University of Southern California Dissertations and Theses

Exploring experiences of minority-stress and alcohol use among sexual minorities using articulated thoughts in simulated situations: a proof of concept study

(USC Thesis Other)

Exploring experiences of minority-stress and alcohol use among sexual minorities using articulated thoughts in simulated situations: a proof of concept study

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Exploring Experiences of Minority-Stress and Alcohol Use Among Sexual Minorities Using
Articulated Thoughts in Simulated Situations: A Proof of Concept Study
By
Kyla-Rose Walden
A Thesis Presented to the
FACULTY OF THE USC DORNSIFE DEPARTMENT OF PSYCHOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
PSYCHOLOGY (CLINICAL SCIENCE)
December 2023
Copyright 2023 Kyla-Rose Walden

ii.
Acknowledgments
I want to thank my mentors and committee members, Drs. Susan Luczak, Jerry Davison,
and Richard John for their support and guidance throughout the course of this project and my
graduate career. I also want to thank the Sexual Minority Alcohol Research Team (SMART; an
extra acknowledgment to my mom, Dorothy Rosano, for coining that acronym) research
assistants from the Luczak Laboratory for their dedication and hard work on this project: Raney
Kennedy, Maya Thamer-Nall, Sydney Cooper, and Alexa Kahn. I also want to thank all research
assistants in the Luczak Lab for their help with piloting the protocol and other support. Special
thanks to Sophia Carvalho, Claire Suisman, Jordan Wong, and Eric Penichet for playing the roles
as voice actors in our ATSS audio scenarios, and to Lilly Brown of Queer Field Day and Sarah
Hennessy for helping with social media recruitment. Lastly, I want to thank my colleagues Emily
Saldich and Georgia Wong for their support and encouragement throughout the course of my
research.

iii.
Table of Contents
Acknowledgements………………………………………………………………………………..ii
Table of Contents…………………………………………………………………………………iii
List of Tables …………………………………………………………………………………….iv
List of Figures…………………………………………………………………………………….v
Abstract …………………………………………………………………………………………..vi
Chapter One: Introduction………………………………………………………………………...1
Chapter Two: Method……………………………………………………………………………14
Chapter Three: Results.…………………………………………………………………………..23
Chapter Four: Discussion………………………………………………………………………...38
References………………………………………………………………………………………..48
Tables…………………………………………………………………………………………….56
Figures……………………………………………………………………………………………68
Appendices……………………………………………………………………………………….73
Appendix A: Descriptive/Expression Codes…………………………………….66
Appendix B: Control ATSS Scenario Script……………………………………..68
Appendix C: She Pronoun Experimental ATSS Scenario Script………………...71
Appendix D: He Pronoun Experimental ATSS Scenario Script…………………75

iv.
List of Tables
Table 1: Code Frequencies……………………………………………………………………….56
Table 2: Rates of Themes by Gender Identity in Experimental Condition ……………………...57
Table 3: Rates of Themes by Racial Identity in Experimental Condition ……………………....58
Table 4: Rates of Themes by Sexual Orientation in Experimental Condition.…………………..59
Table 5: Rates of Themes by Age in Experimental Condition.………………………………….60

v.
List of Figures
Figure 1: ACQ-Now Scores on Baseline, Pre-Test, and Post-Test Surveys…………………….61
Figure 2: PANAS Negative Affect Scores on Baseline, Pre-Test, and Post-Test Surveys……...62
Figure 3: Desire to Drink 0-100 on Baseline, Pre-Test, and Post-Test Surveys………………..63
Figure 4: Anxiety 0-100 on Baseline, Pre-Test, and Post-Test Surveys………………………...64
Figure 5: Otherness 0-100 Pre-Test, and Post-Test Surveys…………………………………….65

