Homelessness

Perceived Racial, Sexual Identity, and Homeless Status-Related Discrimination Among Black Adolescents and Young Adults Experiencing

Homelessness: Relations With Depressive Symptoms and Suicidality

Maurice N. Gattis and Andrea Larson University of Wisconsin-Madison

There is a dearth of empirical evidence that addresses how racial minority, sexual minority, and homeless statuses, with their accompanying experiences of stigma and discrimination, are related to mental health in adolescent and young adult populations. The current study addresses this gap by examining the associations between multiple forms of discrimination, depressive symptoms, and suicidality in a sample of 89 Black adolescents and young adults (52% female; 47% nonheterosexual, ages 16 –24) experiencing homelessness. Results from a series of ordinary least squares and logistic regressions suggested that perceived homelessness stigma and racial dis- crimination were associated with higher levels of depressive symptoms, controlling for gender, age, and other types of discrimination, while perceived sexual identity discrimination showed no association. Having ever spent a homeless night on the street, an indicator of homelessness severity, accounted for a substantial amount of the association between homelessness stigma and depressive symptoms. In contrast, suicidality was not significantly associated with any measure of discrimination, homelessness severity, or personal characteristics. We also found no indication that the associations between perceived discrimination targeted at racial and homelessness statuses and mental health differed by sexual minority status. Our results suggest that depressive symptoms and suicidality are prevalent among Black homeless youth, and that depressive symptoms are particularly associated with racial discrimination and indicators of homelessness. The roles of discrimination and a lack of safe housing may be taken into account when designing programs and policies that address the mental health of Black adolescents and young adults experiencing homelessness.

R acial and sexual minority youth who also experiencehomelessness are tasked with simultaneously managingstressors that accompany racial minority, sexual minority, and homeless statuses during critical stages of development. Over- all, evidence suggests that adolescents and young adults who endorse one or more of these marginalized statuses report higher rates of depressive symptoms and suicidality (e.g., Adkins, Wang,

Dupre, van den Ord, & Elder, 2009; Edidin, Ganim, Hunter, & Karnik, 2012; Gore & Aseltine, 2003; Hatzenbuehler, McLaugh- lin, & Nolen-Hoeksema, 2008; National Center on Family Home- lessness, 2011; Safren & Heimberg, 1999), with a substantial body of evidence suggesting that discrimination targeted at any of these statuses contributes to worse mental health outcomes (e.g., Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Brody et al., 2006; Kessler, Mickelson, & Williams, 1999; Paradies, 2006; Pascoe & Smart Richman, 2009; Thoma & Huebner, 2013).

Although researchers are increasingly examining how margin- alization impacts adolescents and young adults, we continue to lack a clear understanding of how the combination of racial mi- nority, sexual minority, and homeless statuses may contribute to developmental outcomes. Though it is clear that the stigmatized nature of these statuses predicts experiences of discrimination targeted at each status (e.g., Corrigan et al., 2003; Phelan, Link, Moore, & Stueve, 1997), it is less clear how these experiences of stigma and discrimination targeted at multiple statuses may, when experienced concurrently, be associated with mental health. This project seeks to improve the knowledge base regarding how Black

This article was published Online First October 12, 2015. Maurice N. Gattis and Andrea Larson, School of Social Work, Univer-

sity of Wisconsin-Madison. This study was funded by the College of Letters and Sciences at

University of Wisconsin-Madison. The study would not have been possible without the assistance of Peter Wright, Tim Baack, Julie Bock, and the youth at Pathfinders in Milwaukee. Thank you to project assistants Kevin Henry III, Christine Ricks, and Sean Hubbard.

Correspondence concerning this article should be addressed to Maurice N. Gattis, University of Wisconsin-Madison School of Social Work, 1350 University Avenue, Madison, WI 53703. E-mail: [email protected]

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American Journal of Orthopsychiatry © 2015 American Orthopsychiatric Association 2016, Vol. 86, No. 1, 79 –90 http://dx.doi.org/10.1037/ort0000096

79

racial status, sexual minority status, and homelessness are associ- ated with depressive symptoms and suicidality among adolescents and young adults, and investigate how much of the association is accounted for by perceived discrimination targeted at each status.

Status and Mental Health Status variables have been empirically linked to mental health

outcomes for over a century, with a preponderance of evidence suggesting that positions of marginalized social status are predic- tive of worse mental health (for a discussion see Muntaner, Ng, Vanroelen, Christ, & Eaton, 2013). Social stress models, out- growths of the social causation hypothesis (Dohrenwend & Dohrenwend, 1969), suggest that disadvantages and strains asso- ciated with any marginalized status create burdens capable of generating psychological distress (Pearlin, 1989; Schwartz & Meyer, 2010). In other words, individual and group positions in the social hierarchy affect the probability of experiencing particular external circumstances capable of producing stress, which then affect the probability of experiencing mental health problems.

Importantly, stress determined by social position is not neces- sarily an objective feature of any given circumstance but is rather borne of discrepancies between the demands produced by the external environment and the resources of the individual or group in question (Aneshensel, 1992). Thus, while some circumstances reflective of status hierarchies may not reliably affect mental health outcomes, other circumstances may be more pervasively threatening and damaging despite available compensatory mech- anisms. Homelessness can arguably be defined in the latter sense, not only because of its intimate link to severe economic hardship but also because it is characterized by unpredictability, dislocation (Bassuk, 2010), disruption in social support systems, risks to safety, and barriers to adequate service receipt (Kilmer, Cook, Crusto, Strater, & Haber, 2012; Nyamathi et al., 2012). Homeless- ness often follows a host of other preceding stressors (e.g., Ryan, Kilmer, Cauce, Watanabe, & Hoyt, 2000; Tyler & Cauce, 2002), resulting in “risk trajectories” of homeless youth:

these trajectories begin with abusive and otherwise dysfunctional home experiences, with [homeless youth] tending to fall into more negative street experiences, including victimization and association with other youth experiencing substantial challenges [. . .] increasing the likelihood of depressive symptoms and suicidality. (Kidd, 2006, p. 395)

Indeed, a large body of research indicates that persons who experience homelessness exhibit higher levels of psychological distress than their housed counterparts (Cochran, Stewart, Ginzler, & Cauce, 2002; McCaskill, Toro, & Wolfe, 1998; Ritchey, La Gory, Fitzpatrick, & Mullis, 1990; Weinreb, Buckner, Williams, & Nicholson, 2006). These findings have been replicated in younger samples, with adolescents and young adults who experience home- lessness showing an increased risk for a range of mental health problems (Edidin et al., 2012; Kidd, 2006; National Center on Family Homelessness, 2011; Nyamathi et al., 2012; Saperstein, Lee, Ronan, Seeman, & Medalia, 2014; Unger, Kipke, Simon, Montgomery, & Johnson, 1997), including substantially higher rates of depressive symptoms and suicidality when compared to the general population (for discussions, see Kidd, 2006 and Unger et al., 1997). Further, quality of housing among persons experi-

encing homelessness can meaningfully affect health outcomes, with those who are unsheltered or in unstable situations being at higher risk of victimization while also being less likely to use health care services (for discussions, see National Health Care for the Homeless Council, 2011 and Stein, Nyamathi, & Zane, 2009).

A specified version of the more general social stress model has been defined in minority stress theory (Meyer, 2003, 1995), which explicitly addresses psychological distress resulting from the ex- perience of minority status (Brooks, 1981). Originally framed in reference to sexual minority status, this theory posits that sexual minorities face unique and chronic stressors related to their sexual orientation that are associated with subsequent negative mental health outcomes. In line with other conceptualizations of social stress models considering social status, minority stress theory argues that “sexual minority status itself does not matter so much as the norms, values, mores, and related processes of the social contexts in which sexual minority individuals live” (Martin-Storey & Crosnoe, 2012, p. 1001, emphasis added). Research that has examined the link be- tween sexual orientation status and mental health overwhelmingly suggests that gay, lesbian, and bisexual (GLB) youth are at greater risk of experiencing a range of negative mental health outcomes when compared to their heterosexual peers, including higher rates of depressive symptoms and suicidality (Conron, Mimiaga, & Landers, 2010; Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013; Galliher, Rostosky, & Hughes, 2004; Hatzen- buehler et al., 2008; Loosier & Dittus, 2010; Marshal et al., 2011; Safren & Heimberg, 1999; Savin-Williams, 1994).

