Journal of Homosexuality, 62:971–992, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2015.1008285

Minority Stress and Binge Eating Among Lesbian and Bisexual Women TYLER B. MASON and ROBIN J. LEWIS Department of Psychology, Old Dominion University, Norfolk, Virginia, USA

Previous research demonstrates that lesbian and bisexual (LB) women report more binge eating behaviors compared to heterosexual women although the explanations for this disparity are not well understood. LB women also experience distal (e.g., discrimination) and proximal (e.g., expectations of rejection) minority stressors that are related to negative mental and physical health outcomes. The present study investigated the association between minority stressors and binge eating behaviors in LB women. A sample of 164 LB women completed an online survey that included measures of distal and proximal sexual minority stressors, emotional-focused coping, social isolation, negative affect, and binge eating. The resultant model partially supported both the psychological mediation framework and the affect regulation model. The principal finding was that among LB women, proximal stressors were associated with social isolation and emotion-focused coping, which in turn were associated with negative affect and ultimately binge eating. Overall, the study provides evidence that minority stress is associated with binge eating and may partially explain the disparity in binge eating between LB and heterosexual women. KEYWORDS lesbian, binge eating, negative affect, minority stress

The 2011 Institute of Medicine (IOM) report on sexual minority health documented important health disparities between heterosexual and both lesbian and bisexual women. Specifically, obesity is more prevalent among lesbian and bisexual (LB) women (Aaron & Hughes, 2001; Austin et al., 2009; Bowen, This article is based on Tyler B. Mason’s master’s thesis completed under the direction of Robin J. Lewis. Address correspondence to Tyler B. Mason, Department of Psychology, Old Dominion University, Norfolk, VA 23529, USA. E-mail: [email protected] 971

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Balsam, & Ender, 2008; Case et al., 2004). Population-based studies have confirmed an increased risk for obesity for lesbian women but not bisexual women (Boehmer, Bowen, & Bauer, 2007; Conron, Mimiaga, & Landers, 2010). Other non-population based studies have found increased obesity among bisexual women, however (e.g., Struble, Lindley, Montgomery, Hardin, & Burcin, 2011). In light of these findings, there has been increasing emphasis on reducing obesity and improving the health of LB women. For example, the U.S. Department of Health and Human Services (HHS) recently took actions to improve the health of LB women with discrimination policies and specific examination of lesbian, gay, and bisexual (LGB) health in the Healthy People 2020 project (HHS, 2012). Similarly, the Agency for Healthcare Research and Quality (AHRQ) has supported research aimed at reducing obesity in LB women (AHRQ, 2011). One significant contributor to obesity is eating behavior (Bulik, Sullivan, & Kendler, 2003; Campbell, Crawford, Salmon, Carver, Garnett, & Baur, 2007). However, little research has examined the relationship between sexual orientation and eating behaviors (IOM, 2011). With regard to binge eating specifically, research suggests that LB women are more likely to report binge eating compared to heterosexual women (Austin et al., 2009; Heffernan, 1994; Striegel-Moore, Tucker, & Hsu, 1990). In fact, based on results of the Lesbian Healthcare Survey, 68% of lesbian women reported overeating “sometimes” or “often” (Bradford, Ryan, & Rothblum, 1994). Binge eating is also a problem among LB adolescents, who both reported more binge eating compared to heterosexual adolescents in a large U.S. nonprobability sample from the Growing Up Today Study (Austin et al., 2009). Although research points to disparities in binge eating for LB women compared to heterosexual women, little is known regarding why these disparities occur. Given the health risks associated with binge eating, it is essential to increase our understanding of the underlying mechanisms of binge eating among LB women. With the ultimate goal of improving the health and well-being of LB women, the purpose of the current study was to develop and test a preliminary model of binge eating behaviors in LB women. This model was informed by the psychological mediation framework (Hatzenbuehler, 2009) and the affect regulation model of binge eating (Polivy & Herman, 1993).

BINGE EATING AMONG LESBIAN AND BISEXUAL WOMEN: THE AFFECT REGULATION MODEL Relatively little research has focused on eating-disordered behavior among LB women, and even less has specifically targeted binge eating behavior. Based on this sparse literature, we know that LB women report more binge eating behavior compared to heterosexuals (e.g., Austin et al., 2009;