vi.
Abstract
Sexual minority individuals are at an elevated risk for mental health and substance use problems.
Limited research has examined how these experiences relate to alcohol use problems
in-the-moment. Moreover, assessing minority-stress in real-time under naturalistic conditions can
pose methodological difficulties. As such, the present study sought to expand upon prior research
by using the Articulated Thoughts in Simulated Situations (ATSS) paradigm to describe sexual
minority identified participants’ reactions to an anti-gay microaggression scenario. A novel
method of administering ATSS virtually with the goal of streamlining administration and
reducing researcher burden was piloted. Participants (N = 34) expressed anger, anxiety,
avoidance, alcohol coping motives, and identity-related stress in response to the novel ATSS
microaggression scenario. Participants reported finding the scenario realistic (48% yes; 48%
maybe; 4% no), and offered feedback to improve the content, accessibility, and methodology. In
addition, daily diary monitoring (once per day) was used to assess the frequency of sexual
orientation microaggressions in the participants’ daily lives. Compliance was high, (95%) but
microaggressions occurred infrequently (2). This research expands knowledge of the negative
affect regulation model of problem alcohol use and furthers our understanding of why
non-heterosexual individuals may drink to cope with discrimination in-the-moment. Moreover,
this study demonstrates the feasibility and acceptability of a novel method of ATSS
administration in terms of both the content and methodology and offers a proof-of-concept for
ATSS administration that reduces researcher burden. These findings can inform future research
that assesses these constructs across diverse samples and contexts.
Keywords. Lesbian, gay, bisexual, alcohol use problems, minority-stress, articulated thoughts in
simulated situations.

Exploring Minority-Stress and Alcohol Use 1
Chapter One: Introduction
Alcohol use problems are prevalent in the United States. Seventeen million adults in the
US have been diagnosed with an alcohol use disorder (AUD) as of 2017 (see Douaihy & Daley,
2017). AUDs encompass a variety of symptoms that relate to preoccupation with alcohol,
drinking despite negative consequences, alcohol dependence, and various other behaviors that
span across a variety of domains according to criteria defined in the Diagnostic and Statistical
Manual of Mental Disorders (5th ed., 2013). Alcohol use problems are heritable and may have
genetic and familial influences (Cotton, 1979; Sher et al., 2005). In addition, minoritized
populations may be at an elevated risk for alcohol use problems due to the unique identity-based
stressors that they experience. Sexual minorities, for example, have been found to be at an
elevated risk for alcohol and substance use problems (see Cochran et al., 2003; Hatzenbuehler
2014). Sexual minority is an umbrella term for individuals who identify as non-heterosexual,
such as lesbians, gays, bisexuals, and other labels (e.g., queer, pansexual). While the present
study focuses on sexual orientation related discrimination, the acronym Lesbian, Gay, Bisexual,
Transgender, Queer, Asexual, and Intersex (LGBTQIA+) is used to refer to this population
throughout this manuscript. Experiences of discrimination and prejudice have been linked to
elevated levels of psychological distress and substance use among LGBTQIA+ individuals,
characterized by Meyer (2003) as minority-stress theory. The present study expands upon this
theoretical framework to further our understanding of how minority-stress events (e.g.,
discrimination, prejudice, microaggressions) relate to escalations of alcohol use in-the-moment
among non-heterosexual individuals. Below, I review the relevant literature on alcohol use
problem etiology theory, minority-stress theory, and alcohol use among LGBTQIA+ individuals.
Developmental Pathway Models of Problem Alcohol Use

Exploring Minority-Stress and Alcohol Use 2
A variety of developmental pathways to problem alcohol use have been identified in the
literature. Three primary etiological pathways are described by Sher et al. (2005), which include
the behavioral undercontrol, positive affect regulation, and negative affect regulation pathways.
The behavioral undercontrol pathway posits that biobehavioral factors lead to increased
impulsivity that results in escalations of problematic drinking. The positive affect regulation
pathway suggests that individuals consume alcohol to increase positive affect and rewarding
feelings. Conversely, the negative affect regulation pathway suggests that individuals develop
alcohol use problems by drinking to reduce negative affect, stress, or general anxiety and
discomfort. Some researchers have instead conceptualized these three pathways as falling into
two categories: Externalizing pathways (i.e., behavior undercontrol, positive affect regulation)
and internalizing pathways (i.e., negative affect regulation), respectively (see Cloutier et al.,
2019). Below, literature on the latter internalizing pathway is highlighted and described.
Stress, Coping, Negative Affect, and Alcohol Use
Internalizing pathways to alcohol use problems are less well-researched than
externalizing pathways. Yet, trends in the literature do indicate that associations between
increases in negative affect and alcohol use exist across a variety of contexts (e.g., chronic, daily,
and in-the-moment). For instance, Tovmasyan et al. (2022) conducted a meta-analysis examining
the relationship between daily affect and quantity of alcohol consumed and found that pooled
associations across 35 studies between intra-day negative affect and alcohol consumption were
strongly positively correlated. Similarly, Park et al. (2004) found that a sample of college
students consumed more alcohol on stressful days, even when coping styles and weekly drinking
trends were taken into account. These studies map onto a relatively straightforward model of
negative affect regulation, wherein increased negative affect and/or stress escalate alcohol use.

