Concealing Concealment: The Mediating Role of Internalized Heterosexism in Psychological Distress Among Older LGB Adults

Background and Purpose: Underlying mechanisms of risk may not be understood, even when health disparities have been identified. Lesbian, gay, and bisexual (LGB) older adults experience disproportionately high rates of psychological distress, compared to their heterosexual peers. The minority stress model posits that "excess" psychological distress among LGB populations results from unique stressors consequent to societal heterosexism, including internalized heterosexism and concealment of sexual orientation. Previous research has produced conflicting findings regarding the relationship between concealment and psychological distress. There has also been debate as to whether concealment and internalized heterosexism are distinct constructs or are actually different facets of one. The purpose of this study is to test a pathway that links sexual orientation and psychological distress, and to provide evidence that concealment and internalized heterosexism are distinct constructs.

Methods: I analyzed secondary data from the Caring and Aging with Pride (CAP) project, the first federally-funded study to explore the health and aging needs of older sexual and gender minority adults. Surveys were distributed via mailing lists of 11 agencies serving LGBT older adults across the nation. Of the 2,560 participants, 2,372 identified as LGB and were included in this study. I used structural equation modeling (SEM) to examine the underlying structural relationship between the latent variables concealment and internalized heterosexism, and the observed indicator outcome variable psychological distress, as measured by the short form of the Center for Epidemiological Studies Depression Scale (CESD-10), controlling for age, income, education, race/ethnicity, gender, and sexual orientation. SEM can also decompose total effects into direct and indirect components, allowing for interpretation of mediation effects.

Results: The age range was 50 to 95 - years old, with a mean of 67. Most (95%) identified as lesbian or gay, 35% were female, and 87% identified as non-Hispanic white.  Although the majority (92%) had some college education or more, nearly one in three (30%) had household incomes ≤ 200% of the federal poverty level. SEM results indicate that total effect of concealment on psychological distress was significant (b* = - .07, p < .05). Decomposition indicates that the direct effect of concealment on psychological distress was non-significant (b* = - .01, p > .05), while the indirect effect through internalized heterosexism was significant (b* = - .06, p < .001). This suggests that internalized heterosexism mediates 86% of the effect of concealment on psychological distress. Goodness of fit tests indicate the model closely fits the data: χ²(54) = 156.89, p < .001; RMSEA = .03 (90% CI [.03,  .04]); CFI = .98; SRMR = .02. Coefficient of determination = 0.70, indicating that the model accounts for 70% of the variance in psychological distress. Findings also support the perspective that internalized heterosexism and concealment are distinct constructs.

Conclusion and Implications: The significant association between concealment and psychological distress is itself concealed via mediation through internalized heterosexism. This may explain the divergent findings of previous studies, and should be accounted for in future research utilizing the minority stress model in examining psychological distress among LGB populations.