythm in young White gay men (WGM) compared to young Black gay men (BGM).
Keywords:
The sample consisted of 70 healthy gay men (mean [SD] age = 22.9 [3.2]: 68% White and 38% Black) who
Race/ethnicity
collected four saliva samples daily for five days. Repeated measures analysis of covariance and post-hoc
Sexual orientation
Diurnal cortisol
tests revealed that BGM had higher cortisol levels than WGM in the evening. Secondary analyses revealed
Gay/bisexual young men no significant group differences for the cortisol awakening response or systemic output throughout the
day. However, BGM compared to WGM had a lower drop from peak (morning) to lowest (evening) cortisol
concentrations. Taken together, these findings reveal a flatter diurnal cortisol rhythm among BGM com-
pared to WGB. The functional significance of these preliminary findings must be explored further with
assessment of psychosocial factors among sexual minorities at the intersection of multiple identities. In
summary, we expand health disparities research aimed at delineating sexual minority and race/ethnic
variation in stress physiology.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
The majority of diurnal cortisol studies have been conducted
among White heterosexuals. Yet for vulnerable minorities, social
factors like race/ethnicity-related discrimination (Adam et al.,
2015; Huynh et al., 2016) as well as socioeconomic disad-
vantage (Chen et al., 2010) are associated with dysregulated
hypothalamic-pituitary-adrenal (HPA)-axis functioning. Likewise,
sexual minorities are more likely to experience discrimination
based on their sexual orientation compared to heterosexual indi-
viduals (Fredriksen-Goldsen et al., 2013). Recent research shows
that sexual orientation-related stress and stigma can modulate
HPA-axis reactivity among sexual minority individuals compared
to heterosexual individuals (Hatzenbuehler and McLaughlin, 2014;
Juster et al., 2015). Theories of sexual minority stress (Cook and
Calebs, 2016; Meyer, 2003) suggest that there are stressors related
to social stigma and discrimination that generate excess stress.
Stressors related to social stigma and discrimination can increase
risk for physical and mental health problems among sexual minor-
ity individuals (Institute of Medicine, 2011).
Based on extant theoretical and empirical work, we hypothe-
size that men who are both Black and identify as sexual minorities
are at greater risk for dysregulated HPA-axis functioning than men
who do not have intersecting marginalized identities. The cur-
rent study therefore examines sexual and racial/ethnic minority
stress by assessing diurnal cortisol rhythm in young White gay men
(WGM) compared to young Black gay men (BGM).
2. Methods
2.1. Participants

∗ Correspondence to: College of Global Public Health, 726 Broadway, Suite 525, The final sample consisted of 68 young gay and bisexual men
New York, NY, 10003, United States. (two participants were not included in the current analysis because
E-mail address: sc5810@nyu.edu (S.H. Cook). they only completed the baseline assessment) recruited from the

http://dx.doi.org/10.1016/j.psyneuen.2016.10.006
0306-4530/© 2016 Elsevier Ltd. All rights reserved.
2 S.H. Cook et al. / Psychoneuroendocrinology 75 (2017) 1–4
Midwest region of the United States. Participant ages ranged from
18 to 29 years (M = 22.9, SD = 3.3). Further, 61.8% of the sample iden-
tified as White while 38.2% identified as Black/African-American.
With regard to highest level of education achieved, most reported
having at least some college experience: 47.1% had some college
and 47.06% attained a college degree or higher. Regarding employ-
ment status, most reported being a student (69.1%) or working
(26.5%). Most participants reported a current yearly income of less
than or equal to $20,000/year, with 47.06% of the sample earning
$0–$10,000/year and 23.5% earning $11,000–20,000/year. Half of
the participants identified their relationship status as single (55.9%)
and 44.1% reported being married or in a relationship.
2.2. Materials and procedure
The present study was part of a larger project involving a 5-
day daily diary to examine how adult attachment insecurity is
associated with stress. Using a convenience sampling strategy, par-
ticipants were recruited via online and offline recruiting techniques
(e.g., posting study advertisements on websites, in coffee shops, on
university posting boards). Interested individuals were directed to
an online screening survey. To be eligible for the study participants
had to be: (i) between 18 and 29 years of age; (ii) born biologically
male and self-identify as male; (iii) identify as gay or bisexual; and
(iv) have a working smart phone with Internet access.
All participants completed an informed consent prior to com-
mencement. Participants were then given a computer-assisted
baseline survey, which gathered information regarding demo-
graphics, physical health, mental health, and a variety of
psychosocial and behavioral constructs. The baseline survey took
1 h on average to complete. Participants were then given further
information about the 5-day daily diary and saliva sample com-
ponents of the study. Participants were also given saliva sample
collection materials at this time.
To participate in the study, participants collected 4 saliva sam-
ples each day over the course of 5 consecutive days. Samples
were collected at waking (between 0600 h and 1000 h; sample 1),
30 min after waking (between 0630 h and 1030 h; sample 2), mid-
day (between 1200 h and 0200 h; sample 3), and in the evening
(between 0900 h and 1200 h; sample 4). Text message reminders
were sent to participants in order to increase adherence to the study
protocol. Sample collection times were recorded by participants on
the sample collection tubes. If participants’ sample collection times
deviated from the time frame suggested by the study protocol (e.g.,
if they slept later in the morning), then their reported times were
used for the diurnal cortisol data.