While minority stress theory was defined to address the expe- riences of sexual minorities in the presence of a heterosexist society, the underlying concepts are drawn from an understanding of stressors faced by minority populations and thus arguably applicable to other groups. For example, researchers have long considered the link between Black racial status and developmental outcomes because of the enduring negative association between racial minority status and indicators of physical health. However, an often clear association between race and physical health does not consistently extend to mental health outcomes (Keyes, Barnes, & Bates, 2011). Although racial and ethnic minorities report higher levels of acute and chronic stress than their non-Hispanic White peers (Boardman, 2004; Boardman & Alexander, 2011), studies using adult samples report contradictory findings regarding racial status and psychological distress. Some studies indicate that the prevalence of mental health problems, particularly depressive symptoms and depressive disorders, is higher among Whites than Blacks (Blazer, Kessler, McGonagle, & Swartz, 1994; Kessler et al., 1999; Riolo, Nguyen, Greden, & King, 2005), and others report the opposite (González, Tarraf, Whitfield, & Vega, 2010; Jones- Webb & Snowden, 1993; Pratt & Brody, 2008; Taylor & Turner, 2002; Williams, Yu, Jackson, & Anderson, 1997). Findings are somewhat more consistent among younger populations, with mul- tiple studies finding that depressive symptoms are more pro- nounced among Black adolescents and young adults when com- pared to their White counterparts (Adkins et al., 2009; Boardman & Alexander, 2011; Garrison, Jackson, Marsteller, McKeown, & Addy, 1990; Gore & Aseltine, 2003).

Unlike sexual minority status, however, any disparity in mental health outcomes between Black and White adolescents and young adults is confounded by the intimate association between class and race in American society (Srole, Langner, Michael, Opler, &

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80 GATTIS AND LARSON

Rennie, 1960, as cited in Muntaner et al., 2013; Williams & Williams-Morris, 2000). The inverse association between margin- alized socioeconomic status and mental health has been docu- mented across racial and ethnic groups (Williams et al., 1997), and socioeconomic variables are often used to explain health dispari- ties. However, even when researchers consider the intervening role of socioeconomic characteristics, disparities in mental health prob- lems often remain. For example, while the impact of stress on depressive symptoms operates similarly among White and Black young adults, Blacks are at an increased risk of depressive symp- toms because they are more likely to be exposed to a range of stressors, including economic hardship (Boardman & Alexander, 2011). Additionally, the association between socioeconomic status and depressive symptoms may act differently among Black and White adolescents. Specifically, low socioeconomic status may be more harmful to Black adolescents (Adkins et al., 2009), which complements results from adult samples that suggest Blacks re- ceive less health benefit from higher socioeconomic status than Whites (Farmer & Ferraro, 2005).

Discrimination and Mental Health Perceived discrimination, or unfair treatment initiated on the

basis of perceived group membership (Thoits, 2010), has been highlighted as a stressor that is targeted at marginalized popula- tions while leaving more advantaged counterparts untouched (Kes- sler et al., 1999). Research has long documented the deleterious effects of discrimination on measures of the target’s mental health (e.g., Gee, 2002; Karlsen & Nazroo, 2002), with results indicating, on the whole, a negative association between perceived discrimi- nation and mental health that persists across indicators (Pascoe & Smart Richman, 2009).

Some evidence suggests that racial discrimination is one of the most common, if not the most common, type of discrimination initiated because of perceived group status (Corrigan et al., 2003; Grollman, 2012). These experiences of racial discrimination are associated with poorer mental health functioning among Black samples (Kessler et al., 1999; Paradies, 2006; Ren, Amick, & Williams, 1999; Thompson, 1996; Williams & Williams-Morris, 2000; Williams et al., 1997). This pattern of these findings extends to Black adolescents and young adults, with evidence indicating positive associations between perceptions of racial discrimination and a range of mental health problems, including depressive symp- toms and suicidality (Sanders-Phillips, Settles-Reaves, Walker, & Brownlow, 2009; Seaton, Upton, Gilbert, & Volpe, 2014; Thoma & Huebner, 2013). Importantly, this association has been exam- ined longitudinally, with a preponderance of evidence suggesting that as the perception of discrimination incidents increases over time among Black adolescents and young adults, so does psycho- logical distress (Brody et al., 2006; Greene, Way, & Pahl, 2006; Hurd, Varner, Caldwell, & Zimmerman, 2014).

Discrimination initiated because of a target’s perceived minority sexual orientation is also common (Corrigan et al., 2003; Kosciw, Diaz, & Greytak, 2008; Reck, 2009; Savin-Williams, 1994) and negatively associated with mental health (Balsam, Molina, Bead- nell, Simoni, & Walters, 2011). Evidence suggests that stressful events, including victimization, and perceptions of poor social support largely explain the disparity in depressive symptoms and suicidality between sexual minority and heterosexual adolescents

and young adults (Hatzenbuehler, McLaughlin, & Xuan, 2012; Safren & Heimberg, 1999; Toomey, Ryan, Diaz, Card, & Russell, 2010; Williams, Connolly, Pepler, & Craig, 2005). Further, mul- tiple studies suggest the association between sexual minority status and poor mental health outcomes is moderated by the perception of discrimination based on sexual orientation, with adolescents re- porting higher levels of discrimination evidencing poorer mental health than sexual minority peers reporting less discrimination (Almeida et al., 2009; Birkett, Espelage, & Koenig, 2009).

Finally, although stigma toward persons experiencing homeless- ness, particularly in terms of desire for social distance (Belcher & DeForge, 2012; Phelan et al., 1997) remains pervasive in the general population, and qualitative inquiry reports that perceived stigma is a barrier to service receipt among homeless young adults (Kozloff et al., 2013), few studies examine discrimination targeted at homeless status specifically. Notable exceptions exist because of the work of Kidd (2003, 2004, 2007), who reports, via a series of qualitative and quantitative studies, that homelessness-related dis- crimination is related to negative mental health outcomes (e.g., suicidality, loneliness, self-blame) among adolescents and young adults experiencing homelessness.

Multiple Statuses, Discrimination, and Mental Health

Stress that is chronic (e.g., racial or sexual minority status), uncontrollable (e.g., homelessness), and unpredictable (e.g., dis- crimination targeted at any particular status) appears to be partic- ularly harmful to health (Avison & Turner, 1988; Williams & Mohammed, 2009). When combining the stress that is arguably inherent to each marginalized status with the stress of perceived discrimination directed at those statuses simultaneously, the task of managing adolescent and young adult development can become overwhelming. As many adolescents and young adults occupy multiple positions of marginalization and thus are targets of mul- tiple forms of discrimination, overlooking the reality of this dis- proportionate exposure may result in misunderstanding of how status and discrimination contribute to mental health outcomes (Grollman, 2012).

Sexual minority adolescents and young adults appear at partic- ular risk of experiencing homelessness (Corliss, Goodenow, Nich- ols, & Austin, 2011; Kruks, 1991; Ray, 2006), which places them at increased risk of negative mental health outcomes when com- pared to housed GLB peers (Kruks, 1991; Rosario, Schrimshaw, & Hunter, 2012; Walls, Hancock, & Wisneski, 2007) and heterosex- ual peers experiencing homelessness (Cochran et al., 2002; Gattis, 2013; Gattis, 2009; Grafsky, Letcher, Slesnick, & Serovich, 2011; Noell & Ochs, 2001; Whitbeck, Chen, Hoyt, Tyler, & Johnson, 2004). Sexual minorities report higher levels of homelessness stigma than heterosexual peers experiencing homelessness (Kidd, 2007). Finally, though discrimination directed at sexual minority status has been associated with depressive symptoms among homeless adolescent and young adult males, the association does not differ by racial/ethnic minority status (Bruce, Stall, Fata, & Campbell, 2014).

Although youth and adolescents who espouse both sexual mi- nority and racial minority statuses may experience discrimination targeted at perceived racial and sexual orientation group member- ship (Meyer, Schwartz, & Frost, 2008), only a few studies—to our

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81DISCRIMINATION, DEPRESSION, AND SUICIDALITY

knowledge— have explicitly examined how these forms of dis- crimination impact Black adolescents or young adults. Evidence suggests that racial and sexual minority discrimination may com- bine to affect mental health outcomes over and above that resulting from a single form of discrimination (Grollman, 2012), a finding that has been replicated in adult samples (Grollman, 2014). More specifically, Thoma and Huebner (2013) analyzed data from a sample of Black GLB adolescents and young adults and found that perceptions of discrimination targeted at racial and sexual minority status independently predicted depressive symptoms and suicidal- ity, and race discrimination was a stronger predictor of depressive symptoms.