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Heffernan, 1994; Striegel-Moore et al., 1990). Researchers have also suggested that LB women may engage in more binge eating to cope with discrimination and stigmatization associated with their marginalized status (Feldman & Meyer, 2010). The affect regulation model posits that individuals engage in binge eating to cope with negative affect (Polivy & Herman, 1993). As support for the affect regulation model, a recent meta-analysis of ecological momentary assessment studies demonstrated that binge eating among heterosexual men and women indeed was often precipitated by an increase in negative affect (Haedt-Matt & Keel, 2011). Similarly, binge eating has also been associated with lesbian women’s emotional experiences. For example, among lesbian women who engaged in binge eating, the urge to eat was more strongly associated with anxiety, anger, and depression compared to lesbian women who did not engage in binge eating (Heffernan, 1997). Furthermore, lesbian women who engaged in binge eating were more likely to use food as a distraction, for comfort, and to reduce anxiety more than lesbian women who did not engage in binge eating. Thus, based on the affect regulation model, and in line with empirical findings with heterosexual individuals, lesbian women may use binge eating as a response to feelings of depression and other negative emotions as posited by the affect regulation model (Heffernan, 1994). Although binge eating among LB women is an important health concern, the empirical literature in this area is limited, and much of it is rather outdated, with most key studies published more than a decade ago. Additional comprehensive models of binge eating must be developed and tested to advance our understanding in this area. Because LB women are a marginalized and stigmatized group in mainstream heterosexual society, unique experiences such as minority stress that LB women experience may explain disparities in binge eating behavior.

MINORITY STRESS: THE PSYCHOLOGICAL MEDIATION FRAMEWORK Minority stressors are experienced by LB women as a result of their marginalized status and are directly related to negative mental health outcomes in LGB individuals (Hatzenbuehler, 2009; Kelleher, 2009; Lewis, Derlega, Griffin, & Krowinski, 2003). In his seminal paper on sexual minority stress, Meyer (2003) classified minority stressors into two categories: distal stressors and proximal stressors. Distal stressors include external events such as experiences of discrimination, violence, and harassment and are related to psychological distress, physical symptoms, and substance abuse (Kelleher, 2009; Lehavot & Simoni, 2011; Lewis, Derlega, Clarke, & Kuang, 2006). Proximal stressors include subjective stressful experiences

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such as internalized homophobia, expectations of rejections (i.e., stigma consciousness), and stress related to concealment of sexual identity. Proximal stressors are associated with negative mood, depression, and substance abuse (Kelleher, 2009; Lehavot & Simoni, 2011; Lewis et al., 2006). In order to examine complex relationships between minority stressors and health outcomes, the psychological mediation framework was developed (Hatzenbuehler, 2009). This approach suggests that social and individual psychological resources may mediate the relationship between distal and proximal sexual minority stressors and mental and physical health outcomes (Hatzenbuehler, 2009). In a recent test of this mediated model, sexual minority stressors were related to less social support and less spirituality among lesbian and bisexual women, which in turn were linked to greater substance abuse and mental health problems (Lehavot & Simoni, 2011).

MINORITY STRESS AND BINGE EATING: THE HYPOTHESIZED MODEL Research on binge eating and minority stress is sparse. The available research to date has focused on internalized homophobia and general negative eating attitudes. In one study, depressive symptoms mediated the relationship between internalized homophobia and negative eating attitudes in lesbians (Haines, Erchull, Liss, Turner, Nelson, Ramsey, & Hurt, 2008), although binge eating was not assessed. Thus, researchers (e.g., Feldman & Meyer, 2010; Heffernan, 1994) have suggested the application of the minority stress model to the development of disordered eating warrants further research. The hypothesized model (see Figure 1) draws from the psychological mediation framework and the affect regulation model. Essentially the model posits that minority stressors are associated with negative affect and binge eating through the pathway described by the affect regulation model. Distal stressors (i.e., harassment, work discrimination, and other discrimination) and proximal stressors (i.e., internalized homophobia, stigma consciousness, and concealment of sexual orientation) are hypothesized to be associated with greater binge eating through indirect pathways, including pathways from distal and proximal minority stress to binge eating (1) through social isolation and negative affect and (2) through emotion-focused coping and negative affect.

METHOD Participants The study participants were 164 self-identified lesbian and bisexual women, 18–40 years old, who did not engage in any compensatory behaviors indicative of bulimia nervosa. Participants were recruited through the

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Binge Eating Among LB Women

Distal Minority Stress Social Isolation

Negative Affect

Binge Eating

Coping

Proximal Minority Stress

FIGURE 1 Hypothesized model.

Internet by asking “women who are attracted to women” between ages 18 and 40 to complete an online survey about lesbian and bisexual women’s health. Participants were recruited through national LGBT organizations, social media, online forums, Web sites, listservs, and LGBT newsletters. Sexual identity was assessed by asking participants, “How do you define your sexual identity? Would you say that you are: only homosexual/lesbian, mostly homosexual/lesbian, bisexual, mostly heterosexual, only heterosexual, or other.” The majority of LB women identified as lesbian, mostly lesbian, or bisexual; there were some participants who identified as other (including queer, pansexual, heteroflexible, and fluid). Women who identified as heterosexual or mostly heterosexual were excluded from participating in the study. The demographic characteristics of the sample are presented in Table 1.

