title: Multifactorial discrimination as a fundamental cause of mental health inequities.
abstract: The theory of fundamental causes explains why health disparities persist over time, even as risk factors, mechanisms, and diseases change. Using an intersectional framework, we evaluated multifactorial discrimination as a fundamental cause of mental health disparities.
  
  
  
  Using baseline data from the Project STRIDE: Stress, Identity, and Mental Health study, we examined the health effects of discrimination among individuals who self-identified as lesbian, gay, or bisexual. We used logistic and linear regression to assess whether multifactorial discrimination met the four criteria designating a fundamental cause, namely that the cause: 1) influences multiple health outcomes, 2) affects multiple risk factors, 3) involves access to resources that can be leveraged to reduce consequences of disease, and 4) reproduces itself in varied contexts through changing mechanisms.
  
  
  
  Multifactorial discrimination predicted high depression scores, psychological well-being, and substance use disorder diagnosis. Discrimination was positively associated with risk factors for high depression scores: chronic strain and total number of stressful life events. Discrimination was associated with significantly lower levels of mastery and self-esteem, protective factors for depressive symptomatology. Even after controlling for risk factors, discrimination remained a significant predictor for high depression scores. Among subjects with low depression scores, multifactorial discrimination also predicted anxiety and aggregate mental health scores.
  
  
  
  Multifactorial discrimination should be considered a fundamental cause of mental health inequities and may be an important cause of broad health disparities among populations with intersecting social identities.
authors.affiliation: Public Health Program, Santa Clara University, 500 El Camino Real, Santa Clara, CA, 95053, USA.
authors.forename: Mariam
authors.initials: M
authors.lastname: Khan
authors.affiliation: Public Health Program, Santa Clara University, 500 El Camino Real, Santa Clara, CA, 95053, USA.
authors.forename: Misja
authors.initials: M
authors.lastname: Ilcisin
authors.affiliation: Department of Biology, Santa Clara University, 500 El Camino Real, Santa Clara, CA, 95053, USA. ksaxton@scu.edu.
authors.forename: Katherine
authors.identifier: 0000-0002-6071-2048
authors.initials: K
authors.lastname: Saxton
mesh_terms: D000293:Adolescent; D000328:Adult; D001007:Anxiety / Q000209:etiology*; D001008:Anxiety Disorders / Q000209:etiology*; D003863:Depression / Q000209:etiology*; D003866:Depressive Disorder / Q000209:etiology*; D005260:Female; D005783:Gender Identity; D006801:Humans; D016015:Logistic Models; D008297:Male; D008603:Mental Health; D008875:Middle Aged; D044469:Racial Groups; D012307:Risk Factors; D012649:Self Concept; D019529:Sexuality; D012923:Social Class; D063508:Social Discrimination / Q000523:psychology*; D012933:Social Identification; D012959:Socioeconomic Factors; D013315:Stress, Psychological / Q000209:etiology; D019966:Substance-Related Disorders / Q000209:etiology*; D055815:Young Adult
keywords: Discrimination; Fundamental causes; Health equity; Intersectionality; Mental Health