In contrast to findings that suggest that multiple forms of mar- ginalization contribute to worse mental health outcomes, espe- cially in the context of multiple forms of discrimination, evidence suggests that Black adolescents and young adults experiencing homelessness report lower rates of suicidal behavior than homeless youth of other races (Unger et al., 1997). Further, although Black adolescents and young adults who experience homelessness report psychological distress following instances of discrimination (Mil- burn et al., 2010), they report lower levels of discrimination targeted at homelessness status than their White peers (Kidd, 2007).

In summary, evidence suggests that Black GLB adolescents who experience homelessness face unique combinations of stressors that are particularly likely to affect their mental health (e.g., Reck, 2009). Although researchers have carefully considered the poten- tial impact of stigma and discrimination directed at multiple sta- tuses within a single individual (e.g., Corrigan et al., 2003; Kidd, Veltman, Gately, Chan, & Cohen, 2011; Ren et al., 1999), and this work has been tested empirically among adolescent and young adult samples, little explicit attention has been paid to how the combination of racial minority, sexual minority, and homelessness statuses may affect mental health outcomes, particularly in con- texts of discrimination.

Research Question The primary research question is: Are multiple forms of per-

ceived discrimination, targeted at racial minority, sexual minority, and homeless statuses, independently associated with depressive symptoms and suicidality in a sample of Black adolescents and young adults experiencing homelessness? We define a number of hypotheses based on the literature reviewed above. First, we hy- pothesize that while all forms of discrimination will be positively associated with depressive symptoms and suicidality, perceived racial discrimination will be the most pervasive form of discrim- ination and thus will be more strongly associated with depressive symptoms and suicidality than sexual minority discrimination or homelessness stigma. Second, we hypothesize that persons report- ing sexual minority status will report higher levels of depressive symptoms and suicidality than their heterosexual peers.

Method This study utilized a cross-sectional research design with struc-

tured quantitative face-to-face interviews of a convenience sample of 89 Black homeless youths aged 16 –24 years (M � 20.06, SD �

2.06). Human subjects approval was obtained from the Institu- tional Review Board (IRB) at University of Wisconsin-Madison. The interviews took place between October 2012 and October 2013.

Sample

Recruitment procedures. Potential subjects were ini- tially approached to participate in the study when seeking drop-in services at an agency that provides services for youths experienc- ing homelessness in Milwaukee, Wisconsin. A member of the staff explained the study to gauge interest and, if the person expressed interest, assessed whether inclusion criteria were met (between age 16 –24, homeless at least 7 days in the past month, and Black). If eligible, the staff member informed the individual of the require- ments, procedures, and compensation associated with the study. If individuals were willing to consent to the interview, they were referred to a member of the research team who obtained consent and conducted the survey. Upon completion of the survey, each participant was compensated $15.

Dependent Variables

Depressive symptoms. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), originally developed for epidemi- ology studies in the general population and previously used in a racially diverse sample of youth (Skriner & Chu, 2014). Respon- dents were asked 20 questions that inquired about their feelings and behavior in the past week (e.g., “I was bothered by things that usually don’t bother me”, “I did not feel like eating; my appetite was poor”) and respond on a scale from 0 (rarely or none of the time [less than one day]) to 3 (most or all of the time [5–7 days]). The coefficient alpha for this sample is 0.89, indicating excellent internal consistency and replicating reliability levels noted in pre- vious studies with similar populations. A score of 16 or higher on the CES-D indicates risk of clinical depression while a score of 21 or higher is stated to indicate presence of major depressive symp- toms (Bruce et al., 2014).

Suicidality. Suicidal ideation, planning, and attempts were measured using three questions from the Centers for Disease Control and Prevention-funded 2009 Youth Risk Behavior Survey (YRBS). The questions were: (a) “During the past 12 months, did you ever seriously consider attempting suicide?” (1 � yes, 0 � no); (b) “During the past 12 months, did you make a plan about how you would attempt suicide?” (1 � yes, 0 � no); and (c) “During the past 12 months, how many times did you actually attempt suicide?” (dichotomized for analysis, 1 � at least one time, 0 � zero times). These items were summed and averaged to create a composite suicidality measure (M � 0.19, SD � 0.31). This item was transformed into an indicator variable of any en- dorsement of past-year suicidality (1 � yes, 0 � no).

Independent Variables

Homelessness stigma. Perceived stigma related to homelessness was assessed using the 12-item social stigma scale

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82 GATTIS AND LARSON

(Kidd, 2007). Items included: (a) “I have been hurt by how people have reacted to me being homeless”; (b) “People seem afraid of me because I am homeless”; and (c) “I feel that I am not as good as others because I am homeless” (for the full scale and factor analysis, see Kidd, 2007). Each item response was formatted as 4-point Likert- type scale, 1 (strongly agree), 2 (agree), 3 (disagree), 4 (strongly disagree). The full scale (M � 2.53, SD � 0.71) evidenced strong internal consistency in our sample (� � .86).

Racial discrimination. Perceived racial discrimination was measured using the 7-item race-ethnicity discrimination scale from Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV), which was modeled after the Expe- riences of Discrimination (EOD) scales and intended to measure experienced rather than perceived discrimination (for discussion of scale construction and reliability information from a random sam- ple of National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) respondents, see Ruan et al., 2008). The scale was included to make it possible to examine how members of the sample compare to national data with regard to racial discrim- ination. Each respondent was read the following question stem: “Now I’d like to know about how often you have experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of your race. During the last 12 months about how often did you experience discrimination. . . .” Items included: (a) “ability to obtain health care/health insurance”; (b) “in how you were treated when you got care”; and (c) “obtaining a job, on the job, or getting admitted to school or training program, or in the courts or by the police, or obtaining housing.” Responses were reported on a 5-point Likert scale, 0 (never), 1 (almost never), 2 (sometimes), 3 (fairly often), or 4 (very often) and then summed and averaged to create a single racial discrimination score (M � 6.56, SD � 5.32, � � .79).

Sexual orientation discrimination. Perceived sexual orientation discrimination was measured using the sexual orienta- tion discrimination scale from AUDADIS-IV, also modeled after the EOD (for discussion of scale construction and reliability in- formation from a random sample of NESARC respondents, see Ruan et al., 2008). Each respondent that reported a sexual identity other than 100% heterosexual (straight; n � 45; see below for definition of sexual identity variable) was read the following question stem: “Now I’d like to know about how often you have experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following situations because of your sexual orientation. During the last 12 months about how often did you experience discrimination . . .” and asked to respond to the same items included in the racial discrimination scale, except that the answers pertained to sexual orientation discrimination rather than racial discrimination. After the question stem, the items were worded identically, except for Item 5 which replaced racist with homophobic. For respondents who reported an identity of 100% heterosexual, zero values were entered to retain our full sample. Responses were summed and averaged to create a single perceived sexual orientation discrimi- nation score (M � 3.02, SD � 4.86, � � .87).

Sexual identity. Sexual identity was assessed by asking participants to “Please choose the description that best fits how you think about yourself”. Mutually exclusive response categories included (a) 100% heterosexual (straight; n � 44); (b) mostly heterosexual (straight), but somewhat attracted to people of my own sex (n � 7); (c) bisexual—attracted to men and women equally (n � 9); (d) mostly homosexual (gay or lesbian), but somewhat attracted to people of the opposite sex (n � 9); (e) 100% homosexual (gay or lesbian; n � 16); (f) not sexually attracted to either males or females (n � 1); (g) man having sex with men (MSM; n � 0); (h) woman having sex with women (WSW; n � 0); or (i) pansexual (n � 3). Because our small sample size would not allow investigation of each category, we created a dichotomized item that assigned the value of zero to respondents reporting a 100% heterosexual identity (n � 44), and a value of one to respondents reporting any other identity (n � 45).

Homelessness severity. Because some evidence sug- gests that youth who sleep on the street fare worse than youth who use shelter services or sleep elsewhere (Patel & Greydanus, 2002), we considered whether or not youth reported ever sleeping on the street as a measure of homelessness severity. Participants who reported ever spending one or more nights on the street in an abandoned building or another place out in the open (Whitbeck et al., 2004) were assigned a value 1 (n � 41) and all others were assigned a value of 0 (n � 48).

Covariates. Mental health indicators have been shown to vary according to gender and age, with females and adolescent age associated with higher rates of depressive symptoms (e.g., Adkins et al., 2009; Pratt & Brody, 2008). Both gender and age have been associated with perceptions of discrimination as well (Kessler et al., 1999). Thus, we considered gender identity (male n � 35, 36.84%, female n � 49, 51.58%, or other [e.g., male to female, two-spirit] n � 5, 5.26%) and age (continuous) as covariates in all models.