Measures INTERNALIZED HOMOPHOBIA SCALE–REVISED (IHP-R; HEREK, 2009) The IHP-R measured the internalization of society’s negative attitudes toward sexual minorities, or internalized homophobia, in LB women. The scale has five items that participants rated on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score indicated higher internalized homophobia. A sample item is “I have tried to stop being attracted to women in general.” Convergent validity was demonstrated by a positive association between outness and the IHP-R in a sample of LGB men and women. Predictive validity was demonstrated by the IHP-R predicting lower

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T. B. Mason and R. J. Lewis TABLE 1 Demographic variables Variable Sexual Orientation Only Lesbian Mostly Lesbian Bisexual Other Sexual Attraction Only Women Mostly Women Equally Men and Women Mostly Men Age 18–25 26–30 31–35 36–40 Latin/Hispanic Origin Yes No Missing Race White Black American Indian or Alaskan Native Asian Other Multiracial Missing Education More Than Bachelor’s Degree Bachelor’s Degree Associate’s Degree/Some College High School Diploma Less Than High School Diploma Missing Locality Urban Suburban Rural

N

%

68 48 36 12

41.5 29.3 22.0 7.2

64 71 21 8

39.0 43.3 12.8 4.9

124 26 11 3

75.6 15.9 6.7 1.8

20 143 1

12.2 87.2 .6

102 21 3 6 3 27 2

62.2 12.8 1.8 3.7 1.8 16.5 1.2

22 53 65 20 3 1

13.4 32.3 39.6 12.3 1.8 .6

80 67 17

48.8 40.9 10.3

self-esteem, more depression, and more anxiety (Herek et al., 2009). The Cronbach’s alpha in the current study was .86.

STIGMA CONSCIOUSNESS QUESTIONNAIRE (SCQ; PINEL, 1999) The SCQ is a 10-item measure that assessed the extent to which LGBT individuals expect to be evaluated based on stereotypes. Higher scores on the SCQ indicated that the respondent perceived more discrimination toward them or their group. Respondents used a 7-point Likert scale ranging from

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1 (strongly disagree) to 7 (strongly agree). A sample item is, “Stereotypes about lesbians have not affected me personally.” The correlation between the SCQ and trust in others was -.17, and the correlation between the SCQ and self-consciousness was .31, demonstrating evidence for convergent validity (Pinel, 1999). The Cronbach’s alpha in the current study was .77.

CONCEALMENT Concealment of sexual orientation was measured by a single item developed by Franke and Leary (2001) asking, “How open are you about your sexual preference/orientation?” The response choices were I work very hard to hide it, I don’t want people to know, I selectively tell people I trust, I am not too worried about people knowing, and I never hesitate to tell people. Higher scores indicated more concealment. The item has been associated with internalized homophobia and stigma consciousness in precious research (Lewis, Derlega, Griffin, & Krowinski, 2003).

HETEROSEXIST HARASSMENT, REJECTION, (HHRDS; SZYMANSKI, 2006)

AND

DISCRIMINATION SCALE

The HHRDS measured self-reported lifetime heterosexist harassment, rejection, and discrimination. The measure has three subscales: Harassment and Rejection, Workplace and School Discrimination, and Other Discrimination. Participants disclosed the percentage of time they experienced specific events based on their status as a lesbian or bisexual woman from 1 (never) to 6 (almost all of the time). Higher scores represent more harassment or discrimination. A sample item is: “In your lifetime, how many times have you been treated unfairly by teachers or professors because you are a lesbian/gay/bisexual person?” Evidence for predictive validity of the HHRDS is supported by positive correlations between the HHRDS and psychological distress (r = 35), somatization (r = .30), obsessive compulsiveness (r = .34), interpersonal sensitivity (r = .29), depression (r = .23), and anxiety (r = .37) (Szymanski, 2006). Cronbach’s alphas for the current study were .81, .81, and .76 for the Harassment and Rejection, Workplace and School Discrimination, and Other Discrimination subscales, respectively.

FRIENDSHIP SCALE (FS; HAWTHORNE, 2006) The Friendship Scale was used to measure social isolation. The Friendship Scale includes six items, and participants use a 5-point scale with responses ranging from 1 (almost always) to 5 (not at all). A sample item is “I feel isolated from other people.” Convergent validity was demonstrated by the

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correlation between the FS and the social dimension of the WHOQOL scale (r = .44). The Cronbach’s alpha in the current study was .88.

