FVS7

Weaponized Oppression: Identity Abuse and Mental Health in the Lesbian, Gay, Bisexual, Transgender, and Queer Community

Julie M. Woulfe Montefiore Medical Center, Bronx, New York

Lisa A. Goodman Boston College

Objective: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) survivors of intimate partner violence (IPV) experience unique IPV tactics called identity abuse (i.e., abuse tactics within an intimate partnership that leverage systemic oppression to harm an individual). This study explored the effect of identity abuse on symptoms of depression and posttraumatic stress disorder (PTSD). It investigated whether affirmative LGBTQ identity moderates this relationship. Method: A total of 734 sexual minority adults aged 18 to 61 were recruited between October 2014 and September 2015 through online listservs and forums. They completed online surveys with measures of identity abuse, PTSD symptoms, depres- sion symptoms, and affirmative LGBT identity. Ordinary least squares regression analysis was used to explore the study’s main hypotheses. Results: Identity abuse exposure in adulthood explained variance in depression (� � .10, p � .01) and PTSD (� � .11, p � .01) scores while controlling for other forms of IPV and demographic variables. Similarly, identity abuse exposure in the past year explained variance in depression (� � .09, p � .05) and PTSD (� � .14, p � .01) scores while controlling for other forms of IPV and demographic variables. As expected, positive identity affirmation moderated the relationship between adult identity abuse exposure (� � �.07, p � .05) and past year identity abuse exposure (� � �.09, p � .01) and symptoms of depression. Conclusion: Results of this study suggest that identity abuse is associated with symptoms of depression and PTSD, and that affirmative identity may be an important buffer of these effects.

Keywords: LGBTQ, intimate partner violence, domestic violence, identity abuse

Intimate partner violence (IPV; i.e., physical, sexual, or psycho- logical harm) is a critical concern in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, with rates of vio- lence that are as high if not higher than cisgender, heterosexual populations (Black et al., 2010; Langenderfer-Magruder, Whit- field, Walls, Kattari, & Ramos, 2016; Meyer, 2003). In a national probability sample of 18,049 respondents, 43.8% of lesbian women and 61.1% of bisexual women (as compared with 35% of heterosexual women) and 26% of gay men and 37.3% of bisexual men (as compared with 29% heterosexual men) reported experi- encing rape, physical violence, and/or stalking by a partner over the course of their lifetime (Walters, Chen, & Breiding, 2013). Although there have not been national population surveys exam- ining rates of IPV in the transgender and gender nonconforming (TGNC) community, one state-based LGBT Health Survey re- ported that of all respondents, transgender individuals reported

significantly more lifetime exposure to IPV than cisgender respon- dents (38% of transgender respondents as compared with 20.4% of cisgender respondents; Langenderfer-Magruder et al., 2016).

Further, LGBTQ survivors1 face unique barriers to accessing the social support and formal services needed to recover from abuse (Basow & Thompson, 2012; Edwards, Sylaska, & Neal, 2015; Turell & Herrmann, 2008) and must navigate the stressors of ongoing heterosexism and gender oppression, which already place them at disproportionate risk for psychological distress (Lehavot & Simoni, 2011; Meyer, 2003). In addition to these challenges, LGBTQ survivors experience unique tactics of violence that le- verage systemic oppression such as heterosexism and cissexism to harm an individual. This dynamic is known as identity abuse (Ard & Makadon, 2011; West, 2012). For LGBTQ survivors, examples of such abuse include threatening to “out” a survivor to family or an employer or restricting access to a supportive LGBTQ commu- nity (National Center on Domestic and Sexual Violence [NCDSV], 2014).

Emerging evidence indicates that identity abuse is prevalent among LGBTQ individuals. In a previous study, we developed and validated a measure based on a broad review of the empirical and practice-based literature on identity abuse in the LGBTQ commu- nity (Balsam & Szymanski, 2005; FORGE, 2014; NCDSV, 2014),

1 The term survivor will be used in place of victim throughout this study in alignment with feminist theory that places the emphasis on the strength of individuals who have experienced violence.

This article was published Online First August 1, 2019. Julie M. Woulfe, Department of Psychiatry and Behavioral Sciences,

Montefiore Medical Center, Bronx, New York; Lisa A. Goodman, Depart- ment of Counseling Developmental and Educational Psychology, Lynch School of Education, Boston College.

Correspondence concerning this article should be addressed to Julie M. Woulfe, Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467. E-mail: [email protected]

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Psychology of Violence © 2019 American Psychological Association 2020, Vol. 10, No. 1, 100–109 2152-0828/20/$12.00 http://dx.doi.org/10.1037/vio0000251

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and then assessed its prevalence among a sample of 734 LGBTQ participants. In that study, nearly one fifth (16.8%) reported expe- riencing identity abuse in the past year and 40.1% reported expe- riencing identity abuse at some point in adulthood. (For further details on the relative prevalence of identity abuse across sub- groups of the LGBTQ community, see Woulfe & Goodman, 2018.) Despite these high rates, however, we know little about the relationship between identity abuse and mental health. This rela- tionship is critical to understand, as identity abuse leverages cul- tural and systemic discrimination and may have a distinct effect on survivors as compared with other forms of psychological abuse. Given that LGBTQ survivors experience identity abuse in the context of ongoing heterosexism and homo-, bi-, and transphobia, which already place them at a disproportionate risk for psycho- logical distress (Lehavot & Simoni, 2011), the mental health consequences of identity abuse may be particularly damaging.