Analysis

After completing univariate and bivariate analyses, we defined a model in line with theoretical considerations outlined previously. We tested a series of ordinary least squares (OLS) and logistic regressions to investigate the relative input of primary independent variables of interest (perceived racial, sexual, and homelessness- related discrimination) on outcomes of interest, controlling for status, homelessness severity, and personal characteristics. Al- though our research question of interest would be more thoroughly tested by using an intersectionality framework and a series of interaction terms in multiple regression models (Muntaner et al., 2013), this was precluded by sample and data limitations. None- theless, we considered two status-by-discrimination interactions by testing if the association between (a) homelessness stigma and mental health and (b) racial discrimination and mental health differed by sexual minority status. All analyses were completed using Stata v.13 and all multivariate models were adjusted using the Bonferroni correction (i.e., because 10 predictors were used to test two dependent variables, alpha level set to 0.0025).

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83DISCRIMINATION, DEPRESSION, AND SUICIDALITY

Results Univariate analyses indicated that approximately 70% of the

sample (n � 66) reported a CES-D score of 16 or higher and approximately 61% reported scores of 21 or higher (M � 26.13, SD � 2.49), indicating a high prevalence of depressive symptoms. Approximately 30% of the sample endorsed any measure of sui- cidality in the past year, with 22% reporting consideration of suicide, 18% reporting a suicide plan, and close to 14% reporting a suicide attempt. Finally, 41 respondents (43%) reported having ever slept on the street.

Bivariate Analyses

Results of our bivariate correlations are displayed in Table 1. In line with previous literature, depressive symptoms were positively correlated with suicidality, perceived homelessness stigma, racial discrimination, sexual orientation discrimination, and time on the street. Suicidality was also positively associated with perceived homelessness stigma, racial discrimination, and endorsing a sexual identity other than 100% heterosexual, though perceived sexual orientation discrimination showed no association. Time on the street was, as expected, positively associated with perceived home- lessness stigma, and reporting a gender identity other than male or female was associated with perceived sexual discrimination. Fe- males were more likely to report sexual identities other than heterosexual, and males were more likely to report ever spending a night on the street.

Multivariate Analyses

Depressive symptoms. We next completed a series of OLS regressions to test the relative strength of the associations between stigma and discrimination with depressive symptoms while controlling for potentially confounding variables. Results of these models are summarized in Table 2. Our models indicate that perceived homelessness stigma and racial discrimination showed consistent positive associations with depressive symptoms, con- trolling for other factors, whereas perceived sexual orientation discrimination showed no association. Specifically, adolescents

and young adults who reported levels of homelessness stigma one standard deviation above the mean reported depressive symptoms approximately one third of a standard deviation above the mean, relative to their peers in the sample. Model 3 shows that the association between homelessness stigma and depressive symp- toms attenuated when controlling for homelessness severity, so that the association between perceived homelessness stigma and depressive symptoms was no longer significant. Though the asso- ciation between time on the street and depressive symptoms was positive (� � 0.42, t � 2.31, p � .024), it was not statistically significant according to the 0.0025 corrected alpha level.

Perceived racial discrimination was consistently associated with depressive symptoms and this association did not attenuate when considering homelessness severity or personal characteristics. Spe- cifically, adolescents and young adults who reported racial dis- crimination experiences one standard deviation above the mean also reported depressive symptoms approximately one third of a standard deviation above the mean, on average. We found no significant associations between personal characteristics and de- pressive symptoms in any model. Finally, Model 3, which included all forms of discrimination, homelessness severity, and personal characteristics, accounted for 40% the variance in depressive symptoms in our sample.

Investigating moderation. We tested whether the as- sociation between homelessness stigma, racial discrimination, and depressive symptoms differed by sexual minority identity in Mod- els 4 and 5 of Table 2. Neither interaction term was significant, suggesting that the association between each respective form of discrimination and depressive symptoms was consistent across sexual orientation statuses in our sample.

Suicidality. We tested a series of logistic regressions to determine associations with any past-year endorsement of suicid- ality, and results of these models are summarized in Table 3. In contrast to findings for depressive symptoms, we found no signif- icant association between any form of discrimination, homeless- ness severity, or personal characteristics and suicidality.

Although reporting a sexual orientation other than 100% het- erosexual was associated with an increased likelihood of endorsing

Table 1. Correlations Between Independent and Dependent Variables

1 2 3 4 5 6 7 8 9 10

1. Depressive symptoms — 2. Suicidality .35��� — 3. Perceived homelessness stigma .46��� .27� — 4. Perceived racial discrimination .52��� .31�� .33�� — 5. Perceived sexual discrimination .30�� .18 .14 .25� — 6. Sexual identity—other than heterosexual .20 .23� .08 �.07 .65��� — 7. Time on the street .32�� .15 .32�� .12 .07 .06 — 8. Gender—male �.09 �.14 �.07 .10 �.16 �.35��� .27� — 9. Gender—female .04 .07 .04 �.11 �.001 .28�� �.25� �.89��� —

10. Gender—other .12 .14 .09 .02 .35�� .14 �.03 �.20 �.27� — 11. Age .10 .04 .01 .15 .20 .21� .03 �.08 .06 .04

Note. n ranges from 83– 89 observations. � p � .05. �� p � .01. ��� p � .001.

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past-year suicidality at an alpha level of 0.05, after controlling for all forms of discrimination and personal characteristics (OR � 4.77, z � 1.98, p � .048), this association was not significant when accounting for multiple tests using the Bonferroni correction. The same is true for racial discrimination (OR � 2.17, z � 2.43, p � .015), with the associated odds ratio suggesting that a one standard deviation increase in racial discrimination was associated with twice the odds of reporting past-year suicidality, controlling for other forms of discrimination, homelessness severity, and personal characteristics. While neither of these associations was significant in our sample, we highlight the direction and strength of associa- tion to encourage investigation of these associations in larger samples.

Investigating moderation. Mirroring our approach to depressive symptoms, we tested whether the association between homelessness stigma, racial discrimination, and suicidality dif-

fered by sexual minority identity in Models 4 and 5 of Table 3. Neither interaction term was significant, suggesting that the asso- ciation between each respective form of discrimination and sui- cidality was consistent across sexual orientation statuses in our sample.

Post Hoc Power Analysis

Because of our small sample size, we completed a post hoc power analysis to investigate detectable effect sizes. Results sug- gest that our sample size of 86, when used in a multiple regression model including six predictors (Model 1 in Tables 2 and 3), was capable of detecting an effect size of 0.17 (power � 0.80, alpha level � 0.05), and an effect size of 0.20 in models including eight predictors (Models 4 and 5 in Tables 2 and 3). When adjusting the alpha level to 0.01, the detectable effect size shifted to 0.25 for six predictors, and 0.28 for eight. However, our reported results

Table 2. OLS Regression, Associations Between Predictors (Status Variables, Discrimination, and Personal Characteristics) and the Outcome Depressive Symptoms

1 2 3 4 5 � (SE) � (SE) � (SE) � (SE) � (SE)

Other than 100% heterosexuala .38 (.25) .32 (.24) .29 (.18) .27 (.19) Perceived homelessness stigma .31� (.09) .30� (.09) .23 (.09) .32 (.13) .23 (.09) Perceived racial discrimination .30� (.10) .35� (.10) .35� (.10) .34� (.09) .28 (.14) Perceived sexual orientation discrimination .09 (.09) .03 (.19) �.03 (.12) Time on street .42 (.18) .44 (.18) .43 (.18) Sexual minority status � homelessness stigma �.16 (.17) Sexual minority status � racial discrimination .10 (.18) Gender—femaleb .13 (.18) .03 (.19) .17 (.19) �.04 (.20) .18 (.19) Gender—otherb .37 (.46) .36 (.46) .48 (.45) .42 (.46) .44 (.42) Age .02 (.04) .01 (.04) .01 (.04) .03 (.04) .01 (.04)

Note. n � 86. Model 1 R2 � .34, Model 2 R2 � .36, Model 3 R2 � .40, Model 4 R2 � .41, Model 5 R2 � .41. Coefficients and standard errors from ordinary least square regressions are presented, with standardized coefficients for predictors homelessness stigma, racial discrimination, and sexual orientation discrimination (M � 0, SD � 1). a Omitted group: 100% heterosexual. b Omitted group: Gender—male. � p � .0025.