THE COGNITIVE EMOTION REGULATION QUESTIONNAIRE (CERQ; GARNEFSKI, KRAAIJ, & SPINHOVEN, 2001) The CERQ measures cognitive emotional coping strategies individuals use after experiencing negative life events. The current study focused on the emotional coping subscales including self-blame, rumination, and catastrophizing. Participants rated how they generally think when confronted with a negative event using a 5-point scale ranging from 1 (almost never) to 5 (almost always). A sample item is “I think that I have to accept that this has happened.” Multiple regressions using the nine subscales as predictors explained 38% of the variance in depression and 33% of the variance in anxiety, providing evidence for predictive validity (Garnefski & Kraaij, 2006). Cronbach’s alphas for the current study were .81, .60, and .89 for the self-blame, rumination, and catastrophizing subscales, respectively.

MENTAL HEALTH INVENTORY (MHI; VEIT & WARE, 1983) The MHI is an 18-item measure of mental health consisting of four subscales: anxiety, depression, behavioral/emotional control, and positive affect. The MHI has two factors: (1) negative affect, consisting of the anxiety, behavioral/emotional control, and depression subscales, and (2) psychological well-being, consisting of the positive affect subscale (Veit & Ware, 1983). In this study, the MHI was used to measure negative affect—thus the positive affect subscale was not used. Participants report on their mood and behavior over the past four weeks on a 6-point scale. The response choices ranged from 1 (none of the time) to 6 (all of the time). A sample item is: “During the past 4 weeks, how much of the time did you feel depressed?” Concurrent validity is demonstrated by positive correlation of the MHI with SF - Role Emotional Scale (r = .59), the SIP - Emotional Behavior Scale (r = .56), and the UCLA Loneliness-Companionship scale (r = .53; Ritvo, Fischer, Miller, Andrews, Paty, & LaRocca, 1997). The Cronbach’s alphas for the current study were .86, .90, and .83 for the anxiety, depression, and behavioral/emotional subscales, respectively.

BINGE EATING SCALE (BES; GORMALLY

ET AL .,

1982)

The BES is an instrument that measures binge eating severity. Participants were given 16 groups of statements and instructed to indicate the statement in each group that best describes how they felt. Each item has three to

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four statements, and each statement is assigned a value between 0 and 3. Higher scores indicated more severe binge eating behaviors. A sample item is “I have no difficulty eating slowly; I may eat quickly, but I never feel too full; sometimes after I eat fast I feel too full; usually I swallow my food almost without chewing, then feel as if I ate too much.” In previous research, correlations between the BES and objective and subjective combined food intake journals were .42 for binge calories, .46 for binge days, and .48 for binge episodes (Timmerman, 1999). This demonstrated that the BES is useful for measuring uncontrolled eating. The Cronbach’s alpha in the current study was .88.

Procedure The study was approved by a university human subjects committee, and all participants were treated in accordance with APA ethical guidelines. Participants accessed the survey through an online link created with a survey management system and completed the questionnaires from a computer at the location and time of their own choice. No identifying information was obtained, so all surveys were submitted anonymously. Using a Webbased survey allowed us to access the difficult-to-reach population of LB women and also allowed us to ensure anonymity. Evidence suggests that Web-based surveys are a satisfactory data collection method because they produce similar results to traditional surveys and are not immensely affected by repeat or unmotivated respondents (Gosling, Vazire, Srivastava, & John, 2004). Respondents were allowed to skip any question that they did not feel comfortable answering. At the end of the survey, a list of resources and their contact information was provided for any participants who wanted additional information or assistance in accessing resources. Participants were directed to a separate link where they were able to enter their e-mail information to enter a raffle for one of four $25 gift cards. This information could not be associated with their responses in any way.

RESULTS Descriptive Analyses For descriptive purposes, participants were classified into binge eating categories based on the BES. Based on Gormally et al.’s recommendations, participants who scored ≤17, 18–26, and ≥27 were classified into non-binge eating, moderate binge eating, and severe binge eating categories, respectively. The majority of participants (81.7%) reported that they did not engage in binge eating, 13.4% engaged in moderate binge eating, and 4.9% engaged in severe binge eating. When lesbian and bisexual women were considered separately, the patterns of binge eating were very similar. Among lesbian and

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T. B. Mason and R. J. Lewis

bisexual women, respectively, 80.2% and 86.1% did not engage in binge eating, 13.8% and 11.1% engaged in moderate binge eating, and 6% and 2.8% engaged in severe binge eating. An ANOVA did not reveal any significant differences in binge eating between lesbian, bisexual, and other identified women, F (2, 161) = .53, p = .59, η2 = .01.

