The Effects of Stigma

John Pachankis is an associate professor at the Yale School of Public Health who specializes in mental and emotional health issues related to lesbian, gay, bisexual and transgender (LGBT) individuals. Specifically, his research seeks to identify the social and psychological factors that contribute to disproportionate mental health problems such as depression among the LGBT population. Over the next few years, Pachankis wants to develop effective interventions that address these issues and partner with community-based organizations to test their effectiveness. Pachankis, Ph.D., is a clinical psychologist and joined the School of Public Health’s faculty last summer.

How much research about LGBT individuals’ mental health is being done today?

JP: It took a while for the mental health field to understand even the basics about the distribution of psychiatric disorders across sexual orientations because U.S. population-based health and mental health surveys only began asking respondents about their sexual orientation relatively recently. But by the time I started graduate school, in 2002, LGBT mental health research began to attract mainstream attention. It was around this time that several population-based studies showed that lesbian, gay, and bisexual individuals experienced poorer mental health compared to heterosexuals. Since then, LGBT mental health research has really taken off, with sexual orientation disparities in disorders like major depression, generalized anxiety, and substance use disorders being one of the most consistent findings in psychiatric epidemiology today.

What are the most and least studied aspects of the LGBT population today?

JP: Since we now have clear evidence that LGBT individuals are at least twice as likely as their heterosexual peers to experience depression, anxiety, and substance use disorders, attention has turned to explaining reasons for these disparities and trying to reduce them. One clear reason for these disparities is stigma, both structural forms of stigma, such as laws and policies that deny LGBT individuals the same rights afforded to heterosexuals, and more day-to-day forms of stigma, such as being treated unfairly or internalizing stigma and always being on the lookout for rejection. One line of my research seeks to uncover the mechanisms through which stigma compromises the mental health of LGBT individuals by asking, for example, “Does stigma lead some LGBT people to conceal their identities, which then sets off a cascade of poor coping strategies, such as social isolation, substance use, and strong emotional reactions?” and “In what situations and life contexts is it adaptive to conceal one’s sexual orientation and in what situations is concealment maladaptive and unhealthy?” These studies try to understand the ways that growing up with a stigma—one that’s concealable and often not disclosed to peers and parents for several years— might powerfully shape the health of LGBT people as adults. As for understudied aspects of LGBT mental health, my hope is that more attention will turn toward developing interventions that can alleviate the mental health burden of stigma among LGBT individuals and modifying social structures to stop stigma at its source, though changing laws and policies affecting LGBT individuals and also through parenting and school interventions.

What are some important areas for future research in this field?

JP: While we know that LGBT individuals are more likely to seek mental health treatment compared to heterosexuals, we still know very little about the quality of mental health care that LGBT individuals receive and whether existing mental health treatments work just as well for LGBT people as they do for heterosexuals. LGBT people who seek mental health treatment might be coping with the additional burden of stigma—things like early or ongoing family rejection, not fitting in with peers, internalized homophobia, and challenges to finding a supportive community. Knowing how and when to address these issues in treatment remains largely unstudied. Some of my team’s current projects seek to identify the important features of LGBT individuals’ lives to assess in mental health treatment and testing techniques to help LGBT people cope with these added stressors to thereby reduce depression, anxiety, and substance use, and improve overall health.

Is the United States a leader in this field?

JP: The U.S. has come a long way in a short amount of time to become one of the leaders of LGBT mental health research. Several important, large U.S. population-based health surveys now include assessments of sexual orientation and gender identity and allow for the possibility of testing whether mechanisms like stigma and stress explain mental health disparities by sexual orientation and gender identity. The National Institute of Health has also become increasingly interested in improving the health of LGBT individuals and is currently funding some very exciting work in this area.

Are there aspects of LGBT research that apply to other population groups? If so, what is an example?

JP: If we wanted to right now, we could pretty easily list at least 100 different stigmatized conditions or identities that affect different people. Some of these stigmas—like older age, having a mental illness, being overweight or divorced, and smoking—are so common that we could argue that nearly everyone alive today will possess a stigmatizing identity or condition at some point in their lives. So I think it’s really important for researchers who study the health of a particular stigmatized group to consider the experiences of that group that are shared and unique when compared to other stigmatized groups. This approach would help our research generalize across multiple groups. For example, research on gay or lesbian people could inform research on other stigmas that are concealable, that become relevant around adolescence, and that one’s parents typically do not also possess.