This article begins with a discussion of minority stress theory as a guiding framework for this study. It then goes on to explore the relationship between identity abuse and two mental health out- comes that have been demonstrated to be associated with IPV: symptoms of depression and posttraumatic stress disorder (PTSD; depression: Buller, Devries, Howard, & Bacchus, 2014; McLaugh- lin, Hatzenbuehler, Xuan, & Conron, 2012; PTSD: Pantalone, Hessler, & Simoni, 2010; Walters et al., 2013). It then explores whether a strong sense of LGBTQ identity, which acts as a buffer against other forms of anti-LGBTQ discrimination, similarly mod- erates the relationship between identity abuse exposure and symp- toms of depression and PTSD.

Minority Stress Theory

Although all forms of abuse have been associated with mental health difficulties such as depression and PTSD, minority stress theory suggests that identity abuse may be associated with espe- cially poor mental health outcomes for survivors. The minority stress model, developed by Meyer (2003) and expanded to TGNC communities by Hendricks and Testa (2012), argues that hetero- sexism and cissexism create a series of stressors for LGBTQ people that ultimately increase vulnerability to mental health chal- lenges. These stressors include external (“distal”) stressors (e.g., discrimination, rejection, hate crimes; Herek & Garnets, 2007; Meyer, 2003) as well as internal (“proximal”) stressors (e.g., inter- nalized stigma). Existing research supports the link between chronic stress and poor mental health (Cicchetti & Toth, 1997; Hyman, 2013), as well as the relationship between minority stress exposure and depression (Feinstein, Goldfried, & Davila, 2012; Lehavot & Simoni, 2011; Lewis, Derlega, Griffin, & Krowinski, 2003) and PTSD (Alessi, 2010; Cochran, Balsam, Flentje, Malte, & Simpson, 2013).

The minority stress model also outlines a number of protective factors that buffer the effects of minority stress. These include developing a positive identity of oneself as an LGBTQ individual, or identity affirmation. Minority stress theorists suggest that de- veloping a positive identity as a member of an oppressed group is central to the process of adapting to stigma (Balsam & Mohr, 2007; Mohr & Kendra, 2011). This premise has received support from research demonstrating that LGBTQ identity affirmation acts as a buffer between victimization and poor mental health outcomes (Hershberger & D’Augelli, 1995), is associated with lower psy- chological distress (Balsam & Mohr, 2007), and correlates nega-

tively with measures of depression, guilt, fear, hostility, and sad- ness, and positively with measures of general life satisfaction, self-assurance, and social self-esteem (Mohr & Kendra, 2011). In short, LGBTQ individuals who feel more positively about being LGBTQ cope more successfully with the challenge of minority stress.

The construct of identity affirmation is particularly relevant as a protective factor given that identity abuse tactics directly target a sense of pride in one’s identity. Identity abuse emphasizes LGBTQ survivors’ marginalized position and denigrates an aspect of their identity that is already threatened by internalized, interpersonal, cultural, and structural heterosexism and gender oppression. Direct attacks on LGBTQ survivors’ sense of identity may make them more vulnerable to minority stress, and consequently increase the likelihood of experiencing symptoms of PTSD and depression. Although there is no research to date in direct support of this hypothesis, research on other forms of bias-based victimization (e.g., bullying, hate crimes) indicates that these crimes often have greater associations with poorer mental health outcomes than harassment or violent crimes alone (Herek, Cogan, Gillis, & Glunt, 1998; Poteat, Mereish, DiGiovanni, & Koenig, 2011). Alternately, high LGBTQ identity affirmation could be a critical buffer against the effects of identity abuse.

Although previous studies have begun to explore the role of identity abuse in the lives of LGBTQ survivors (Balsam & Szy- manski, 2005; National Coalition of Anti-Violence Programs, 2013, 2015), the current study further examines the relationship between identity abuse and mental health outcomes. It is also explores the extent to which affirmative LGBTQ identity moder- ates the relationship between identity abuse and psychological distress. We hypothesized as follows:

Hypothesis 1: Exposure to identity abuse (both in the past year and in adulthood) would contribute uniquely to variance in symptoms of depression and PTSD while controlling for other forms of IPV exposure and demographic variables.

Hypothesis 2: Identity abuse would contribute as much vari- ance as other forms of IPV exposure.

Hypothesis 3: Identify affirmation would moderate the rela- tionship between identity abuse exposure (past year and adult- hood) and symptoms of PTSD and depression while holding demographic variables and other forms of IPV exposure constant.