Data Analysis Strategy Structural equation modeling (SEM) with Mplus 5.2 was used to analyze the hypothesized model (see Figure 1; Muthén & Muthén, 2008). Bootstrapping with 5,000 bootstrap samples was used to reduce the impact of nonnormality, outliers, and a small sample size (Mooney & Duval, 1993) The data were analyzed for missing data patterns. The analysis showed that .61% of data points were missing. Approximately two thirds (61%) of respondents had complete data for all items, and 38% of items were complete for all respondents. The highest percentage of missing data for an item was 3.7%, and the highest percentage of missing data for an individual was 4.3%. The EM algorithm was used to replace missing values for items (Dempster, Laird, & Rubin, 1977). Each scale was imputed separately. Little’s Missing Completely at Random (MCAR) analysis was nonsignificant for all scales, indicating that it was acceptable to impute missing values. Descriptive statistics and a correlation matrix of study variables are presented in Tables 2 and 3, respectively.

TABLE 2 Descriptive statistics of variables Variable Distal Minority Stress Harassment Work Discrimination Other Discrimination Proximal Minority Stress Internalized Homophobia Stigma Consciousness Concealment Social Isolation Emotion-Focused Coping Self-Blame Rumination Catastrophizing Negative Affect Anxiety Affect Depression Binge Eating

N

M

SD

Min

Max

164 164 164

16.74 6.09 5.58

7.27 2.90 2.75

7 4 3

42 24 18

164 164 164 164

8.15 40.70 2.13 13.73

4.33 10.01 .78 5.60

5 10 1 6

25 70 5 30

164 164 164

5.21 6.73 4.93

2.30 2.13 2.39

2 2 2

10 10 10

164 164 164 164

16.69 10.88 11.75 9.42

5.59 4.62 4.83 8.07

5 4 4 0

30 24 24 46

981

.62

.68 .63∗∗

∗∗

Other .11 .03 .006

IH .24 .29∗∗ .18∗ .22∗∗

∗∗

Stigma .001 .08 .02 .50∗∗ .31∗∗

.10 .13 −.002 .33∗∗ .34∗∗ .31∗∗

.06 .12 .10 .19∗ .19∗ .11 .17∗

Outness Isolation Blame −.05 .05 .01 .07 .13 .10 .22∗∗ .45∗∗

Rum −.05 −.06 −.02 .16∗ .13 .20∗ .34∗∗ .45∗∗ .56∗∗

Catas .04 .11 .08 .14 .17∗ .23∗∗ .39∗∗ .33∗∗ .31∗∗ .45∗∗

Anxiety .12 .10 .07 .23∗∗ .22∗∗ .19∗ .61∗∗ .33∗∗ .29∗∗ .43∗∗ .71∗∗

Control

.10 .12 .09 .21∗ .20∗ .29∗∗ .57∗∗ .32∗∗ .38∗∗ .42∗∗ .75∗∗ .82∗∗

Depress

.21∗∗ .14 .18∗ .16∗ .25∗∗ .05 .21∗∗ .28∗∗ .14 .25∗∗ .32∗∗ .36∗∗ .34∗∗

Binge

Note. Work = Work Harassment; Harass = Harassment; Other = Other Harassment; IH = Internalized Homophobia; Stigma = Stigma Consciousness; Conceal = Concealment; Isolation = Social Isolation; Blame = Self-Blame; Rum = Rumination; Catas = Catastrophizing; Control = Behavioral/Emotional Control; Depress = Depression. ∗ p < .05. ∗∗ p < .01.

Work Harass Other IH Stigma Conceal Isolation Blame Rum Catas Anxiety Control Depress

∗∗

Harass

TABLE 3 Pearson correlations among study variables

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A measurement model was created for the latent variables, and then structural paths were added based on the hypothesized model. The following model fit indices were used as guidelines in evaluating model fit: comparative fit index (CFI) ≥ .95, root mean square error of approximation (RMSEA) ≤ .06, and standardized root mean square residual (SRMR) ≤ .08 (Hu & Bentler, 1999).