Table 3. Logistic Regression, Associations Between Predictors (Status Variables, Discrimination, and Personal Characteristics) and the Outcome Suicidality

1 2 3 4 5 OR (SE) OR (SE) OR (SE) OR (SE) OR (SE)

Other than 100% heterosexuala 4.95 (3.89) 4.77 (3.76) 2.18 (1.26) 2.04 (1.21) Perceived homelessness stigma 1.55 (.42) 1.51 (.42) 1.40 (.40) 1.27 (.51) 1.42 (.42) Perceived racial discrimination 1.69 (.46) 2.12 (.66) 2.16 (.69) 1.82 (.52) 1.49 (.68) Perceived sexual orientation discrimination .96 (.26) .59 (.22) .59 (.21) Time on street 1.59 (.90) 1.55 (.87) 1.61 (.90) Sexual minority status � homelessness stigma 1.19 (.65) Sexual minority status � racial discrimination 1.35 (.77) Gender—femaleb 2.12 (1.14) 1.38 (.81) 1.64 (1.03) 1.86 (1.13) 1.88 (1.15) Gender—otherb 8.09 (11.05) 7.54 (10.38) 8.56 (11.80) 4.78 (6.29) 4.61 (6.07) Age .97 (.12) .95 (.12) .94 (.12) .93 (.12) .94 (.12)

Note. n � 86. Model 1 Pseudo R2 � .12, Model 2 R2 � .16, Model 3 R2 � .17, Model 4 R2 � .15, Model 5 R2 � .15. Odds ratios and standard errors from logistic regressions are presented, with standardized coefficients for predictors homelessness stigma, racial discrimination, and sexual orientation discrimination (M � 0, SD � 1). a Omitted group: 100% heterosexual. b Omitted group: Gender—male. � p � .0025.

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85DISCRIMINATION, DEPRESSION, AND SUICIDALITY

should be considered in accordance with our use of the Bonferroni correction and associated alpha level of 0.0025 to determine sig- nificant findings.

Discussion The results of the present study add to the existing literature

regarding perceived discrimination and mental health and extend it to Black adolescents and young adults experiencing homelessness, half of whom identified as a sexual minority. Our results suggested that depressive symptoms and past-year suicidality are common among adolescents and young adults experiencing homelessness. Furthermore, depressive symptoms are associated with homeless- ness and racial discrimination, providing support for social stress and minority stress models as well as previous empirical findings (e.g., Kidd, 2003, 2004, 2007; Sanders-Phillips et al., 2009; Thoma & Huebner, 2013). The association between homelessness stigma and depressive symptoms attenuated once homelessness severity was included in the model, suggesting that certain experiences of homelessness may be particularly predictive of depressive symp- toms. Alternately, we found no evidence that sexual orientation discrimination was associated with depressive symptoms, in con- trast to previous findings (Almeida et al., 2009; Balsam et al., 2011; Birkett et al., 2009), though we note that heterosexual adolescents and young adults were assigned a value of zero on the sexual orientation discrimination measure, likely reducing actual variability and undercutting our ability to detect significant asso- ciations. Though our results suggested that sexual minority status and racial discrimination may be associated with past-year suicid- ality, these associations were not significant after correcting for multiple tests. These findings contrasted those from the models considering depressive symptoms, suggesting that even though depressive symptoms and suicidality were correlated in our sam- ple, they were associated with varying sets of predictors.

Importantly, perceived racial discrimination showed the most consistent pattern of association with mental health outcomes in our sample, when compared to other forms of discrimination, homelessness severity, and personal characteristics. This evidence provides partial support for the hypothesis that racial discrimina- tion would more robustly predict depressive symptoms and sui- cidality than perceived sexual orientation discrimination or home- lessness stigma and confirms previous literature regarding the association between race, sexual orientation discrimination, and mental health (Crawford, Allison, Zamboni, & Soto, 2002; Groll- man, 2012; Paradies, 2006). In reference to social stress and minority stress models, we suggest that because racial status is not concealable in the ways in which sexual identity or homelessness status may be, perceived discrimination targeted at race may be especially stressful. In other words, avoiding the experience and associated detrimental effects of racial discrimination may be nearly impossible for Black youth, particularly in situations of homelessness. However, the fact that homelessness severity did not attenuate the impact of racial discrimination on depressive symptoms, as it did in terms of homelessness stigma, is notable. This suggests that racial discrimination is not as dependent on indicators of homelessness that may serve to increase the accessi- bility of homeless youth to members of the public who would initiate discrimination. This conjecture aligns with the long history of literature that suggests that racial discrimination is pervasive

and occurs across settings (e.g., Corrigan et al., 2003), making it nearly impossible for Black adolescents and young adults to avoid.

Limitations

The findings of the study should be considered in accordance with several limitations. First, the data are cross-sectional and therefore direction of causality in any association cannot be deter- mined. While previous research documents that perceived racist and antigay discrimination is associated with depressive symptoms and suicidality in Black GLB youths (Thoma & Huebner, 2013), and longitudinal and experimental research has found that perceived dis- crimination negatively impacts mental health (Pascoe & Smart Rich- mand, 2009), other studies have noted that depressed mood predicts homelessness (Fothergill, Doherty, Robertson, & Ensminger, 2012), and it is possible that mental health status might have an effect on perceptions of discrimination as well. Indeed, evidence of the independent and joint action of social selection and causation processes on mental health outcomes suggests that both causal directions warrant consideration (for a discussion, see Muntaner et al., 2013).

Second, we relied on a small convenience sample of adolescents and young adults receiving services to access this largely hidden and invisible population. As a result, we cannot assume that the sample is representative of Black adolescents and young adults experiencing homelessness. Notably, Black adolescents and young adults experiencing homelessness who are not accessing services may be more vulnerable and thus experience different outcomes related to perceptions of discrimination, particularly if these ado- lescents and young adults also identify as GLB. There may also be differences in experiences of minors experiencing homelessness versus adults experiencing homelessness as the age range in our sample is 16 –24. Further, our small sample size limited the nature of our analyses and prevented a full exploration of intersectional- ity, which would have been the analytic approach most supported by previous literature and theory. Though accessing persons ex- periencing homelessness is difficult from a sampling point of view, future research should weigh the value of sample size in accor- dance to the desire to investigate combinatory or moderation effects.

Third, we note that our measures used are based on self-report with no objective verification of the events reported and analyzed in this study. Furthermore, while perceived racial and sexual discrimination were measured over the past year, perceived home- lessness stigma was measured over the course of an individual’s life. Thus, the data were collected retrospectively and thus subject to recall bias which may have led to inaccurate reporting of events. Despite evidence that the CES-D operates similarly across race and ethnicity in youth samples, (Skriner & Chu, 2014) we urge caution when comparing the CES-D scores measured here to other groups. Fourth, we did not include a measure of identity salience which would have helped gain a deeper understanding of how important racial, and sexual, and homeless identities were to individuals involved in the study. Finally, it is possible that reports of one’s own experiences of stigma or discrimination may be related to how long a person has been homeless and that was not accounted for.

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Implications and Conclusion

As Unger and colleagues (1997) stated more than a decade ago, interested parties “could benefit from an improved understanding of the mental health needs of homeless adolescents. This knowl- edge could be used to identify youths at risk of becoming homeless and to provide appropriate services to those currently homeless” (p. 377). Our results, in line with many previous findings, suggest that depressive symptoms and suicidality are present at alarming levels among Black adolescents and young adults experiencing homelessness. Additionally, racial discrimination and indicators of homelessness matter to the mental health of this population, pro- viding support for Grollman’s (2012) assertion that a lack of attention to multiple forms of marginalization, and their accompa- nying multiple forms of discrimination, may undercut attempts to appropriately study, prevent, and/or adequately treat mental health problems among homeless adolescents and young adults.

We support Kilmer and colleagues’ (2012) challenge for home- lessness interventions to incorporate a “multilevel, ecological ap- proach, rather than interventions aimed solely at distinct compo- nents of these [. . .] experiences, such as housing, parenting behaviors, mental health services, and the like” (p. 393), as ado- lescents and young adults experiencing homelessness are often linked to interventions and supports that do not address the com- prehensive nature of their needs (Swick, 2005). In terms of prac- tice implications, we first maintain that because homelessness itself is a highly stressful experience, it should be immediately ameliorated though the use of primary preventions such as housing-first policies (Lanzerotti, 2004). These interventions, though arguably a “distinct component” of assistance argued against by some housing researchers, undercut the detrimental effects of experiences dependent on homelessness, including those of discrimination targeted at homeless status. Undercutting expo- sure to this discrimination, particularly when the interventions prevent the most severe forms of homelessness, can do much to prevent psychological distress associated with these experiences.