Method

Participants

Participants included 734 LGBTQ adults, ranging in age from 18 to 61 years (Mage � 33.49, SD � 12.91) who were recruited between October 2014 and September 2015. About half identified as women (53.1%), and about a quarter (27.4%) identified as men. Participants who identified as transgender or as either man or woman were initially grouped under a “Trans-binary” label, and participants who identified their gender as genderqueer were grouped under a “Gender non-binary” label. These groups were compared on all violence and mental health measures. Because

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101WEAPONIZED OPPRESSION

there were no significant differences on any of these variables, the groups were combined under the umbrella term TGNC (19.3%).

Participants identified their sexual orientation as gay (23.6%), bisexual (13.6%), lesbian (22.8%), and queer or pansexual (38.7%). Ten participants (1.4%) did not identify their sexual identity. Nine participants (1.2%) identified as straight and also as TGNC. Par- ticipants selected these labels from a list of response options and were instructed to check as many as applied. Participants were also able to write in identity labels that had not been represented. For the purposes of this study, these participants were assigned the label of the most encompassing identity. For example, if a partic- ipant endorsed both lesbian and bisexual—given that the bisexual label captured the participants’ attractions across gender, bisexual was retained rather than lesbian. Queer was selected over all other terms given its status as an umbrella identity.

The majority of participants identified as White (81.1%), fol- lowed by Asian American or Pacific Islander (7.5%), Hispanic or Latina/o American (6.5%), biracial or multiracial (4.5%), Black or African American (3.7%), First Nation, Native American, Amer- ican Indian, or Alaska Native (2%), Middle Eastern or Arab American (1.6%), Native Hawaiian or other Pacific Islander (0.6%), and a race/ethnicity identity label that was not listed in the response options (i.e., “other”; 0.4%). Given the small percentage of respondents in several of these subgroups, racial/ethnic groups were collapsed into the following categories: White (78.5%), peo- ple of color (POC; 21.1%), and “other” (0.4%).

Regarding geographic location, participants reported living in the following U.S. regions: Northeast (33%), West or Northwest (26.3%), South/Southwest (18.7%), Midwest (16.9%), or other U.S. territories (5.0%). Finally, participants varied across the fol- lowing educational levels: bachelors or associate degree (38.1%), master’s degree (30.1%), a doctoral or professional degree (16.25%), and some high school, high school diploma, or a general education diploma (GED; 15.5%).

Procedure

Participants were recruited through LGBTQ-specific online fo- rums and listservs that focused on IPV, LGBTQ concerns, or both. These included the listservs of groups that provide direct service to the LGBTQ community (e.g., Queer Muslims of Boston), LGBTQ centers at educational institutions (e.g., Salt Lake Community College LGBT Center), and social media pages (e.g., Milwaukee LGBTQ Center Facebook Page). Recruitment sites were selected based on their potential to reach a large number of LGBTQ people, their focus on reaching LGBTQ people generally—rather than LGBTQ people who identify as survivors of violence, and whether they reached LGBTQ individuals with intersecting marginalized identities (e.g., age, religion, race/ethnicity, ability status). We made a concerted effort to recruit racially and ethnically diverse LGBTQ participants by recruiting through culturally specific groups as well as online forums and listservs. If sites had a moderator (as in the case of listservs) they were contacted to obtain permission to forward a study announcement to its members or directly post on the site. We also used snowball sampling by sending this announcement out to colleagues and friends con- nected to the LGBTQ community. Overall, we contacted 122 LGBTQ community groups specifically geared toward LGBTQ communities of color, and 301 community groups in total. Four

listservs focused on LGBTQ IPV specifically. Potential partici- pants were invited to be part of an anonymous, voluntary, online study on relationships in the LGBTQ community, and were offered the opportunity to enter a raffle to win one of five $25 gift cards. Participants were required to be at least 18 years of age and identify as a sexual or gender minority. The study was approved by the researchers’ institutional review board.

Measures

Demographics. Demographic variables included participants’ age, self-identified gender identity, educational attainment, racial/ ethnic identity, and sexual orientation. These results are further described in Table 1.

Identity abuse. The Identity Abuse Scale covers four domains of identity abuse: (a) outing, or threatening to disclose a partner’s LGBTQ identity without their consent (e.g., “The person threat- ened to tell my employer, family, or others about my sexual orientation or gender identity”); (b) undermining, attacking, or denying a partner’s identity as an LGBTQ person (e.g., “The person questioned whether my sexual orientation or gender iden- tity was ‘real’”); (c) the use of slurs or derogatory language regarding the target’s sexual orientation or gender identity (e.g., “The person called me pejorative names that have to do with my LGBTQ status”); and (d) threatening to isolate the survivor from the LGBTQ community (e.g., “The person prevented me from seeking support within the LGBTQ community”; see Woulfe & Goodman, 2018, for a more detailed description of the develop- ment and validation of this measure). The final measure consisted of seven items. For each item, participants reported whether the

Table 1 Sample Demographics

Demographics Participants included

(%, n � 734)

Age (n � 733) 33.49 Gender (n � 733)

Man 27.4 Woman 53.1 Transgender/nonbinary 19.4

Race/ethnicity (n � 734) White 78.5 People of color 15.9 Other 5.6

Sexual orientation (n � 734) Bisexual 13.6 Gay 23.6 Lesbian 22.8 Queer/pansexual 39.2

Highest level of education (n � 734) Some high school, high school, or GED 15.5 Bachelors or associates degree 38.1 Master’s degree 30.1 Doctoral/professional degree or higher 16.2

Geographic location (n � 733) Midwestern United States 16.9 Northeastern United States 33 West and Northwestern United States 26.3 Southern and Southwestern United States 18.7 Other (U.S. territory, international) 5

Note. GED � general equivalency diploma.