Measurement Model Four latent variables were constructed. The distal minority stress latent variable consisted of harassment and rejection, workplace and school discrimination, and other discrimination. The proximal minority stress latent variable consisted of internalized homophobia, stigma consciousness, and concealment. The emotion-focused coping latent variable consisted of rumination, self-blame, and catastrophizing. Finally, the negative affect consisted of depression, anxiety, and emotional control. Prior to estimating the structural model, a confirmatory factor analysis (CFA) was conducted to assess the adequacy of each observed variable as an indicator for the latent variable it was hypothesized to measure. One of the factor loadings on each latent variable was set to equal 1 in order to set the scale for each latent variable. The latent variables were allowed to freely correlate. The measurement model demonstrated good model fit, χ2 (48) = 65.41, p < .05, CFI = .98, RMSEA = .05, and SRMR = .05. Observed variables satisfactorily loaded onto their associated latent variable, with all loadings meeting the cutoff guideline for a fair loading of .45 (DiStefano & Hess, 2005). See Figure 2 for standardized estimates.

Structural Model The hypothesized structural model demonstrated adequate model fit, χ2 (68) = 111.29, p < .001, CFI = .95, RMSEA = .06, and SRMR = .06 (Hu & Bentler, 1999; Marsh, Hau, & Wen, 2004). The model was deemed adequate because all fit indices met or were close to meeting the recommended stringent cutoffs, the model was supported by previous research (Hatzenbuehler, 2009) and was unchanged from the a priori hypothesized model. Significance testing was done using 95% bias-corrected (BC) confidence intervals (CIs) generated from 5,000 bootstrap samples for both direct and indirect effects. BC confidence intervals are presented in Table 4. If the confidence interval did not include 0, then it was significant. There was a significant indirect association between proximal minority stress and negative affect through social isolation and through emotion-focused coping. There was a significant indirect association between (1) social isolation and bingeeating and (2) emotion-focused coping and binge eating through negative

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Binge Eating Among LB Women .18* Harassment and Rejection Work Discrimination

.75* .83*

Distal Minority Stress

.01

Other Discrimination

Stigma Consciousness

.37*

Binge Eating

.42*

.92*

Depression

.45*

.80*

89*

.50*

.66* Proximal Minority Stress

Anxiety

EmotionFocused Coping

.32*

.70* Concealment

.35*

Negative Affect

–.03 .15

Internalized Homophobia

.47

Social Isolation

.83*

.60* Self-Blame

Behavioral Control

.79* .70* Rumination

Catastrophizing

.04

FIGURE 2 Model with standardized path coefficients. Significance is based on bootstrapped CI. ∗ Indicates 95% CI does not include 0. TABLE 4 Path estimates with bootstrapped SEs and Cis Path Direct Paths Distal→Proximal Distal→Binge Distal→Isolation Distal→Cope Proximal→Isolation Proximal→Cope Proximal→Binge Isolation→NA Cope→NA NA→Binge Indirect Paths Proximal→Isolation→NA Proximal→Cope→NA Proximal→Isolation→NA→Binge Proximal→Cope→NA→Binge Isolation→NA→Binge Cope→NA→Binge

β

B

SE

95% CI

.15 .18 .01 .03 .50 .32 .04 .47 .42 .35

.08 .26 .01 −.01 .97 .16 .10 .37 1.36 .63

.08 .13 .10 .03 .52 .11 .43 .06 .33 .14

[−.08, .21] [.02, .55] [−.21, .19] [−.06, .04] [.55, 2.48] [.03, .45] [−.65, .98] [.26, .49] [.82, 2.11] [.35, .96]

.23 .14 .08 .05 .17 .15

.36 .21 .23 .13 .24 .86

.21 .15 .15 .11 .07 .31

[.17, .93] [.04, .62] [.09, .69] [.03, .46] [.12, .39] [.42, 1.69]

Note. Distal = distal minority stress; Proximal = proximal minority stress; NA = negative affect.

affect. There was a significant indirect association between proximal minority stress and binge eating through social isolation and negative affect, and between proximal minority stress and binge eating through emotion-focused coping and negative affect. The model explained 25.0% of the variance in social isolation (R2 = .250), 10.3% of the variance in emotion-focused coping (R2 = .103), 54.2% of

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the variance in negative affect (R2 = .542), and 17.4% of the variance in binge eating (R2 = .174). See Table 4 for path estimates, standard estimates, and bootstrapped BC confidence intervals. Modification indices did not suggest adding any additional paths.

Summary There were two significant indirect pathways predicting binge eating through minority stressors. Proximal minority stressors were indirectly related to binge eating behaviors through social isolation and negative affect. Also proximal minority stressors were indirectly related to binge eating behaviors through emotion-focused coping and negative affect. These results support the psychological mediation framework and the affect regulation model.

