title: Structural stigma and all-cause mortality in sexual minority populations.
abstract: Stigma operates at multiple levels, including intrapersonal appraisals (e.g., self-stigma), interpersonal events (e.g., hate crimes), and structural conditions (e.g., community norms, institutional policies). Although prior research has indicated that intrapersonal and interpersonal forms of stigma negatively affect the health of the stigmatized, few studies have addressed the health consequences of exposure to structural forms of stigma. To address this gap, we investigated whether structural stigma-operationalized as living in communities with high levels of anti-gay prejudice-increases risk of premature mortality for sexual minorities. We constructed a measure capturing the average level of anti-gay prejudice at the community level, using data from the General Social Survey, which was then prospectively linked to all-cause mortality data via the National Death Index. Sexual minorities living in communities with high levels of anti-gay prejudice experienced a higher hazard of mortality than those living in low-prejudice communities (Hazard Ratio [HR] = 3.03, 95% Confidence Interval [CI] = 1.50, 6.13), controlling for individual and community-level covariates. This result translates into a shorter life expectancy of approximately 12 years (95% C.I.: 4-20 years) for sexual minorities living in high-prejudice communities. Analysis of specific causes of death revealed that suicide, homicide/violence, and cardiovascular diseases were substantially elevated among sexual minorities in high-prejudice communities. Strikingly, there was an 18-year difference in average age of completed suicide between sexual minorities in the high-prejudice (age 37.5) and low-prejudice (age 55.7) communities. These results highlight the importance of examining structural forms of stigma and prejudice as social determinants of health and longevity among minority populations.
authors.affiliation: Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 549.B, New York, NY 10032, United States. Electronic address: mlh2101@columbia.edu.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Hatzenbuehler
authors.affiliation: Department of Sociology, University of Nebraska-Lincoln, Lincoln, NE, United States.
authors.forename: Anna
authors.initials: A
authors.lastname: Bellatorre
authors.affiliation: Department of Sociology, University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Yeonjin
authors.initials: Y
authors.lastname: Lee
authors.affiliation: RAND Corporation, Santa Monica, CA, United States.
authors.forename: Brian K
authors.initials: BK
authors.lastname: Finch
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, United States.
authors.forename: Peter
authors.initials: P
authors.lastname: Muennig
authors.affiliation: Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, United States.
authors.forename: Kevin
authors.initials: K
authors.lastname: Fiscella
mesh_terms: D000328:Adult; D001727:Bisexuality / Q000706:statistics & numerical data*; D002423:Cause of Death / Q000639:trends*; D005260:Female; D006306:Health Surveys; D006716:Homosexuality / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008913:Minority Groups / Q000706:statistics & numerical data*; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D018570:Risk Assessment; D064890:Social Determinants of Health; D057545:Social Stigma; D014481:United States / Q000453:epidemiology
keywords: Mortality; Prejudice; Sexual orientation; Stigma; United States