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102 WOULFE AND GOODMAN

event had occurred once in the past year, twice in the past year, 3–5 times in the past year, 6–10 times in the past year, 11–20 times in the past year, more than 20 times in the past year, not in the past year but it did happen, or that the event had never happened. We developed a past year frequency variable by summing responses to the past-year items. Cronbach’s � for the past year Identity Abuse Scale was � � .8. We also created a dichotomous adult exposure according to whether or not participants endorsed any of the items, past year or adulthood.

Physical and sexual assault severity. To assess severity of history of physical or sexual violence, this study used the CTS2S (Straus & Douglas, 2004), a short form of the Revised Conflict Tactics Scale (CTS2). This measure contains 20 items that assess victimization and perpetration of violence in four domains: assault, injury, psychological aggression, and sexual coercion. For this study, we excluded the psychological aggression items, given that we had a separate measure to assess this construct. Participants responded using an 8-point Likert scale that captures both past- year frequency (on a scale from 0 [did not occur] to 6 [occurred more than 20 times]) and presence in adulthood (e.g., since age 18—yes or no). Previous literature has indicated the concurrent validity between the short form and full scales of the CTS2 as ranging from .6 to .94 for those who report being victimized (Straus & Douglas, 2004). The four physical assault items were analyzed separately from the two sexual assault items in the preliminary analyses and ordinary least squares (OLS) regression models to explore distinctions between physical and sexual vio- lence. For each subscale, two variables were created: A continuous variable for “past year frequency” that represented the sum of responses for each item, and a dichotomous variable for adult abuse—present or absent. For this investigation, the Cronbach’s � for past year CTS was � � .89.

Psychological abuse. In the absence of psychological abuse measures specifically normed on the LGBTQ community, we chose the commonly used short form version of the Psychological Maltreatment of Women Inventory (PMWI; Tolman, 1999). This measure contains 14 items that assess psychological violence in relationships. It consists of two subscales: Domination/Isolation (e.g., “The person monitored my time and made me account for my whereabouts”) and Emotional/Verbal Abuse (e.g., “The person called me names”). The response options ask how frequently each item occurred in the past 6 months, with choices including never, rarely, occasionally, frequently, or very frequently. We made three adjustments to this scale. First, we shifted the reference time period to match that of the CTS2 (1 year). Second, we changed the response options to match the CTS2, including identical past year frequency questions and a question about whether these behaviors happened in adulthood rather than in the past year. Finally, given that the scale was originally created for women who experienced abuse by male intimate partners, we adjusted the wording of the measure so that it would apply to survivors and perpetrators of all genders.

As with the CTS-2, we created two variables: a continuous variable representing past year frequency and a dichotomous variable representing abuse in adulthood. A prior investigation into the psychometric characteristics of the scale indicated relatively high internal consistency: The Dominance/Isolation subscale demonstrated an � of .88, and the Emotional/Verbal subscale demonstrated an � of .92 (Tolman, 1999). For this

investigation, the Cronbach’s � for past year Psychological Maltreatment of Women Inventory was � � .87. With regard to validity, a prior investigation found that the measure had ade- quate construct validity, and that it discriminated between com- munity samples and samples of women who sought services for IPV (Tolman, 1999).

Depressive symptoms. To measure depressive symptoms, we used the Center for Epidemiological Studies Depression Scale, Revised (CESD-R; Van Dam & Earleywine, 2011). This 20-item scale assesses the frequency of symptoms over the course of the previous 2 weeks. The CESD-R is a revised version of the CESD (Radloff, 1977), updated to reflect current criteria for depression (Van Dam & Earleywine, 2011). This measure has been used with IPV survivors (Sabri et al., 2013) and in research on minority stress in the LGBTQ community (Lick, Tornello, Riskind, Schmidt, & Patterson, 2012). In a recent validation study of this measure using a large general population sample (n � 7,389), the measure demonstrated good construct validity in that it was mod- erately correlated with a theoretically similar (e.g., anxiety) mea- sure, and strong reliability, with a Cronbach’s � of .93 (Van Dam & Earleywine, 2011). For this investigation, the Cronbach’s � for the CESD-R was � � .95.

PTSD symptoms. To measure symptoms of PTSD, we used the PTSD Checklist Civilian Version (PCL-C; Blanchard, Jones- Alexander, Buckley, & Forneris, 1996). This 17-item measure assesses symptoms in relation to generic “stressful experiences” and asks participants to rate each item on a 5-point scale according to how much it has bothered them “in the past month.” The PCL-C was selected for its ability to assess for multiple traumas and its previous use with samples of survivors of sexual assault and IPV (Blanchard et al., 1996; Woodcock, 2007). The response items were modified to ask about the previous 2 weeks, to make the response time consistent with the CESD-R. An earlier validation study demonstrated that the PCL-C had a high correlation with the Clinician Administered PTSD scale (CAPS, � � .929) and a PCL-C score of 44 correctly identified 17 of 18 participants who had been diagnoses with PTSD using the CAPS. The internal consistency score for the PCL-C was � � .94 for this sample (Blanchard et al., 1996). For this investigation, the Cronbach’s � for the PCL-C was � � .92.