DISCUSSION The goal of this study was to develop and test a model connecting the unique stressors that LB women experience with the propensity to engage in binge eating behavior. The model was developed based on the affect regulation model (Polivy & Herman, 1993) and the psychological mediation framework (Hatzenbuehler, 2009). Results indicated that proximal minority stress and binge eating were indirectly associated through (1) social isolation and negative affect and (2) emotion-focused coping and negative affect. This is consistent with the affect regulation model and previous research in which stressful experiences (e.g., life stress) can lead to negative affect, which in turn can lead to binge eating behaviors (Sulkowski, Dempsey, & Dempsey, 2011). However, the affect regulation model also suggests that negative affect should decrease after binge eating. Because we did not assess negative affect and binge eating temporally, the current results offer only partial support for the affect regulation model. In order to provide more complete support for the affect regulation model among LB women, future research must extend the test of this model to examine what occurs following binge eating. The current results also demonstrate that the unique stressors that LB women experience related to their sexual orientation are associated with binge eating through pathways suggested by the psychological mediation framework and the affect regulation model. These proximal minority stressors are associated with social isolation or use of maladaptive emotioncoping strategies, which in turn are associated with increased negative affect. Consistent with the affect regulation model, LB women may engage in binge eating behaviors to obtain relief from unwanted negative feelings. In addition, it is possible to use information from the model in the current study to guide efforts to reduce binge eating and improve LB women’s health. For

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example, based on our results, if LB women increase their social interactions and improve their coping strategies as they deal with proximal minority stress, this may be associated, in turn, with reduced negative affect and reduced binge eating in order to cope with the negative affect. There was a significant direct path from distal minority stress to binge eating. However, the indirect pathway between distal minority stress and binge eating was not supported. Because we measured lifetime experience of discrimination rather than recent or daily discrimination, it may be that experiencing daily repetitive discrimination would be associated with more negative affect and increase the propensity to engage in binge eating behaviors. For example, in a study of racial discrimination, daily discrimination mediated the relationship between lifetime racial discrimination and negative affect (Ong, Fuller-Rowell, & Burrow, 2009). It may also be the case that discrimination is associated with binge eating by triggering momentary negative affect. Proximal minority stress was related to increased social isolation and more emotion-focused coping. Social isolation and emotion-focused coping were significantly related to more negative affect. Considering these paths together, proximal minority stress and negative affect were significantly indirectly associated through social isolation and emotion-focused coping. Thus, proximal stressors such as internalized homophobia, stigma consciousness, and concealment were associated with increased social isolation and emotion-focused coping, in turn increasing negative affect. These findings are consistent with the psychological mediation framework that predicts that individuals tend to use emotional-coping strategies to cope with minority stressors or to become socially isolated, which is then associated with negative mental health outcomes. Specifically, previous research demonstrates that activating supportive social networks after experiencing minority stress can assist with maintaining good mental health among LGBT individuals (Hatzenbuehler, 2009; Herek & Garnets, 2007; Lehavot & Simoni, 2011). Similarly, in the absence of social support, stigmatized individuals may isolate themselves from society to avoid potential rejection in the future (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997). Also, LB women may decide to conceal their identity and isolate themselves from parts of society to protect their identity from becoming compromised (Pachankis, 2008). Further, memories of social rejection can lead to individuals avoiding future social interactions (Higgins, King, & Mavin, 1982). Therefore, LB women who expect to be rejected and stigmatized may be more inclined to isolate themselves to avoid the actual rejection. Therefore, as in our study, when proximal stressors were associated with social isolation, LB women do not access this important resource, in turn increasing negative mental health outcomes. Regarding emotion-focused coping (e.g., rumination, self-blame, catastrophizing), the belief that one may be victimized in the future or that

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one is at fault for the stress they are experiencing leads to more mental health problems (Szymanski & Owens, 2008). When LB women repetitively focus on their identity and potential stigmatization, then they are more likely to ruminate. Rumination is a strong predictor of negative mental health outcomes (Nolen-Hoeksema, Wisen, & Lyubominsky, 2008); therefore, it is not surprising that ruminating on minority stressors would lead to these symptoms. Another aspect of emotion-focused coping is catastrophizing. With the existence of hate crimes and other victimization directed at LGBT individuals, LB women may develop a belief that the world is an unsafe place for them and that bad things are likely to happen to them. Overall, the indirect role of social isolation and emotion-focused coping are consistent with previous research and offer insight as to a pathway by which minority stress relates to negative mental health outcomes. The cognitive and social strategies LB women use to deal with this stress directly affect mental health outcomes. Those LB women who isolate themselves, ruminate, and catastrophize will feel worse; conversely, those who affiliate with others and who are able to use more effective cognitive coping strategies will likely feel and function better.