Exploring Minority-Stress and Alcohol Use 3
However, some studies indicate more complex interactions between stress, alcohol expectancies,
and coping strategies. For instance, Cooper et al. (1992) found that stressors predicted alcohol
problems among a sample of men, but only when they had avoidant coping styles or positive
alcohol expectancies. Similarly, other research indicates that men who have positive alcohol
expectancies tend to drink more on stressful days and stronger alcohol coping motives are related
to greater frequencies and quantities of alcohol use (Armeli et al., 2000; White et al., 2018).
Coping efficacy may serve as a protective factor against problem alcohol use (see Anderson,
2006), though this may vary by coping style (see Dermody et al., 2013). Moreover, gender may
moderate these relationships, given that the negative affect regulation pathway is more common
in women compared to men (see Sher et al., 2005; Swaim et al., 2001). These studies elucidate
that individual differences in coping, expectancies, drinking motives, and even
sociodemographic factors may interact with negative affect regulation to produce drinking
outcomes.
It is important to note that the literature is mixed. A body of research indicates that stress
and negative affect do not relate to escalations of alcohol use (e.g., Duif et al., 2020; Courtney &
Russell, 2021). These findings may be explained by alternative models of affect regulation, such
as affect intensity regulation theory, which posits that affect intensity regulation is a more
straightforward framework to explain these relationships (see Tovmasyan et al., 2022). Future
research is needed to enhance our understanding of how stress and negative affect relate to the
etiology and maintenance of alcohol use problems and why individuals drink to cope. However,
one possible mechanism relates to “liking” versus “wanting” alcohol. The concepts of wanting
and liking play an important role in the development of alcohol and substance use problems.
Incentive sensitization theory (IST) suggests that wanting and liking are dissociated in addiction

Exploring Minority-Stress and Alcohol Use 4
and are controlled by separate neurological systems (Hobbs et al., 2005). Research indicates that
heavy social drinkers have higher scores on measures of implicit wanting and liking compared to
light social drinkers, but that wanting drives alcohol consumption more than liking in high-risk
drinkers (Tibboel et al., 2015; Arulkadacham et al., 2017). Some theories posit that incentive
wanting processes increase while automatic, hedonic liking concurrently decreases during the
development of substance use problems (Palfai & Ostafin, 2003; Robinson & Berridge, 1993).
Taken together, wanting alcohol rather than liking alcohol may indicate a trend toward
problematic alcohol use and may serve as a mechanism in the internalizing pathways to alcohol
use problems.
Alcohol Use Among Lesbians, Gays, and Bisexuals
Minority-Stress Theory
Drinking to cope may manifest in a variety of ways across populations, given that
different sociodemographic groups experience their own unique challenges and stressors.
Particularly, minority communities may be exposed to stigma, discrimination, and prejudice that
exacerbate chronic and daily stress (e.g., Mulia et al., 2008). These groups include ethnic,
gender, and sexual minority groups. It is well established that LGBTQIA+ individuals
experience elevated psychological problems due to persistent structural and interpersonal
identity-related stressors, termed by Meyer et al. (2003) as minority-stress theory. Indeed,
evidence suggests that LGBTQIA+ identified individuals do have higher prevalences of mental
health diagnoses and greater levels of psychological distress compared to their heterosexual
counterparts (Cochran et al., 2003). A large body of research has investigated the relationship
between perceived discrimination and mental health outcomes among LGBTQIA+ (e.g., Mays &
Cochran, 2001; McCabe et al., 2010). Factors such as structural stigma (e.g., state- or