LGBTQ identity affirmation. To assess individuals’ percep- tions of their LGBTQ identity, the three-item Identify Affirmation subscale (e.g., “I’m proud to be LGBTQ”) of the Lesbian Gay and Bisexual Identity Scale (Mohr & Kendra, 2011) was used. Re- sponse options ranged from 1 (disagree strongly) to 6 (agree strongly). We modified the items to refer to the more inclusive acronym “LGBTQ” for items that referred to “LGB” as identity labels. In Mohr and Kendra’s, 2011 evaluation of the measure, convergent and divergent validity was established by examining the measure’s correlation with similar constructs (e.g., positive adjustment, positive affect) and dissimilar constructs (e.g., inter- nalized homonegativity, acceptance concerns). The measures cor- related in conceptually consistent directions. With regard to reli- ability, across two samples mean internal consistency estimates ranged from .75 to .91, and 6-week test–retest correlations ranged from .70 to .92. For this investigation, the Cronbach’s � for subscale was � � .88.

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Data Analysis Plan

Preliminary analyses. Missing data were located, analyzed, and addressed using the Missing Values Analysis procedure for IBM SPSS Statistics Version 22 (IBM Corp, 2013). Missing data percentages ranged from 0% (on Identity Abuse measure) to 1.6% (on demographic measures), a nearly negligible amount as defined by Schlomer, Bauman, and Card (2010). A total of 1,045 clicked the survey link or initiated the online survey. Of those participants, 305 were removed for terminating their participation in the online survey prematurely or dropping out of the survey before complet- ing any of the items of the main measures of the study. Six more were deleted: one who identified as under 18, and five who did not show any indication of holding an LGBTQ identity.

Power analysis. To ensure adequate power and sufficient variability within each construct for a study with up to 12 predictor variables (i.e., gender, sexual orientation, race, education, geo- graphic location, the four violence exposure variables, the moder- ator variable, and the interaction: Identity Abuse � Moderator Variable) and small expected effect sizes (e.g., .1), the approxi- mate number of participants needed was calculated to be 270 participants (Cohen, 1992; Faul, Erdfelder, Buchner, & Lang, 2009). Consequently, the study sample size was anticipated to be sufficient for the OLS analyses.

Correlations. Due to the large number of variables, we chose to report for descriptive purposes only the pairwise correlations between the main variables of interest (see Table 2). The correla- tions were based on computed scales. The variables were associ- ated in conceptually consistent directions.

OLS regression analyses. We used OLS regression analysis to explore the study’s main hypotheses. Examining the skew and kurtosis ranges as well as examining histograms of each indepen- dent variable, we identified three variables that did not meet the assumption of normality: all three past year violence exposure variables. In line with recommendations from Hair (2010), the past year violence exposure variables were transformed using log trans- formations. We ran regression analyses using physical, psycholog- ical, and identity abuse as predictor variables and either depressive or PTSD symptom scores as dependent variables, and then ana- lyzed the semipartial correlations between each abuse variable, respectively, and each mental health variable to assess the specific effect of each independent variable on the dependent variable. For moderation analyses, demographic and physical and psychological

violence exposure variables were entered into the first step of the regression equation, the centered main effect variable and moder- ator variable in the second step, and the interaction term in the third step. For significant moderator effects, we further examined the results by testing simple slope regressions. All analyses were run using IBM SPSS Statistics Version 22 (IBM Corp, 2013).

Results

Hypothesis 1: What Is the Relationship Between Identity Abuse and Depression and PTSD Symptoms Controlling for Other Forms of IPV?

The first set of hypotheses explored the contribution of identity abuse to symptoms of depression and PTSD while controlling for both demographic variables and other forms of IPV (physical and psychological). Consistent with our first hypotheses, identity abuse exposure accounted for an additional 1% of the variance in de- pression scores after controlling for other forms of IPV and de- mographic variables (� � .10, p � .01; see Table 3). Similarly, adult identity abuse accounted for an additional 1% of the variance in PTSD symptoms after controlling for other forms of IPV and demographic variables (� � .11, p � .01; see Table 3).

Past year identity abuse exposure similarly contributed signifi- cantly to mental health outcomes. Past year identity abuse expo- sure contributed slightly less than 1% additional variance in de- pressive symptoms while controlling for other forms of IPV and demographic variables (� � .09, p � .05; see Table 3). Past year identity abuse exposure contributed about 1% additional variance in PTSD symptoms while controlling for other forms of IPV exposure and demographic variables (� � .14, p � .01; see Table 3).

Hypothesis 2: Does Identity Abuse Contribute as Much Variance to Depression and PTSD Symptoms as Other Forms of IPV Exposure?