What has been your most surprising research finding to date?

JP: Some of my research shows that some young gay and bisexual men might be particularly achievement-focused as a way to cope with stigma. Unfortunately, we also find that basing one’s self-worth on achievement-related domains such as work and school, appearance, and competition—as some gay and bisexual men seem more likely to do than heterosexual men—has negative health consequences. This achievement-focus might also have negative consequences for the gay community as a whole. Some of the most exciting work in our lab right now is designed to clarify the impact of this achievement focus on gay and bisexual men’s mental health and their experience of the gay community. Many of the gay and bisexual men in our New York City studies talk about finding the gay community, at least in NYC, to be really status-focused and inhospitable to diversity. In this way, their perception of the community is that it internalizes and replicates stigma from the larger outside world. Unfortunately, stigma can be imperceptible although its negative effects can be substantial. I hope to shed some light on stigma’s pernicious manifestations with the LGBT community thereby putting the blame where it’s due—on stigma—rather than on ourselves.

How did you become interested in this field?

JP: Recognizing that one’s social environment fundamentally shapes one’s identity—and therefore who one is and becomes in life—was a profound personal insight, as was the recognition that we can alter people’s environments so that they have happier, healthier lives. I had the good fortune to experience some very different environments throughout my life and therefore to see firsthand how healthy and unhealthy environments shape people’s thought processes, their emotional experiences, and ultimately their behaviors. These experiences led me to become a clinical psychologist. I specifically became interested in LGBT mental health after working at an HIV testing and counseling clinic in a community-based organization in Louisiana when I was in college.

What challenges, if any, are there as far as how LGBT research is received?

JP: I think that, unfortunately, a lot of people don’t see the relevance of LGBT research for non-LGBT people and for population health in general. While LGBT research certainly benefits LGBT people, it also benefits everyone, both in the sense that social inequalities are unhealthy for everyone and in the sense that lessons learned from studying the health of one group often have direct relevance to the health of other groups.

What is one of the most effective interventions for improving the mental health of LGBT population?

JP: The surest way to improve the mental health of the LGBT population would be to change stigmatizing social structures, like laws and policies that treat LGBT people differently from heterosexuals. Some excellent work using natural experiments in the U.S. demonstrates this. Teaching families and schools to be more supportive of LGBT people would undoubtedly also improve the health of LGBT youth and adults. Some of my current research develops cognitive-behavioral interventions to help helping LGBT revise the negative lessons they may have internalized about themselves, maybe from an early age, that drive unhealthy emotional reactions to stress and unhealthy behaviors, like substance use and risky sex.

Are there any particular challenges involved when reaching out to subjects for your studies?

JP: It’s often the case that the populations in most need of good health research are the hardest to access. For example, it’s hard to find LGBT people who are in the closet or people who have sex with people of the same gender but who might not identify as LGBT. I think that building strong connections with community organizations and having done clinical work with the population for several years has helped establish trust within the community and has provided good knowledge of how to involve hard-to-recruit samples in research.

What are your long-term research goals?

JP: I primarily plan to take advantage of being a clinical psychologist in a school of public health. Clinical psychology training is great at teaching people how to think deeply about people’s behaviors and how to modify them, while public health encourages students to think about the health influence of broader social structures. Both fields are united in encouraging us to identify previously invisible forces that shape our health and wellbeing. Thinking about ways to measure complex and invisible phenomenon is what excites me the most about the current research in my lab. I plan to spend much of my time over the next couple of years developing effective interventions to improve the health of the LGBT community, both through early efficacy trials and ultimately through partnering with community-based organizations to test their effectiveness in community settings. I’ll also continue trying to understand stigma’s impact on the health of LGBT individuals through working with population-based datasets, conducting experiments, continuing a multiyear longitudinal study on young gay men’s health that my lab has been conducting for the past six years, and getting involved in research partnerships with the local LGBT community in Connecticut.