Samples were collected via passive drool into a collection tube
with the aid of a straw. Participants were asked to collect at least
1 mL of saliva. Participants were instructed to abstain from eating
or brushing their teeth 60 min before taking a sample. Also, par-
ticipants were told to avoid anything with high caffeine content,
sugar content, or acidity before collecting samples. Participants
were asked to rinse their mouth with water 10 min prior to sam-
ple collection. Participants were told to store their samples in a
freezer or in a provided lunchbox with icepack until they were able
to freeze the samples.
After each of the first three saliva samples taken each day, partic-
ipants were sent a text message or email with a link to a brief survey.
After the final saliva sample of the day, participants received a link
to a slightly longer nightly survey. After day 5 of the study, par-
ticipants returned materials for a debriefing interview. Individuals
could receive up to $115 for study participation. All surveys were
administered online (through Qualtrics). Statistical analyses were
completed using Stata v13 Data Analysis and Statistical Software
(College Station, TX, US).
2.3. Measures
2.3.1. Race/ethnicity
Race/ethnicity was categorized as follows: White/non-
Hispanic = 0, and Black (Hispanic or non-Hispanic) = 1.
2.3.2. Salivary cortisol
Assays were conducted at the Core Assay Facility, University of
Michigan using the Salimetrics Cortisol Enzyme Immunoassay Kits
(Salimetrics, LLC, Carlsbad, CA, US) to measure cortisol concentra-
tions. Prior to analysis, saliva samples were kept frozen at −20◦ C.
Saliva samples were thawed then centrifuged with the enzyme
immunoassay at 500 rpm for 5 min, then incubated at room tem-
perature for 1 h. The plates were then washed and centrifuged again
for 5 min at 500 rpm, then left to incubate again at room tempera-
ture for 25 min. Stop solution was added, samples centrifuged again
for 3 min at 500 rpm, and measurements taken within 10 min after
the addition of the stop solution. Individual samples with a coef-
ficient of variability greater than 15% were re-run. The inter-assay
coefficient of variability was 9.31%. The intra-assay coefficient of
variability was 5.44%.
We used aggregated data over the course of two weekend days
and three weekdays to enhance ecological validity. Raw values
were analyzed in addition to the time-dependent scores described
below. A normal diurnal cortisol rhythm consists of an acute
increase during the first hour after awakening – referred to as the
cortisol awakening response or CAR (Stalder et al., 2016) – followed
by gradual decreases throughout the day, reaching the lowest levels
before bedtime. Deviations of this normal circadian process, espe-
cially the CAR (Chida and Steptoe, 2009) and bedtime elevations
are associated with distinct psychiatric symptoms.
Summary measures of cortisol used the area under the curve
(AUC) formula (Pruessner et al., 2003) to represent (1) the CAR (AUC
with respect to increase from awakening to +30 min after); (2) Max-
Min (AUC with respect to decrease from +30-min post-wake, pre-
lunch, and pre-bedtime); and (3) overall systemic output (AUC with
respect to ground across the day using all samples).
2.4. Statistical analysis
Repeated measures analysis of covariance (ANCOVA) for diurnal
cortisol measures throughout the day was employed adjusting for
time of awakening. Greenhouse-Geisser corrections are reported
whenever appropriate. Effect sizes can be interpreted according
to convention as a small (2 P = 0.01), medium (2 P = 0.06), or large
(2 P = 0.14). Significant interaction effects were examined post-hoc
using one-way analysis of variance.
3. Results
Main analyses assessed race/ethnicity differences using ANCO-
VAs while controlling for mean awakening time (M = 9.06,
SE = 0.09). A significant time X group interaction effect was
detected (F(2.47,140.7) = 5.18, p = 0.004, 2 P = 0.083). Post-hoc analy-
ses revealed that BGM had higher cortisol levels than WGM in the
evening (p = 0.015, 95% CI: 0.15, 0.27; Fig. 1A).
Secondary one-way ANCOVAs revealed no significant group dif-
ferences for the CAR (p > 0.87) or AUCg across the day (p = 0.336).
By contrast, the Min-Max AUC was significantly higher among BGM
compared to WGM (F(1,55) = 7.0, p = 0.011, 2 P = 0.111; Fig. 1B). This
finding revealed a lower drop from peak (+30 min after awaken-
ing) to lowest (evening) concentrations. Re-analyses according to
day-types revealed significant results for weekdays, but results for
weekends were only trending.
 S.H. Cook et al. / Psychoneuroendocrinology 75 (2017) 1–4
Fig. 1. Diurnal cortisol as a function of race/ethnicity among young sexual minority men ages 18 to 29 years. (A) Results assessing repeated-measures of estimated mean
(±standard error) diurnal cortisol showed that Black men had elevated cortisol at bedtime compared to White men. (B) Results using area under the curve with respect to
decrease (AUCd Max-Min representing decrements from time-points +30 after awakening, to midday, to evening) revealed a flattened diurnal output among Black men.