The second hypothesis explored the relative strength of the relationship between each abuse variable and mental health. With regard to depressive symptoms, the semipartial correlation be- tween identity abuse and symptoms of depression (SR2 � .13; p � .01) and physical abuse and symptoms of depression (SR2 � .13; p � .01) were both significant. The semipartial correlation be-

Table 2 Means, Standard Deviations, and Correlations of Variables of Interest

Measures M SD 1 2 3 4 5 6 7 8

1. Past year physical abuse log transformed 0.078 0.23 2. Adult physical abuse 0.39 0.49 .32��

3. Past year psychological abuse log transformed 0.50 0.58 .39�� .24��

4. Adult psychological abuse 0.77 0.42 .08� .34�� .31��

5. Past year identity abuse log transformed 0.11 0.29 .44�� .20�� .57�� .13��

6. Adult identity abuse 0.40 0.49 .11�� .40�� .24�� .33�� .34��

7. Depression 17.04 14.37 .18� .19�� .21�� .07 .23�� .20��

8. PTSD 29.15 10.44 .18�� .20�� .29�� .16�� .30�� .23�� .79��

9. LGBTQ identity 5.02 1.02 �.05 �.03 �.02 �.003 �.06 �.04 �.12�� �.09�

Note. PTSD � posttraumatic stress disorder; LGBTQ � lesbian, gay, bisexual, transgender, and queer. � p � .05. �� p � .01.

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tween psychological abuse and depression symptoms was not significant. With regard to PTSD, the semipartial correlation be- tween identity abuse and symptoms of PTSD (SR2 � .13; p � .01) and physical abuse and symptoms of PTSD (SR2 � .15; p � .01) were both significant. Again, the semipartial correlation between psychological abuse and PTSD was not significant. These results indicate that the strength of the relationship between identity abuse and symptoms of depression and PTSD is similar to the strength of the relationship between physical abuse and symptoms of depres- sion and PTSD.

Hypothesis 3: Does Identity Affirmation Buffer the Relationship Between Identity Abuse and Mental Health?

The final set of analyses tested our hypothesis that identity affirmation would moderate the relationship between identity abuse exposure and depressive and PTSD symptoms while holding demographic variables constant. Consistent with our second set of hypotheses, identity affirmation significantly moderated the rela- tionship between adult identity abuse exposure and symptoms of depression (� � �.07, p � .05; see Table 4). We further examined the moderation effect by testing two simple slope regressions for each of the identity affirmation groups described above (e.g., low, high) in which the predictor was adult identity abuse exposure and the outcome was depressive symptoms. We found that adult iden- tity abuse exposure predicted depression symptoms in the low- affirmation group (� � .19, p � .01) but not for those in the high affirmation group. However, contrary to expectation, identity af- firmation did not moderate the relationship between adult identity abuse exposure and symptoms of PTSD.

With regard to past year identity abuse, identity affirmation significantly moderated the relationship between past year identity abuse exposure and symptoms of depression (� � �.09, p � .01; see Table 4). We again further examined the moderation effect by testing two simple slope regressions for each of the identity affir- mation groups described earlier (e.g., low, high) in which the

predictor was past year identity abuse exposure and the outcome was symptoms of depression. We also found that past year identity abuse exposure predicted depression symptoms in the low- affirmation group (� � .28, p � .01) but not for those in the high affirmation group. Identity affirmation did not moderate the rela- tionship between past year identity abuse exposure and symptoms of PTSD.

Discussion

The current study supported our first hypothesis that exposure to identity abuse (both in the past year and in adulthood) would contribute uniquely to variance in symptoms of depression and PTSD while controlling for other forms of IPV exposure and demographic variables. It is important to note, however, that although the relationships between identity abuse and symptoms of PTSD and depression were statistically significant, once the effects of physical, sexual, and psychological abuse were controlled for they contributed a very small percentage of variance to these outcome measures. Consequently further research is needed to better understand this relationship. Perhaps more importantly, these results also supported our second hypothesis that identity abuse’s relationship to symptoms of depression and PTSD was of comparable magnitude to physical abuse’s relationship to these mental health outcomes. Although this study design prevents causal conclusions, these findings indicate that LGBTQ people who experience identity abuse report significantly more symptoms of PTSD and depression than those who do not, and that identity abuse is as strongly related to mental health outcomes as physical

Table 3 Regression Analysis of Identity Abuse in Adulthood and Past Year and Depression and Posttraumatic Stress Disorder (PTSD)

Models

Depression PTSD

�R2 � �R2 �

Adult identity abuse Step 1 .15�� .13��

Step 2 .01�� .01��

Adult identity abuse .10�� .11��

Past year identity abuse Step 1 .16�� .14��

Step 2 .01�� .01��

Past year identity abuse .09� .14��

N 706

Note. The following variables were controlled for in Step 1 of the regression analysis: Race (White � 0; POC � 1), education (more than GED � 0; GED or below � 1), gender (0 � male; 1 � other), sexual orientation (0 � gay; 1 � other), exposure to physical and psychological abuse (no exposure � 0; exposure � 1), and age (left as a continuous variable). POC � people of color; GED � general equivalency diploma. � p � .05. �� p � .01.