Exploring Minority-Stress and Alcohol Use 5
country-level anti-gay legislation), interpersonal experiences of discrimination based on one’s
sexual orientation, internalized homophobia, and a lack of connectedness to one’s family or the
queer community are just some of the risk factors for the development of psychological problems
that sexual minority individuals must navigate (Pachankis & Bränström, 2018; Van Der Star &
Bränström, 2015; Newcomb & Mustanski, 2010; Kail et al., 2015).
A smaller part of the literature has examined the relationship between LGBTQIA+
identity-related stressors and alcohol use. It has been well established that LGBTQIA+
individuals have higher rates of alcohol use and are at an increased risk for the development of
alcohol use problems (e.g., Romano et al., 2021; Hughes et al, 2016; Fish & Baams, 2018;
Cochran et al., 2003), report more negative alcohol use related consequences (Reed et al., 2009),
and have higher rates of binge drinking and poorer mental health (Burgess et al., 2008).
Numerous studies have investigated why these disparities manifest. Unsurprisingly, experiences
of discrimination and prejudice based on sexual identity have been repeatedly associated with
alcohol and substance use problems. Hamilton and Mahalik (2009) found that both
minority-stress and perceptions of social norms interacted to predict health risk behaviors (such
as alcohol and illicit drug use) among sexual minorities. In another study, two-thirds of a large
US national sample of LGBT adults were found to have experienced discrimination on the basis
of sexual orientation, gender, or race in the past year, and the likelihood of having a substance
use disorder was four times greater among those who experienced all three types of
discrimination (McCabe et al., 2010). Evidence from Hatzenbeuhler et al. (2010) indicates that
structural stigma (in this study, living in states that banned gay marriage in the time between the
first and second wave of data collection) resulted in a 42% increase in alcohol use disorders
among a nationally representative LGB sample. These studies indicate a consistent and direct

Exploring Minority-Stress and Alcohol Use 6
relationship between minority-stressors and alcohol use problems. On the other hand, some
research indicates that sexual orientation based discrimination has an indirect effect on alcohol
use via psychological distress, suggesting a pathway where increased discrimination exacerbates
poorer mental health, which then serves as a risk factor for problem alcohol use to cope (see
Moody et al., 2020). Taken together, these studies indicate that perceived discrimination based
on one’s sexual orientation is related to escalations of alcohol use, possibly due to factors
surrounding increases in negative affect and subsequently wanting (versus liking) alcohol.
Moderating Demographic and Identity Factors
Sociodemographic Factors. A variety of moderating and mediating factors may
influence the relationship between minority-stress and alcohol use. Some findings indicate that
these associations may be mediated by personal characteristics, such as one’s levels of outness
(i.e., being known to be gay/bisexual by family, friends, employer, etc.) and emotion
dysregulation (see Villareal et al., 2021; Pachankis et al., 2018). These risk and protective factors
may and may not be directly related to being LGBTQIA+. For example, religious affiliation may
not necessarily serve as a risk factor for mental health or substance use problems on its own but
may exacerbate psychological distress among sexual minority identified individuals—especially
when their religion specifically prohibits homosexuality or homosexual acts (see Flentje et al.,
2014). Education may also affect the frequency and quantity of drinking across various
sociodemographic populations, due to the fact that drinking rates are higher among college
students compared to those who are not enrolled in college, and about two in five American
college students are heavy drinkers (O’Malley et al, 2002; Turrsi et al., 2008). It is evident that
several demographic factors can increase the risk for alcohol use problems, independent of
and/or in tandem with sexual identity. In some instances, having multiple minority identities

Exploring Minority-Stress and Alcohol Use 7
(such as being both non-heterosexual and belonging to a marginalized racial group) can relate to
AUD risk. The intersections of social identities relevant to alcohol use problem risk are
described below.
Ethnicity and Gender. Ethnic/racial identity may bear influence over the manifestation
of psychological and substance use problems among LGBTQIA+ individuals. While the
prevalence of psychological problems is generally higher among individuals who are sexual
minority identified, persons who are both LGBTQIA+ and African American have been
demonstrated to have lower prevalences of psychiatric disorders compared to individuals who
are non-heterosexual and white (see Rodriguez-Seijas et al., 2019; Meyer et al., 2008).
Consistent with this, base rates for drinking are lower among LGBTQIA+ youth who are African
American (Newcomb et al., 2011). However, some research indicates that substance use
disparities among queer people of color contrast with the patterns observed for mental health
disparities among ethnic minority non-heterosexual individuals. For example, data from the
National Survey on Drug Use and Health indicate that disparities in heavy episodic drinking and
other substance use outcomes (i.e., marijuana, cigarette smoking) were observed across nearly all
racial groups, but disparities were greater in magnitude for Black and Hispanic LGB women
compared to White LGB women (see Schuler et al., 2020). These findings indicate that
race/ethnicity and sexual orientation may intersect to shape alcohol use among sexual minorities
of color and that gender may also moderate these outcomes.
Indeed, gender has consistently been found to be an important factor. For instance, a
longitudinal multilevel study examining alcohol problems among LGBT youth indicated that
psychological distress and sexual orientation based discrimination were associated with
increased alcohol use—but only among women (Newcomb et al., 2011). Moreover, men tended