Note: * p < 0.05.
4. Discussion
The objective of the current study was to examine differences
in diurnal cortisol rhythm between young White gay men (WGM)
and young Black gay men (BGM). Understanding the processes by
which stressful social factors “get under the skin” of individuals
at the intersection of marginalized identities continues to be lim-
ited in psychoneuroendocrine research. As hypothesized, we found
differences in HPA-axis functioning by race/ethnicity. Specifically,
higher evening cortisol levels were shown among BGM compared
to WGM. While we cannot address the clinical or functional signif-
icance of our cross-sectional findings, this biological signature may
be detrimental to health and well-being.
Our findings reveal a flattened diurnal cortisol curve among
BGM compared to WGM. In terms of raw data, cortisol concentra-
tions only differed significantly at bedtime between the two groups.
While groups did not differ overall or for the CAR, the overall HPA-
axis decline was flattened among BGM (AUCd Max-Min). While
beyond the scope of the current analysis, these findings suggest
that social factors associated with being a ‘double minority’ may
differentially calibrate circadian HPA-axis functioning in BGM com-
pared to WGM. Hatzenbuehler and McLaughlin (2014) propose that
one of the key social factors influencing cortisol functioning may
be stress from social stigma and discrimination. They showed that
sexual minority youth who grew up in environments with a high
degree of social stigma towards sexual minorities (e.g., discrim-
inatory state policies) had a blunted cortisol response following
exposure to a modified Trier Social Stress Test compared to sexual
minority youth who grew up in less stigmatizing environments.
Although the researchers did not specifically address intersection-
ality among both sexual orientation by race/ethnicity, they provide
compelling evidence that structural stigma is related to blunted
HPA-axis functioning under stressful situations.
In the current study, the observed flattened diurnal pattern
observed among BGM combined with their elevated evening lev-
els suggests less daily variation that may be unhealthy. This
complements previous work demonstrating that racially Black
individuals have a flatter diurnal curve than racially White indi-
viduals (Adam et al., 2015). Researchers have argued that this
flattened curve may be the product of social stress associated with
being a racial/ethnicity minority in society (Adam et al., 2015). Fur-
ther, research conducted by Juster et al. (2015) shows that sexual
minority individuals experience a modified stress response when
3
compared to heterosexual individuals. Interestingly, researchers
have found that sexual minority men show lower cortisol reactivity
than heterosexual men (Juster et al., 2015). By contrast, previ-
ous studies have not shown differences in diurnal cortisol (Austin
et al., 2016; Juster et al., 2013) when sexual orientation is assessed
alone. Combined with these findings, our results expand this body
of research by indicating that those at the intersection of multi-
ple stigmatized identities (e.g., sexual and racial/ethnic minorities)
may indeed experience distinct diurnal cortisol profiles that should
be explored further.
This novel study is not without limitations. Recent studies (e.g.,
Shearer et al., 2016) suggest that social stressors and subsequent
mental health symptoms for gay men compared to bisexual men
of different racial/ethnic backgrounds may differ. This was not
addressed by our study and our current analysis did not assess psy-
chosocial constructs. Although no differences were found between
the cortisol levels for weekdays and weekend days, the aggregation
of the cortisol data has the potential to obscure important intra-
individual variation that was not our current focus. In addition,
we did not exclude participants for use of steroid medications (e.g.
some asthma medications). These substances could influence the
validity of our findings. However, we did ask about medication use
and found that very few young men used any medications. Further,
there was no statistically significant difference in cortisol between
young men who did use medications (with or without steroids)
and those who did not. Lastly, we would like to note that although
our results may hint at the importance of examining diurnal corti-
sol among racial/ethnic and sexual minority men, we cannot make
definitive conclusions about these populations because we did not
have a majority Black referent group. This limitation should be
addressed in future studies.
To conclude, our study of young sexual minority men demon-
strates that Black ‘double minority’ men manifest elevated evening
cortisol and an overall flattened diurnal curve compared to White
sexual minority men. In addition, HPA-axis functioning between
these two groups is likely to be determined by key social and devel-
opmental processes (e.g., sexual identity formation and disclosure
processes) that may differ by race/ethnicity. As such, these factors
should be explored in future studies of HPA-axis functioning among
sexual minority men. The results of the present study expand health
disparities research that has often focused solely on race/ethnic
differences by using approaches that assess intersecting identities.
4 S.H. Cook et al. / Psychoneuroendocrinology 75 (2017) 1–4
Conflict of interest
The authors unanimously declare no conflicts of interest.
Role of funding source
This work was supported by funding from the University of
Michigan (PI: Stephanie H. Cook).
Contributors
S. Cook conceived the study, constructed the study design, and
drafted the manuscript and all co-authors approved the final ver-
sion of the manuscript for submission. R. P. Juster, J. C. analyzed and
interpreted the data. B. Calebs, J. Heinze, contributed to the study
design and data collection. A. Miller contributed significantly to the
writing of the manuscript.
Acknowledgements
We thank our participants for their commitment to this
demanding study. We would also like to thank Teera Parr for per-
forming our biochemical assays.
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