Table 4 Identity Affirmation Moderating the Relationship Between Identity Abuse Exposure in Adulthood and Past Year and Depression, Controlling for Exposure to Physical and Psychological Abuse

Models

Depression

R2 �

Adult identity abuse Step 1 .15��

Step 2 .16��

LGBTQ identity �.10��

Adult identity abuse .09�

Step 3 .17�

LGBTQ Identity � Adult Identity Abuse �.07�

Past year identity abuse Step 1 .16��

Step 2 .18��

LGBTQ identity �.09�

Past year identity abuse .07 Step 3 .18��

LGBTQ Identity � Past Year Identity Abuse �.09�

N 704

Note. The following variables were controlled for in Step 1 of the regression analysis: Race (White � 0; POC � 1), education (more than GED � 0; GED or below � 1), gender (0 � male; 1 � other), sexual orientation (0 � gay; 1 � other), exposure to physical and psychological abuse (no exposure � 0; exposure � 1), and age (left as a continuous variable). LGBTQ � lesbian, gay, bisexual, transgender, and queer; POC � people of color; GED � general equivalency diploma. � p � .05. �� p � .01.

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and psychological abuse, two types of abuse that are known to contribute to a range of mental health difficulties (Black et al., 2010; Bostwick, Boyd, Hughes, & McCabe, 2010; Grant et al., 2011; McLaughlin et al., 2012; Walters et al., 2013).

Notably, these findings are consistent with predictions based on the minority stress model. According to this perspective, systems of oppression are translated into the experience of chronic stress (Meyer, 2003). Identity abuse may indeed be one such experience. Akin to discrimination, rejection, and hate crimes, identity abuse places an additional psychological burden on survivors, taxing their ability to cope (Aneshensel, 2009; Meyer, 2003). This may in turn increase vulnerability to mental health difficulties (Anesh- ensel, 2009; Turner & Avison, 2003), such that LGBTQ individ- uals who experience identity abuse report more symptoms of depression and PTSD.

Our third hypothesis that identity affirmation would moderate the relationship between identity abuse exposure and symptoms of PTSD and depression was partially supported. Consistent with literature suggesting that developing a positive identity as a mem- ber of an oppressed group is an important aspect of adapting to stigma (Balsam & Mohr, 2007; Mohr & Kendra, 2011), our results indicated that an affirmative LGBTQ identity did indeed weaken the relationship between exposure to past year and adult identity abuse, respectively, and depressive symptoms. Those with an affirmative LGBTQ identity may be better equipped to avoid internalizing the stigmatizing messages inherent in identity abuse, resulting in fewer symptoms of depression, particularly those related to negative self-concept (e.g., feelings of worthlessness and guilt; American Psychiatric Association, 2013). Further, those with stronger affirmative LGBTQ identities may need to expend fewer cognitive resources to actively protect against the stigma that identity abuse elicits. They may therefore be less psychically taxed and may experience fewer cognitive symptoms of depression (e.g., decrease in energy, lack of focus; American Psychiatric Associa- tion, 2013; Hatzenbuehler, 2009).

This same buffering effect was not found for PTSD symptoms. This is surprising given that one of the explanations for greater distress following bias-based victimization compared with other forms of victimization is that it triggers victims’ negative schemas about themselves and the world, which are in turn associated with PTSD symptoms (Kaysen, Lostutter, & Goines, 2005). In the case of identity abuse, we had predicted that affirmative LGBTQ iden- tity could prevent survivors from internalizing negative beliefs about themselves—namely, the anti-LGBTQ messages of the abuse itself. However, change in cognition and mood constitutes only one of four core domains of PTSD (e.g., reexperiencing, avoidance, negative cognitions and mood, arousal; American Psy- chiatric Association, 2013). Thus, it is possible that even if affir- mative LGBTQ identity protects against the development of neg- ative cognitions about the self and world, it has less impact on the somatic processes of PTSD—such as central nervous system, neu- roendocrine, and immune dysfunction (Gupta, 2013)—and therefore fails to buffer the impact of identity abuse on PTSD symptoms.

Limitations

Despite its contributions to the existing literature, this study was limited in key ways related to sampling, measurement, and con- ceptual framework, as described next. Regarding sampling, the

study sample is not representative of the population of LGBTQ individuals in the United States. Rather, it is a convenience sample based on listserv recruitment and snowball sampling. Despite deliberate sampling in LGBTQ POC and gender-diverse commu- nities, the study sample overrepresented White and cisgender participants, and underrepresented LGBTQ POC and TGNC peo- ple. Consequently, conclusions cannot be drawn about the rela- tionships between identity abuse and mental health outcomes in LGBTQ communities of color or for TGNC communities.

The identity abuse measure also has several measurement lim- itations. First, the identity abuse measure is a limited assessment of the construct of identity abuse in that it does not distinctly capture variability between participants who experienced a single act of violence and those who have experienced chronic identity abuse over many years. Future iterations of this measure may be devel- oped that attempt to capture these differences.