Second, we maintain that discrimination research has too often focused on (a) single forms of marginalization, and (b) the expe- riences of the targets of discrimination. Our findings suggest that racial discrimination may be particularly harmful to adolescents and young adults, even in contexts of homelessness and sexual minority discrimination. These results, and their alignment with a long history of research, point to the need for inquiry and inter- ventions that address the initiation of discrimination. As stated above, racial discrimination is pervasive and appears particularly alarming during stressful circumstances (e.g., homelessness) that occur during critical stages of development. Interventions aimed at helping Black adolescents and young adults endorsing any sexual identity who experience homelessness should carefully consider how to prevent the deleterious impact of the chronic, uncontrolla- ble, and unpredictable stressors endemic to experiences of mar- ginalization. Specifically, researchers and practitioners alike must shift their focus from assisting adolescents and young adults tasked with overwhelming amounts of stress to manage their distress and instead focus on systemic interventions that undercut the initiation of these stressors. Housing first policies and antidiscrimination efforts, particularly in the form of law supported by aggressive enforcement, are worthy of sustained support.

Keywords: homeless; Black youth; racism; homophobia; mental health; discrimination

References Adkins, D. E., Wang, V., Dupre, M. E., van den Ord, E. J. C. G., & Elder,

G. H., Jr. (2009). Structure and stress: Trajectories of depressive symp- toms across adolescence and young adulthood. Social Forces, 88, 31– 60. http://dx.doi.org/10.1353/sof.0.0238

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: The influence of per- ceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38, 1001–1014. http://dx.doi.org/10.1007/s10964-009- 9397-9

Aneshensel, C. S. (1992). Social stress: Theory and research. Annual Review of Sociology, 18, 15–38. http://dx.doi.org/10.1146/annurev.so.18 .080192.000311

Avison, W. R., & Turner, R. J. (1988). Stressful life events and depressive symptoms: Disaggregating the effects of acute stressors and chronic strains. Journal of Health and Social Behavior, 29, 253–264. http://dx .doi.org/10.2307/2137036

Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Micro- aggressions Scale. Cultural Diversity & Ethnic Minority Psychology, 17, 163–174. http://dx.doi.org/10.1037/a0023244

Bassuk, E. L. (2010). Ending child homelessness in America. American Journal of Orthopsychiatry, 80, 496 –504. http://dx.doi.org/10.1111/j .1939-0025.2010.01052.x

Belcher, J. R., & DeForge, B. R. (2012). Social stigma and homelessness: The limits of social change. Journal of Human Behavior in the Social Environment, 22, 929 –946. http://dx.doi.org/10.1080/10911359.2012 .707941

Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes. Journal of Youth and Adoles- cence, 38, 989 –1000. http://dx.doi.org/10.1007/s10964-008-9389-1

Blazer, D. G., Kessler, R. C., McGonagle, K. A., & Swartz, M. S. (1994). The prevalence and distribution of major depression in a national com- munity sample: The National Comorbidity Survey. The American Jour- nal of Psychiatry, 151, 979 –986. http://dx.doi.org/10.1176/ajp.151.7 .979

Boardman, J. D. (2004). Health pessimism among black and white adults: The role of interpersonal and institutional maltreatment. Social Science & Medicine, 59, 2523–2533. http://dx.doi.org/10.1016/j.socscimed.2004 .04.014

Boardman, J. D., & Alexander, K. B. (2011). Stress trajectories, health behav- iors, and the mental health of black and white young adults. Social Science & Medicine, 72, 1659 –1666. http://dx.doi.org/10.1016/j.socscimed.2011 .03.024

Brody, G. H., Chen, Y. F., Murry, V. M., Ge, X., Simons, R. L., Gibbons, F. X., . . . Cutrona, C. E. (2006). Perceived discrimination and the adjustment of African American youths: A five-year longitudinal anal- ysis with contextual moderation effects. Child Development, 77, 1170 – 1189. http://dx.doi.org/10.1111/j.1467-8624.2006.00927.x

Brooks, V. R. (1981). Minority stress and lesbian women. Lanham, MD: Lexington Books.

Bruce, D., Stall, R., Fata, A., & Campbell, R. T. (2014). Modeling minority stress effects on homelessness and health disparities among young men who have sex with men. Journal of Urban Health, 91, 568 –580. http:// dx.doi.org/10.1007/s11524-014-9876-5

Cochran, B. N., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their het- erosexual counterparts. American Journal of Public Health, 92, 773– 777. http://dx.doi.org/10.2105/AJPH.92.5.773

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

87DISCRIMINATION, DEPRESSION, AND SUICIDALITY

Conron, K. J., Mimiaga, M. J., & Landers, S. J. (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100, 1953–1960. http://dx .doi.org/10.2105/AJPH.2009.174169

Corliss, H. L., Goodenow, C. S., Nichols, L., & Austin, S. B. (2011). High burden of homelessness among sexual-minority adolescents: Findings from a representative Massachusetts high school sample. American Journal of Public Health, 101, 1683–1689. http://dx.doi.org/10.2105/ AJPH.2011.300155

Corrigan, P., Thompson, V., Lambert, D., Sangster, Y., Noel, J. G., & Campbell, J. (2003). Perceptions of discrimination among persons with serious mental illness. Psychiatric Services, 54, 1105–1110. http://dx .doi.org/10.1176/appi.ps.54.8.1105

Crawford, I., Allison, K. W., Zamboni, B. D., & Soto, T. (2002). The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. Journal of Sex Research, 39, 179 –189. http://dx.doi.org/10.1080/00224490209552140

Dohrenwend, B. P., & Dohrenwend, B. S. (1969). Social status and psychological disorder: A causal inquiry. New York, NY: Wiley- Interscience.

Edidin, J. P., Ganim, Z., Hunter, S. J., & Karnik, N. S. (2012). The mental and physical health of homeless youth: A literature review. Child Psychiatry and Human Development, 43, 354 –375. http://dx.doi.org/10 .1007/s10578-011-0270-1

Farmer, M. M., & Ferraro, K. F. (2005). Are racial disparities in health conditional on socioeconomic status? Social Science & Medicine, 60, 191–204. http://dx.doi.org/10.1016/j.socscimed.2004.04.026

Fothergill, K. E., Doherty, E. E., Robertson, J. A., & Ensminger, M. E. (2012). A prospective study of childhood and adolescent antecedents of homelessness among a community population of African Americans. Journal of Urban Health, 89, 432– 446. http://dx.doi.org/10.1007/ s11524-011-9641-y

Fredriksen-Goldsen, K. I., Kim, H. J., Barkan, S. E., Muraco, A., & Hoy-Ellis, C. P. (2013). Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. American Journal of Public Health, 103, 1802–1809. http://dx.doi.org/10.2105/ AJPH.2012.301110

Galliher, R. V., Rostosky, S. S., & Hughes, H. K. (2004). School belonging, self-esteem, and depressive symptoms in adolescents: An examination of sex, sexual attraction status, and urbanicity. Journal of Youth and Adolescence, 33, 235–245. http://dx.doi.org/10.1023/B:JOYO .0000025322.11510.9d

Garrison, C. Z., Jackson, K. L., Marsteller, F., McKeown, R., & Addy, C. (1990). A longitudinal study of depressive symptomatology in young adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 29, 581–585. http://dx.doi.org/10.1097/00004583- 199007000-00011

Gattis, M. N. (2009). Psychosocial problems associated with homelessness in sexual minority youths. Journal of Human Behavior in the Social Environment, 19, 1066 –1094. http://dx.doi.org/10.1080/1091135090 2990478

Gattis, M. N. (2013). An ecological systems comparison between homeless sexual minority youth and homeless heterosexual youth. Journal of Social Service Research, 39, 38 – 49. http://dx.doi.org/10.1080/01488376 .2011.633814

Gee, G. C. (2002). A multilevel analysis of the relationship between institutional and individual racial discrimination and health status. American Journal of Public Health, 92, 615– 623. http://dx.doi.org/10 .2105/AJPH.92.4.615

González, H. M., Tarraf, W., Whitfield, K. E., & Vega, W. A. (2010). The epidemiology of major depression and ethnicity in the United States. Journal of Psychiatric Research, 44, 1043–1051. http://dx.doi.org/10 .1016/j.jpsychires.2010.03.017

Gore, S., & Aseltine, R. H., Jr. (2003). Race and ethnic differences in depressed mood following the transition from high school. Journal of Health and Social Behavior, 44, 370 –389. http://dx.doi.org/10.2307/ 1519785

Grafsky, E. L., Letcher, A., Slesnick, N., & Serovich, J. M. (2011). Comparison of treatment response among GLB and non-GLB street- living youth. Children and Youth Services Review, 33, 569 –574. http:// dx.doi.org/10.1016/j.childyouth.2010.10.007

