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We introduce internalized heterosexist racism (IHR), or the internalization of damaging stereotypes, harmful beliefs, and negative attitudes about being a sexual minority person of color. We also present the initial development and validation of the Brief Internalized Heterosexist Racism Scale for gay and bisexual Black men (IHR-GBBM), a unidimensional, 10-item measure of IHR. Exploratory factor analyses on an internet-obtained sample of gay and bisexual Black men ( N  = 312; Mean age = 30.36 years) show that the IHR-GBBM had evidence of good internal consistency, and good convergent, discriminant, concurrent, and incremental validity. The IHR-GBBM was positively correlated with internalized racism, internalized heterosexism, and discrimination (racist, heterosexist). IHR was also negatively correlated with race stigma consciousness, weakly positively correlated with sexual identity stigma consciousness, but not correlated with either race identity, sexual identity, or social desirability. Hierarchical regressions showed that the IHR-GBBM explained an additional variance of 2.8% and 3.1% in anxiety symptoms and substance use coping, respectively, after accounting for (1) sociodemographics, (2) internalized racism and internalized heterosexism, and (3) an interaction of internalized racism and internalized heterosexism. Older participants and those who were “out” about their sexual identity reported lower IHR. Those who did not know/want to report their HIV status reported greater IHR. Results revealed no sexual identity, sexual position, relationship status, income, education, or employment status differences in IHR. We hope the development of the IHR-GBBM spurs future research on predictors and consequences of IHR. We discuss limitations and implications for the future study of internalized heterosexist racism.

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health’s commitment to social justice makes it a natural fit with intersectionality’s focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.

Experiences of heterosexism are rampant online, where bias and harassment against LGBTQ+ individuals spread conveniently and widely. Yet, research has been limited in understanding the exposure to online heterosexism among LGBTQ+ individuals partly due to the lack of a quantitative measure to advance this research. Thus, the current study developed and examined the psychometric properties of the Perceived Online Heterosexism Scale (POHS). Items were developed via a literature review, a survey of social media platforms, and an expert review. Exploratory ( N  = 288) and confirmatory ( N  = 653) factor analyses yielded a 4-factor structure and produced a 20-item scale with the following subscales: (1) Heterosexist Cyberaggression (4 items), (2) Online Heterosexist Stereotyping (4 items), (3) Online Exposure to Systemic Heterosexism (8 items), and (4) Heterosexist Online Media (four items). Internal consistency estimates ranged from .91 to .96, and the POHS accounted for 65.9% of the variance. Examination of a second-order model suggested that a total scale score can also be used. Initial construct validity was evidenced as POHS scores were associated with an existing heterosexism measure, anxiety and depressive symptoms, internalized heterosexism, and LGBTQ+ community connectedness in line with theory and empirical evidence. Implications for research practice are discussed.

We present a conceptual framework that highlights how unique dimensions of individual-level HIV-related stigma (perceived community stigma, experienced stigma, internalized stigma, and anticipated stigma) might differently affect the health of those living with HIV. HIV-related stigma is recognized as a barrier to both HIV prevention and engagement in HIV care, but little is known about the mechanisms through which stigma leads to worse health behaviors or outcomes. Our conceptual framework posits that, in the context of intersectional and structural stigmas, individual-level dimensions of HIV-related stigma operate through interpersonal factors, mental health, psychological resources, and biological stress pathways. A conceptual framework that encompasses recent advances in stigma science can inform future research and interventions aiming to address stigma as a driver of HIV-related health.

Meta-analytic methods were used to analyze 179 effect sizes retrieved from 32 research reports on the implications that sexual minority stress may have for same-sex relationship well-being. Sexual minority stress (aggregated across different types of stress) is moderately and negatively associated with same-sex relationship well-being (aggregated across different dimensions of relationship well-being). Internalized homophobia is significantly and negatively associated with same-sex relationship well-being, whereas heterosexist discrimination and sexual orientation visibility management are not. Moreover, the effect size for internalized homophobia is significantly larger than those for heterosexist discrimination and sexual orientation visibility management. Sexual minority stress is significantly and negatively associated with same-sex relationship quality but not associated with closeness or stability. Sexual minority stress is significantly and negatively associated with relationship well-being among same-sex female couples but not among same-sex male couples. The current status of research approaches in this field is also summarized and discussed.

Many individuals who identify as lesbian, gay, bisexual, queer, and with other non-heterosexual orientations (LGBQ+) experience stigma, prejudice, and/or discrimination because of their sexuality. According to minority stress and identity development theories, these experiences can contribute to difficulties with self-acceptance of sexuality. Lower self-acceptance is considered a risk factor for adverse mental health outcomes. The current review aims to investigate whether self-acceptance of sexuality is associated with minority stressors or difficulties with mental health in LGBQ+ individuals, as well as whether there are differences in self-acceptance between different sexual orientations. Five bibliographic databases were searched. Thirteen studies were identified which used quantitative methodology to investigate associations between self-acceptance, minority stressors, and/or mental health within LGBQ+ samples, or differences in self-acceptance between different sexual orientations. The results from these cross-sectional studies suggested that lower self-acceptance of sexuality was associated with higher levels of self-reported minority stressors, including a lack of acceptance from friends and family, a lack of disclosure to others, and internalized heterosexism. Lower self-acceptance of sexuality was associated with poorer mental health outcomes, including greater global distress, depression symptoms, and lower psychological well-being. There was no significant relationship with suicidality. Studies also found that LGBQ+ individuals had lower general self-acceptance compared to heterosexual participants, bisexual individuals had lower sexuality self-acceptance compared to lesbian/gay individuals, and lesbian women had lower sexuality self-acceptance compared to gay men. Given the potential importance of self-acceptance for LGBQ+ populations, further research is required with more robust methodology. Self-acceptance could be a potential target in clinical interventions for LGBQ+ individuals.

