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The minority stress framework and LGBTQIA+ mental health.

The minority stress framework and LGBTQIA+ mental health.

To understand the mental health of queer people, you need to understand the minority stress framework.

I’m a queer person who suffers from anxiety. My mind is often racing and looking for threat:

Am I in danger? Did I do something wrong? Have I failed? Did I forget something that’s going to result in a catastrophe? 

I’m prone to panic attacks, in which my heart races, my chest tightens so I feel I can’t breathe, and I get drenched in sweat. The attacks last about 20 minutes, and they often come out of nowhere. 

I also happen to be a psychiatrist who has spent nearly a decade studying neuroscience and mental health.

My training and personal experiences have given me a unique vantage point when it comes to queer anxiety and depression. After a decade of studying, I’ve come to the conclusion that there’s one concept clinicians need to understand above all else to support the mental health of people like me (read: people who are LGBTQIA+): the minority stress framework.

The minority stress theory, generally attributed to Ilan Meyer at UCLA, describes the ways in which societal treatment of individuals from stigmatized backgrounds impacts mental health. It breaks the consequences of societal stigma down into two types of problems: distal factors and proximal factors.

Distal factors.

Distal factors are factors from the outside world that impact mental health. They include rejection, victimization, discrimination, and non-affirmation of someone’s identity. I’ve experienced all of them.

When I was young, my father told me that being queer was morally wrong and that all gay people should be killed (rejection). In school, I was bullied and people would use queerphobic slurs toward me (victimization). There have been times when people told me I wasn’t really queer, but just confused (non-affirmation). And I’ve experienced people not wanting to work with me professionally because of my queerness (discrimination)

Queer people today are victims to a similar range of distal factors. Sadly, these include large-scale legislative attacks and stigmatizing language used by politicians on a national platform. Racially and ethnically minoritized people have suffered from such distal factors throughout history, and they continue today.

Proximal factors.

The minority stress theory explains that over time these distal factors become so-called proximal factors: toxic entities that live within our own psyches. 

One such proximal factor is internalized stigma. When I was young, I started to believe the negative things people said about queer people: “Maybe being queer is a sin. Maybe I need to force myself not to be queer. Maybe queer people are deviants who need to be cured.” 

I see similar thoughts popping up for my young transgender patients: “Maybe I am a danger to my peers in bathrooms. Maybe me playing sports isn’t fair. Maybe my identity is a mental illness”. 

Though they tend to know on a conscious level that these things aren’t true, it can be hard to shake the nagging voice of their subconscious that keeps suggesting that maybe they are. It’s quite obvious that these internalized ideas are the direct effect of unscientific and queerphobic national rhetoric related to bathroom bills, trans sports bills, and trans youth medical bills.

Another proximal factor is negative expectations, which some people term rejection sensitivity. Essentially, a person comes to expect future rejection based on the fact that they are part of a marginalized group. It’s similar to what we see among people with a history of trauma. If you were in a car crash, you’re going to over-index on how likely it is to be in a car crash the next time you drive. Similarly, because I have experienced so much stigma based on being queer, I continue to over-index on how likely it is to experience it again.

A third proximal factor to be aware of is concealment. From a young age, I learned to hide the fact that I was queer. This was one of the most important things in my life, because I thought I would be the victim of violence or being kicked out of the house if anyone found out. I deepened my voice. I started walking with a stiff posture to make sure no one could read my walk as flamboyant. When I meet new people, my deep voice and stiff posture usually come back, along with my anxiety.

Over time, this concealment of one’s queerness can lead to big problems. It drives shame and guilt, along with isolation from other queer people. Major self-esteem issues can develop, along with constant anxiety related to being “found out.”

The framework.

Below is a flow chart highlighting these proximal and distal factors and how they can lead to mental health problems. I’m including the version for transgender people, but the same concepts apply to most stigmatized groups. You’ll notice the model also highlights physical health problems as an outcome. Chronic social stress has also been linked to physical health conditions like cardiovascular disease.

Chart showing distal stress factors, proximal stress factors, resilience factors, and outcomes on the minority stress framework.
A flowchart describing the gender minority stress framework. From Forcier M, VanSchalkwyk G, & Turban JL (2020) Pediatric Gender Identity: Gender-affirming Care for Transgender & Gender Diverse Youth. Springer Nature.

Resilience factors.

Learning about the minority stress framework can be heartbreaking, but the good news is there are ways to combat the negative effects of societal stigma and their mental health sequelae, using what the framework calls resilience factors.

The first resilience factor is community connectedness. As I started to meet with and connect with other queer people, it helped me realize that many of the negative things I had internalized about queer people weren’t true. It wasn’t available when I was young, but today queer youth have access to places like Trevor Space, where they can safely connect with other queer young people like themselves.

These connections helped me develop a second resilience factor: pride. I realized that queer people have made spectacular contributions to society. For instance, I often talk to my young trans patients about how trans people have been vital trailblazers in law, medicine, the arts, business, and science. People like Rachel Levine (US Assistant Secretary of Health and founder of Penn State’s adolescent medicine division) and Lilly Wachowski (creator of The Matrix) remind us that being part of the queer community is something to be proud of.

I also find that just sharing the minority stress framework with patients helps them to build insight into how their own minds work. This can empower them to realize when their feelings of sadness or anxiety may be coming from distal or proximal stressors, and this knowledge can sometimes allow them to break out of that anxiety or sadness. 

Today I’ve been lucky to have the education and mental health support to combat minority stress and improve my own mental health. I spend my days as a psychiatrist helping other people do the same. If you’re reading as a person struggling with your mental health, I hope this helps you to better understand yourself, and I encourage you to connect with a therapist who can help you continue to improve your mental health; you deserve it. 

And for the mental health providers reading this, I hope you will incorporate the minority stress framework into your work supporting people from marginalized backgrounds. For too long, the mental health profession has neglected people, like me, and it’s time that we dedicate ourselves to developing the skills to help them. 

Jack Turban MD MHS (@jack_turban) is chief fellow in child & adolescent psychiatry at Stanford University School of Medicine, where he researches the mental health of transgender and gender expansive youth.