Greene, M. L., Way, N., & Pahl, K. (2006). Trajectories of perceived adult and peer discrimination among Black, Latino, and Asian American adolescents: Patterns and psychological correlates. Developmental Psy- chology, 42, 218 –236. http://dx.doi.org/10.1037/0012-1649.42.2.218

Grollman, E. A. (2012). Multiple forms of perceived discrimination and health among adolescents and young adults. Journal of Health and Social Behavior, 53, 199 –214. http://dx.doi.org/10.1177/0022146512 444289

Grollman, E. A. (2014). Multiple disadvantaged statuses and health: The role of multiple forms of discrimination. Journal of Health and Social Behavior, 55, 3–19. http://dx.doi.org/10.1177/0022146514521215

Hatzenbuehler, M. L., McLaughlin, K. A., & Nolen-Hoeksema, S. (2008). Emotion regulation and internalizing symptoms in a longitudinal study of sexual minority and heterosexual adolescents. Journal of Child Psy- chology and Psychiatry, 49, 1270 –1278. http://dx.doi.org/10.1111/j .1469-7610.2008.01924.x

Hatzenbuehler, M. L., McLaughlin, K. A., & Xuan, Z. (2012). Social networks and risk for depressive symptoms in a national sample of sexual minority youth. Social Science & Medicine, 75, 1184 –1191. http://dx.doi.org/10.1016/j.socscimed.2012.05.030

Hurd, N. M., Varner, F. A., Caldwell, C. H., & Zimmerman, M. A. (2014). Does perceived racial discrimination predict changes in psychological distress and substance use over time? An examination among Black emerging adults. Developmental Psychology, 50, 1910 –1918. http://dx .doi.org/10.1037/a0036438

Jones-Webb, R. J., & Snowden, L. R. (1993). Symptoms of depression among blacks and whites. American Journal of Public Health, 83, 240 –244. http://dx.doi.org/10.2105/AJPH.83.2.240

Karlsen, S., & Nazroo, J. Y. (2002). Relation between racial discrimina- tion, social class, and health among ethnic minority groups. American Journal of Public Health, 92, 624 – 631. http://dx.doi.org/10.2105/AJPH .92.4.624

Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The preva- lence, distribution, and mental health correlates of perceived discrimi- nation in the United States. Journal of Health and Social Behavior, 40, 208 –230. http://dx.doi.org/10.2307/2676349

Keyes, K. M., Barnes, D. M., & Bates, L. M. (2011). Stress, coping, and depression: Testing a new hypothesis in a prospectively studied general population sample of U.S.-born Whites and Blacks. Social Science & Medicine, 72, 650 – 659. http://dx.doi.org/10.1016/j.socscimed.2010.12 .005

Kidd, S. A. (2003). Street youth: Coping and interventions. Child & Adolescent Social Work Journal, 20, 235–261. http://dx.doi.org/10.1023/ A:1024552808179

Kidd, S. A. (2004). “The walls were closing in and we were trapped”: A qualitative analysis of street youth suicide. Youth & Society, 36, 30 –55. http://dx.doi.org/10.1177/0044118X03261435

Kidd, S. A. (2006). Factors precipitating suicidality among homeless youth: A quantitative follow-up. Youth & Society, 37, 393– 422. http:// dx.doi.org/10.1177/0044118X05282763

Kidd, S. A. (2007). Youth homelessness and social stigma. Journal of Youth and Adolescence, 36, 291–299. http://dx.doi.org/10.1007/s10964- 006-9100-3

Kidd, S. A., Veltman, A., Gately, C., Chan, K. J., & Cohen, J. N. (2011). Lesbian, gay, and transgender persons with severe mental illness: Ne- gotiating wellness in the context of multiple sources of stigma. Ameri-

T hi

s do

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en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

88 GATTIS AND LARSON

can Journal of Psychiatric Rehabilitation, 14, 13–39. http://dx.doi.org/ 10.1080/15487768.2011.546277

Kilmer, R. P., Cook, J. R., Crusto, C., Strater, K. P., & Haber, M. G. (2012). Understanding the ecology and development of children and families experiencing homelessness: Implications for practice, support- ive services, and policy. American Journal of Orthopsychiatry, 82, 389 – 401. http://dx.doi.org/10.1111/j.1939-0025.2012.01160.x

Kosciw, J. G., Diaz, E. M., & Greytak, E. A. (2008). The 2007 national school climate survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York, NY: Gay, Les- bian, and Straight Education Network.

Kozloff, N., Cheung, A. H., Ross, L. E., Winer, H., Ierfino, D., Bullock, H., & Bennett, K. J. (2013). Factors influencing service use among home- less youths with co-occurring disorders. Psychiatric Services, 64, 925– 928. http://dx.doi.org/10.1176/appi.ps.201200257

Kruks, G. (1991). Gay and lesbian homeless/street youth: Special issues and concerns. Journal of Adolescent Health, 12, 515–518. http://dx.doi .org/10.1016/0197-0070(91)90080-6

Lanzerotti, L. (2004). Housing first for families: Research to support the development of a housing first for families training curriculum. San Francisco, CA: National Alliance to End Homelessness.

Loosier, P. S., & Dittus, P. J. (2010). Group differences in risk across three domains using an expanded measure of sexual orientation. The Journal of Primary Prevention, 31, 261–272. http://dx.doi.org/10.1007/s10935- 010-0228-2

Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., . . . Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta- analytic review. Journal of Adolescent Health, 49, 115–123. http://dx .doi.org/10.1016/j.jadohealth.2011.02.005

Martin-Storey, A., & Crosnoe, R. (2012). Sexual minority status, peer harassment, and adolescent depression. Journal of Adolescence, 35, 1001–1011. http://dx.doi.org/10.1016/j.adolescence.2012.02.006

McCaskill, P. A., Toro, P. A., & Wolfe, S. M. (1998). Homeless and matched housed adolescents: A comparative study of psychopathology. Journal of Clinical Child Psychology, 27, 306 –319. http://dx.doi.org/10 .1207/s15374424jccp2703_7

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38 –56. http://dx.doi.org/10.2307/ 2137286

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674 – 697. http://dx.doi.org/10.1037/0033- 2909.129.5.674

Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine, 67, 368 –379. http://dx.doi.org/10.1016/j.socscimed.2008.03.012

Milburn, N. G., Batterham, P., Ayala, G., Rice, E., Solorio, R., Desmond, K., . . . Rotheram-Borus, M. J. (2010). Discrimination and mental health problems among homeless minority young people. Public Health Re- ports, 125, 61– 67.

Muntaner, C., Ng, E., Vanroelen, C., Christ, S., & Eaton, W. W. (2013). Social stratification, social closure, and social class as determinants of mental health disparities. In C. S. Aneshensel, J. C. Phelan, & A. Bierman (Eds.), Handbook of the sociology of mental health (2nd ed., pp. 205–227). New York, NY: Springer. http://dx.doi.org/10.1007/978- 94-007-4276-5_11

National Center on Family Homelessness. (2011). The characteristics and needs of families experiencing homelessness. Waltham, MA: Author.

National Health Care for the Homeless Council. (2011). Homelessness & health: What’s the connection? Nashville, TN: Author.

Noell, J. W., & Ochs, L. M. (2001). Relationship of sexual orientation to substance use, suicidal ideation, suicide attempts, and other factors in a

population of homeless adolescents. Journal of Adolescent Health, 29, 31–36. http://dx.doi.org/10.1016/S1054-139X(01)00205-1

Nyamathi, A., Marfisee, M., Slagle, A., Greengold, B., Liu, Y., & Leake, B. (2012). Correlates of depressive symptoms among homeless young adults. Western Journal of Nursing Research, 34, 97–117. http://dx.doi .org/10.1177/0193945910388948

Paradies, Y. (2006). A systematic review of empirical research on self- reported racism and health. International Journal of Epidemiology, 35, 888 –901. http://dx.doi.org/10.1093/ije/dyl056

Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135, 531–554. http://dx.doi.org/10.1037/a0016059

Patel, D. R., & Greydanus, D. E. (2002). Homeless adolescents in the United States. International Pediatrics, 17, 71–75.