Individuals who identify as heterosexual but engage in same-sex sexual behavior fascinate both researchers and the media. We analyzed the Online College Social Life Survey dataset of over 24,000 undergraduate students to examine students whose last hookup was with a same-sex partner ( N  = 383 men and 312 women). The characteristics of a significant minority of these students (12% of men and 25% of women) who labelled their sexual orientation “heterosexual” differed from those who self-identified as “homosexual,” “bisexual,” or “uncertain.” Differences among those who identified as heterosexual included more conservative attitudes, less prior homosexual and more prior heterosexual sexual experience, features of the hookups, and sentiments about the encounter after the fact. Latent class analysis revealed six distinctive “types” of heterosexually identified students whose last hookup was with a same-sex partner. Three types, comprising 60% of students, could be classified as mostly private sexual experimentation among those with little prior same-sex experience, including some who did not enjoy the encounter; the other two types in this group enjoyed the encounter, but differed on drunkenness and desire for a future relationship with their partner. Roughly, 12% could be classified as conforming to a “performative bisexuality” script of women publicly engaging in same-sex hookups at college parties, and the remaining 28% had strong religious practices and/or beliefs that may preclude a non-heterosexual identity, including 7% who exhibited “internalized heterosexism.” Results indicate several distinctive motivations for a heterosexual identity among those who hooked up with same-sex partners; previous research focusing on selective “types” excludes many exhibiting this discordance.

The mission ofthe National Institutes of Health (NIH) is to seek fundamental knowledge about the nature and behavior of living systems and to apply that knowledge to enhance health and reduce illness and disability. As new tools such as big data analytics, computational biology, and high throughput processes have emerged, the NIH has integrated these tools to fuel scientific advances. One tool that has become more commonly used is the theoretical framework of intersectionality, defined as how multiple marginalized or disadvantaged social statuses interact at the micro level of individuals' lived experience to reflect interlocking systems of privilege and oppression at the macro social structural level (e.g., racism, classism, colonialism, sexism, heterosexism, ableism).1,2 Intersectionality theory, long used in other disciplines, is a relative newcomer to health research. This theory can foster a greater understanding of human health by moving beyond the biomedical model and individual-level determinants to examine the health effects resulting from the intersection of structural power dynamics, such as systemic sexism and racism. In our roles in extramural research administration at NIH, we have seen a growth in research addressing intersectionality, as well as a lack of consensus about best practices for studying this complex construct. In this editorial, we share our views on important areas for research development that we believe will help to advance the science of intersectionality. These views were shaped in part by the numerous grant applications we have seen submitted to the NIH, where we have a first-hand opportunity to view the latest innovations and cutting-edge science, as well as gaps and limitations.

I commence with a confession. As compelling as I find the argument that stigma is a fundamental cause of health inequities,1 and as much as I believe (obviously) that intersectionality is an indispensable critical lens for health equity research,21 am not convinced that intersectional stigma is the right concept to advance more equitable HIV treatment and prevention outcomes. The incongruity of this confession is not lost on me. In addition to my role as a guest editor of this special supplement of AJPH, I am also a principal investigator of an intersectional stigma project funded by the same National Institute of Mental Health (NIMH)3 initiative that sourced this supplement. My primary opposition is that intersectional stigma, at least as currently conceptualized, obscures interlocking oppressive social-structural systems such as structural racism, sexism, and heterosexism (to name some) that more accurately explain why, four decades into the HIV/AIDS epidemic in the United States, we can foresee the end of the epidemic for relatively more privileged groups such as White sexual minority men but not Black and Latino sexual minority men or cisgender and transgender women.

To date, the majority of research studying lesbian, gay, bisexual, transgender, and queer (LGBTQ) health has been conducted in Westernized, predominantly individualistic countries. Building on minority stress theory and models of LGBTQ health, we explored how sexual orientation and nationality moderated the association between internalized heterosexism and life satisfaction for lesbian and bisexual (LB) women living in two countries (Turkey and Belgium) with contrasting social contexts. The results of two-way MANOVA, in a sample of 339 Turkish and 220 Belgian LB women, revealed main effects but no interaction effects. LB women in Belgium reported less internalized heterosexism and more life satisfaction than LB women in Turkey. The results of moderation analyses indicated no moderation effect, however internalized heterosexism and country emerged as the best predictors of life satisfaction. Findings were interpreted with a focus on how culture-specific aspects contribute to life satisfaction among LB women. Our findings suggest mental health professionals working with LB women need to tailor therapeutic interventions to reflect the social context connected to their patients’ nationality, in order to effectively address internalized heterosexism, improve life satisfaction, and promote self- and social advocacy. Cultural values, such as adherence to collectivistic or individualistic norms, should be included as variables in future research examining determinants of LGBTQ health.