1 - (SYM 131) How Does Sexual Minority Stigma “get Under the Skin?”: A Systematic Review and 15-year Update on the Psychological Mediation Framework

Abstract Body

Background: The psychological mediation framework posits that stigma “gets under the skin” by elevating cognitive (e.g., rumination), affective (e.g., emotion dysregulation), and social (e.g., isolation) risk factors for psychopathology (Hatzenbuehler, 2009). In the 15 years since its publication, this framework has served as an important guide for clinicians and interventionists working with sexual minority (e.g., lesbian, gay, and bisexual) clients. Many of its key mechanisms have been targeted by interventions adapted for sexual minorities, leading to promising reductions in this population’s inequitable mental health burden (Pachankis et al., 2015). Given the proliferation of research into such mechanisms, now is an opportune time to update the evidence base for the psychological mediation framework.

Methods:  We systematically identified 1,970 empirical studies citing the psychological mediation framework (Hatzenbuehler, 2009). 224 studies testing universal risk factors as mediators of associations between stigma and psychosocial outcomes among sexual minorities were included in our review. We extracted and synthesized data on the strength of associations between these variables, including evidence of mediation, as well as on sample demographics and study characteristics.

Results: We found the strongest evidence of mediation for rumination, emotion dysregulation, and social support. We uncovered several additional cognitive (e.g., hypervigilance) and affective (e.g., shame) mechanisms as well as new relational (e.g., attachment), personality (e.g., self-criticism), and biological (e.g., inflammation) processes. Limitations included the use of primarily cross-sectional designs with convenience samples and a predominant focus on stigma at the individual (vs. structural) level.

Conclusions:  Cognitive-behavioral therapy (CBT) interventions adapted for sexual minorities may benefit from targeting a wider range of mechanisms than initially proposed by the psychological mediation framework (Hatzenbuehler, 2009). Innovative methods—including longitudinal, population-based studies—are needed to enhance causal inference and the generalizability of findings. As empirical support for novel treatment targets grows, community-engaged research can ensure that interventions effectively address these processes.