Clinical Implications The results of this study underscore the need for clinical providers to understand and assess the minority stress experiences of LB women. Providers must feel comfortable in discussing these experiences because of the strong impact of minority stress on the psychological health of their LB clients. Clinical providers must also recognize the importance of having a close social network and developing adaptive coping skills. These resources will help clients manage the minority stressors that they are experiencing and eventually lessen the harmful consequences of the stress. By teaching LB women social and coping skills, providers may help reduce the negative mental health outcomes that LB women experience, which in turn will reduce their binge eating behaviors. By reducing negative affect, binge eating will also decrease as it will not be needed as a coping strategy. Improving health care providers’ culturally competent treatment is an essential step toward the goal of reducing health disparities and improving LB women’s health.

Limitations The current study developed and tested a new model of pathways to bingeeating behavior among LB women. Although the results make a contribution to the existing literature, limitations must be noted as well. Since data were gathered from all participants at one time, the cross-sectional design of the study limited our ability to make causal inferences. Also, all respondents

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answered the questionnaires about experiences of minority stress first; this may have led to changes in their reports of negative affect and coping. In addition, women who identified as lesbian and bisexual and a small number who identified as “other” were considered together for the purposes of analysis. This may be problematic because there is evidence that bisexual women report more mental health concerns compared to lesbian women (Cochran & Mays, 2009). The online method of collecting data permitted us to access a difficultto-reach population; however, it is necessary to trust that participants responded accurately and honestly and met the inclusionary criteria. Also, as if often the case with individuals who participate in research on sexual orientation, our sample was generally open about their sexual identity and displayed rather low levels of internalized homophobia. Furthermore, as is typical with many online samples, the participants were relatively well educated. Our participants also reported fairly low levels of binge eating behavior, although this was not surprising given that this was a community sample versus individuals who were seeking treatment. Finally, it is important to note that our results based on an online convenience sample may not generalize to the larger population of LB women.

Future Directions The most crucial direction for the continuation of this research is the need to replicate these findings with a larger and more representative sample and to further develop the methodology and measurement approaches. The methodology enacted in this study was useful for exploring the relationships among the variables of interest. Now that a basic model has been developed, researchers need to employ new methods to gather data that are able to make causal inferences with the ultimate goal of developing and evaluating treatments. For example, future studies should use repeated measure designs and longitudinal data collection to investigate binge eating and discrimination with larger, more representative samples of LB women. A larger sample size will also permit comparison of lesbian and bisexual women. The affect regulation model posits that negative affect should decrease during and/or after the binge eating episode. Our model was not able to test mood temporally; thus, future research should examine when the negative affect is heightened and reduced. In addition, the psychological mediation framework emphasizes the importance of not only mediators but moderators as well. Hatzenbuehler (2009) discussed the importance of moderators (e.g., sex, race, developmental influences, identity characteristics) when looking at the impact of sexual minority stressors on health outcomes. Therefore, future research needs to examine potential moderating variables in future models. One such variable that could be included in future research is body image;

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previous research has demonstrated that body shame and surveillance are related to negative eating attitudes in lesbian women (Haines et al., 2008). Another important variable that may be considered in future research relates to the dual identities of LB women who may experience both external and internal heterosexism and sexism related to their status as a sexual minority individual and as a woman. Including both distal stressors and proximal stressors in each of these domains may offer important additional information about the pathways to binge eating for LB women. In fact, recent research suggests that each of these types of stressors account for unique variance in psychological distress among sexual minority women. Furthermore, maladaptive coping strategies mediated the relationship between the stressors and psychological distress (Szymanski & Henrichs-Beck, 2014).

SUMMARY AND CONCLUSIONS This study yields two important findings. First, it offers support for the psychological mediation framework (Hatzenbuehler, 2009) regarding the relationship of sexual minority stress and health outcomes among LB women and the importance of examining potential indirect pathways. Next, consistent with the affect regulation model, minority stress was related to binge eating in LB women through a series of indirect pathways, suggesting that LB women may use binge eating to cope with negative affect. Our results provide preliminary evidence that LB women experience unique stressors related to their sexual minority status that are indirectly related to their bingeeating behaviors. These results add to the literature demonstrating direct and indirect associations between minority stress and LB women’s health outcomes. The recent IOM (2011) report documented numerous health disparities between LB and heterosexual women, although explanations for these disparities lag far behind. As researchers and clinicians strive to reduce health disparities between LB and heterosexual women, it is essential to consider the role of sexual minority stress. These stressors are likely one of the contributing factors to these health disparities, including binge eating and obesity. Thus, developing and evaluating prevention and intervention programs for LB women that focus on coping with distal and proximal sexual minority stressors are essential endeavors to improving health outcomes related to negative affect, binge eating, and obesity.

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