Regarding conceptualization, this study builds on the minority stress model developed by Meyer (2003) to better understand how bias-based IPV may be related to mental health. However, this study focused primarily on external sources of minority stress rather than internal ones. Research on the minority stress model has identified a number of internal factors that interact with ex- ternal ones to influence outcomes. For example, we did not gather information on level of internalized homo/bi/transphobia (New- comb & Mustanski, 2010) or rejection sensitivity (Feinstein et al., 2012), which may have increased vulnerability to identity abuse. We also did not examine how individuals’ openness or “outness” affected the impact of minority stress. Given that outing a partner is a tactic of identity abuse, this will be an important area of investigation for future research.

Another conceptual limitation of this study was its examination of both sexual and gender minority communities rather than sep- arating these two groups. Although this allowed for inclusion of a broad range of identities, it did so at the cost of conflating the experiences of distinct subgroups. Although we recognize the importance of understanding the distinct experiences of single subgroups within the LGBTQ community, we chose a more in- clusive approach for two reasons. First, there is sufficient research evidence to suggest that the constructs under examination in this study (e.g., identity abuse, the minority stress model) are relevant to transgender, bisexual, and queer communities as well as the more traditionally studied cisgender, gay, and lesbian communities (FORGE, 2014). Similarly, although the majority of research on minority stress has focused upon the experiences of gay, lesbian, and cisgender individuals (Balsam & Mohr, 2007; Hendricks & Testa, 2012), anecdotal and qualitative research suggests that these constructs are relevant across the LGBTQ community. The current exclusion of the experiences of people with nonbinary gender and sexual orientation from the literature in turn reinforces their mar- ginalized location within the LGBTQ community. Rather than preemptively exclude members of the LGBTQ community out of concern for possibly small recruitment numbers, this study chose instead to sample broadly and subsequently examine the data for group differences. Those analyses are beyond the scope of this article, though some initial differences in prevalence across gender were presented in the initial article on the identity abuse measure (Woulfe & Goodman, 2018).

Finally, although the identity abuse measure contributed signif- icantly to variance in symptoms of PTSD and depression, that

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contribution was small (1%). There are likely many factors that influence the severity of depression and PTSD symptoms in com- plex and intertwining ways. Indeed, future research should inves- tigate identity abuse not just as an isolated single contributor to mental health outcomes, but one that likely interacts with other forms of abuse to influence clinical outcomes. For example, iden- tity abuse may also exacerbate other mediating factors such as shame (Beck et al., 2011), which in turn affect mental health outcomes.

Research Implications

Results of this study suggest a number of avenues for future research. First, findings indicate that the relationship between identity abuse and mental health symptoms is buffered by LGBTQ identity affirmation. Given that identity abuse can be understood as a form of bias-based victimization, and by extension a source of minority stress, this suggests the need for future identity abuse research to elucidate a more comprehensive and nuanced picture of the pathways from identity abuse exposure to mental health, in- cluding examination of the relationship between identity abuse and other constructs within the minority stress model (e.g., conceal- ment/outness). More recent expansions of the minority stress model suggest that internal and external minority stressors also shape general social and cognitive processes (Hatzenbuehler, 2009). Future research on identity abuse’s effect on such processes such as social isolation and emotional dysregulation will provide a more nuanced understanding of its effect on LGBTQ survivors of IPV.

Future research on identity abuse should also include a wider swath of the LGBTQ community particularly those from margin- alized communities for whom identity abuse must be understood in a more intersectional way. For example, similar to the way that LGBTQ people of color experience specific forms of discrimina- tion (e.g., having to educate White LGBT people about race, being sexualized by other LGBT people because of one’s race or eth- nicity; Balsam, Molina, Beadnell, Simoni, & Walters, 2011), there may be specific identity abuse tactics for subgroups in the LGBTQ community. Some possible examples could include threatening to out a partner within an unsupportive racial/ethnic community, denying a partner’s LGBTQ or racial/ethnic identity because they “cannot be both,” telling a partner they deserve what they get—or that they will not be loved due to their dual minority status, or a partner denying racism in the White LGBTQ community. Finally, we need longitudinal designs to confirm a causal relationship between identity abuse and mental health.

Clinical Implications

In terms of practice, training programs should help practitioners understand the central role of identity abuse and its destructive consequences as a part of the IPV picture in LGBTQ communities. On a programmatic level, agencies could incorporate questions about identity abuse into clinical intakes both in domestic violence programs and in other clinical and social service settings. Further, given our findings indicating that affirmative LGBTQ identity may be critical to buffering the impact of identity abuse, practitioners should consider discussing and working to build LGBTQ identity as part of their mental health treatment.

Summary and Conclusion

The Institute of Medicine ended its report on health disparities in the LGBTQ community by stating, “Lesbian, gay, bisexual, and TGNC individuals have unique health experiences and needs, but as a nation, we do not know exactly what these experiences and needs are” (Graham et al., 2011, p. 4). This study represents a significant step toward illuminating one critical set of experiences and needs in the LGBTQ community, those related to identity abuse. We hope that it provides a compelling rationale for further study of identity abuse, and illuminates concrete next steps toward closing the health disparity gap for LGBTQ survivors.

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Received May 14, 2018 Revision received May 25, 2019

Accepted June 12, 2019 �

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