Pearlin, L. I. (1989). The sociological study of stress. Journal of Health and Social Behavior, 30, 241–256. http://dx.doi.org/10.2307/2136956

Phelan, J., Link, B. G., Moore, R. E., & Stueve, A. (1997). The stigma of homelessness: The impact of the label “homeless” on attitudes toward poor persons. Social Psychology Quarterly, 60, 323–337. http://dx.doi .org/10.2307/2787093

Pratt, L., & Brody, D. (2008). Depression in the United States household population, 2005–2006. Atlanta, GA: Centers for Disease Control and Prevention. http://dx.doi.org/10.1037/e565102009-001

Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385– 401. http://dx.doi.org/10.1177/014662167700100306

Ray, N. (2006). Lesbian, gay, bisexual youths: An epidemic of homeless- ness. New York, NY: National Gay and Lesbian Task Force Policy Institute and the National Coalition for the Homeless.

Reck, J. (2009). Homeless gay and transgender youth of color in San Francisco: “No one likes street kids”—Even in the Castro. Journal of LGBT Youth, 6, 223–242. http://dx.doi.org/10.1080/193616509030 13519

Ren, X. S., Amick, B. C., & Williams, D. R. (1999). Racial/ethnic dispar- ities in health: The interplay between discrimination and socioeconomic status. Ethnicity & Disease, 9, 151–165.

Riolo, S. A., Nguyen, T. A., Greden, J. F., & King, C. A. (2005). Prevalence of depression by race/ethnicity: Findings from the National Health and Nutrition Examination Survey III. American Journal of Public Health, 95, 998 –1000. http://dx.doi.org/10.2105/AJPH.2004 .047225

Ritchey, F. J., La Gory, M., Fitzpatrick, K. M., & Mullis, J. (1990). A comparison of homeless, community-wide, and selected distressed sam- ples on the CES-Depression Scale. American Journal of Public Health, 80, 1384 –1386. http://dx.doi.org/10.2105/AJPH.80.11.1384

Rosario, M., Schrimshaw, E. W., & Hunter, J. (2012). Homelessness among lesbian, gay, and bisexual youth: Implications for subsequent internalizing and externalizing symptoms. Journal of Youth and Ado- lescence, 41, 544 –560. http://dx.doi.org/10.1007/s10964-011-9681-3

Ruan, W. J., Goldstein, R. B., Chou, S. P., Smith, S. M., Saha, T. D., Pickering, R. P., . . . Grant, B. F. (2008). The alcohol use disorder and associated disabilities interview schedule-IV (AUDADIS-IV): Reliabil- ity of new psychiatric diagnostic modules and risk factors in a general population sample. Drug and Alcohol Dependence, 92, 27–36. http://dx .doi.org/10.1016/j.drugalcdep.2007.06.001

Ryan, K. D., Kilmer, R. P., Cauce, A. M., Watanabe, H., & Hoyt, D. R. (2000). Psychological consequences of child maltreatment in homeless adolescents: Untangling the unique effects of maltreatment and family environment. Child Abuse & Neglect, 24, 333–352. http://dx.doi.org/10 .1016/S0145-2134(99)00156-8

Safren, S. A., & Heimberg, R. G. (1999). Depression, hopelessness, sui- cidality, and related factors in sexual minority and heterosexual adoles- cents. Journal of Consulting and Clinical Psychology, 67, 859 – 866. http://dx.doi.org/10.1037/0022-006X.67.6.859

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

89DISCRIMINATION, DEPRESSION, AND SUICIDALITY

Sanders-Phillips, K., Settles-Reaves, B., Walker, D., & Brownlow, J. (2009). Social inequality and racial discrimination: Risk factors for health disparities in children of color. Pediatrics, 124 (Suppl 3), S176 – S186. http://dx.doi.org/10.1542/peds.2009-1100E

Saperstein, A. M., Lee, S., Ronan, E. J., Seeman, R. S., & Medalia, A. (2014). Cognitive deficit and mental health in homeless transition-age youth. Pediatrics, 134, e138 – e145. http://dx.doi.org/10.1542/peds .2013-4302

Savin-Williams, R. C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: Associations with school problems, running away, substance abuse, prostitution, and suicide. Journal of Consulting and Clinical Psychology, 62, 261–269. http://dx .doi.org/10.1037/0022-006X.62.2.261

Schwartz, S., & Meyer, I. H. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science & Medicine, 70, 1111–1118. http://dx .doi.org/10.1016/j.socscimed.2009.11.032

Seaton, E. K., Upton, R., Gilbert, A., & Volpe, V. (2014). A moderated mediation model: Racial discrimination, coping strategies, and racial identity among Black adolescents. Child Development, 85, 882– 890. http://dx.doi.org/10.1111/cdev.12122

Skriner, L. C., & Chu, B. C. (2014). Cross-ethnic measurement invariance of the SCARED and CES-D in a youth sample. Psychological Assess- ment, 26, 332–337. http://dx.doi.org/10.1037/a0035092

Srole, L., Langner, T. S., Michael, S. T., Opler, M. K., & Rennie, T. A. (1960). Mental health in the metropolis: The Midtown Manhattan Study. New York, NY: McGraw-Hill.

Stein, J. A., Nyamathi, A. M., & Zane, J. I. (2009). Situational, psychos- ocial, and physical health-related correlates of HIV/AIDS risk behaviors in homeless men. American Journal of Men’s Health, 3, 25–35. http:// dx.doi.org/10.1177/1557988307307862

Swick, K. J. (2005). Helping homeless families overcome barriers to successful functioning. Early Childhood Education Journal, 33, 195– 200. http://dx.doi.org/10.1007/s10643-005-0044-0

Taylor, J., & Turner, R. J. (2002). Perceived discrimination, social stress, and depression in the transition to adulthood: Racial contrasts. Social Psychology Quarterly, 65, 213–225. http://dx.doi.org/10.2307/3090120

Thoits, P. (2010). Stress and health: Major findings and policy implica- tions. Journal of Health and Social Behavior, 51(Suppl.), S41–S53.

Thoma, B. C., & Huebner, D. M. (2013). Health consequences of racist and antigay discrimination for multiple minority adolescents. Cultural Di- versity & Ethnic Minority Psychology, 19, 404 – 413. http://dx.doi.org/ 10.1037/a0031739

Thompson, V. L. S. (1996). Perceived experiences of racism as stressful life events. Community Mental Health Journal, 32, 223–233. http://dx .doi.org/10.1007/BF02249424

Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and young adult psychosocial adjustment. Devel- opmental Psychology, 46, 1580 –1589. http://dx.doi.org/10.1037/ a0020705

Tyler, K. A., & Cauce, A. M. (2002). Perpetrators of early physical and sexual abuse among homeless and runaway adolescents. Child Abuse & Neglect, 26, 1261–1274. http://dx.doi.org/10.1016/S0145-2134 (02)00413-1

Unger, J. B., Kipke, M. D., Simon, T. R., Montgomery, S. B., & Johnson, C. J. (1997). Homeless youths and young adults in Los Angeles: Prev- alence of mental health problems and the relationship between mental health and substance abuse disorders. American Journal of Community Psychology, 25, 371–394. http://dx.doi.org/10.1023/A:1024680727864

Walls, N. E., Hancock, P., & Wisneski, H. (2007). Differentiating the social service needs of homeless sexual minority youths from those of non-homeless sexual minority youth. Journal of Children & Poverty, 13, 177–205. http://dx.doi.org/10.1080/10796120701520309

Weinreb, L. F., Buckner, J. C., Williams, V., & Nicholson, J. (2006). A comparison of the health and mental health status of homeless mothers in Worcester, Mass: 1993 and 2003. American Journal of Public Health, 96, 1444 –1448. http://dx.doi.org/10.2105/AJPH.2005.069310

Whitbeck, L. B., Chen, X., Hoyt, D. R., Tyler, K. A., & Johnson, K. D. (2004). Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. Journal of Sex Research, 41, 329 –342. http://dx.doi.org/10.1080/002244 90409552240

Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behav- ioral Medicine, 32, 20 – 47. http://dx.doi.org/10.1007/s10865-008- 9185-0

Williams, D. R., & Williams-Morris, R. (2000). Racism and mental health: The African American experience. Ethnicity & Health, 5, 243–268. http://dx.doi.org/10.1080/713667453

Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology, 2, 335–351. http:// dx.doi.org/10.1177/135910539700200305

Williams, T., Connolly, J., Pepler, D., & Craig, W. (2005). Peer victim- ization, social support, and psychosocial adjustment of sexual minority adolescents. Journal of Youth and Adolescence, 34, 471– 482. http://dx .doi.org/10.1007/s10964-005-7264-x

T hi

s do

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er ic

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A ss

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e of

it s

al li

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. T

hi s

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is in

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fo r

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on al

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of th

e in

di vi

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is no

t to

be di

ss em

in at

ed br

oa dl

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