Exploring Minority-Stress and Alcohol Use 8
to have more increases in drinking over the course of the study compared to women. This
appears to be consistent with findings from Amadio et al. (2008) which indicate that gay men
tend to drink more than lesbian women but do not have differences in alcohol-related problems.
Studies also indicate that sexual minority women have greater disparities in alcohol use
compared to heterosexual women, versus when sexual minority men are compared to
heterosexual men (see Hughes et al., 2016). These gender differences may emerge due to varying
social norms within queer spaces and romantic relationships, chronic stress among sexual
minority women, and the increased prevalence of negative affect regulation among women
versus men (Cerezo et al., 2019; Sher et al., 2005).
Gender and Sexual Identity. Being cisgender or transgender may also relate to alcohol
use outcomes among sexual minorities. Cisgender refers to individuals who identify as the
gender that they were assigned at birth, such as someone who is assigned male at birth (AMAB)
and identifies as a man. Transgender is an umbrella term that encompasses individuals who
identify as a gender other than what was assigned at their birth. For example, someone who is
assigned female at birth may identify as a man or non-binary. Transgender individuals face
unique psychosocial stressors that can adversely affect their mental health and substance use (see
Butler et al., 2019; Mizock and Lundquist, 2016). Though research on this population is limited,
findings indicate that when compared to cisgender individuals, transgender individuals may have
lower rates of alcohol use but higher rates of alcohol-related diagnoses (see Williams et al.,
2021). On the other hand, Findings from Coulter et al. (2015) indicate that cisgender individuals
have fewer heavy drinking occasions than transgender people. Little is known about the
intersection of sexual and cis- or transgender identity, specifically regarding substance use issues,

Exploring Minority-Stress and Alcohol Use 9
and more research is needed to understand the manifestation of alcohol and substance use
problems among individuals who are transgender sexual minorities.
Research also indicates that sexual identity (e.g., identifying lesbian versus bisexual) can
influence these relationships. For example, being a bisexual versus lesbian woman has been
suggested to be a risk factor for alcohol and other substance use problems (Cerezo et al., 2019).
Findings indicate that bisexual women may be more likely than both heterosexual and
homosexual women to report past 30 days binge drinking, marijuana use, and tobacco use. This
may be due to higher prevalences of internalizing disorders among bisexual women (see Mays &
Cochran, 2001), which may be related to the increased discrimination and unique psychosocial
stressors that bisexual women face from both their in- and out-groups (e.g., biphobia). Taken
together, problem alcohol use disparities among the LGBTQIA+ population may vary by
race/ethnicity, gender, cis- or transgender identity, and even one’s specific sexual orientation.
Developmental Stage and Drinking Motives
Clear associations exist between sexual orientation, sexual identity-based discrimination,
and substance use. However, drinking motives may also vary among LGBTQIA+. For example,
drinking to cope may be more common among middle-aged and older adults in the general
population, compared to young adults and youth (who are more likely to drink for fun- or
novelty-seeking reasons; see Gilson et al., 2017). However, drinking to cope has been suggested
to be common among sexual minorities regardless of their developmental stage. Felner et al.
(2019) investigated the experience of LGBTQIA+ young adults' substance use in a qualitative
study and found that drinking to cope with distal stressors (e.g., discrimination) and proximal
stressors (e.g. self-stigma) was a common theme. In addition, social norms and accessibility of
alcohol within LGBTQ+ social events and settings were related to drinking. Drinking to cope

Exploring Minority-Stress and Alcohol Use 10
may also be more common following anti-gay occurrences. Boyle et al. (2017) found that
following a major anti-gay violence incident (the Pulse nightclub shooting), 68% of sexual
minority participants perceived their peers to be using alcohol to cope with the psychological
aftermath of the shooting. While only 26% of the sample believed that they themself used
alcohol to cope, believing peers used alcohol to cope increased the odds of participants' alcohol
use by 15 times. Consistent with these findings, alcohol and substance use has been found to be
associated with participation in the LGB community more generally (see Demant et al., 2018).
These findings indicate that drinking to cope is prevalent in the LGBTQIA+ population across
developmental stages and that perceptions of social norms can bear influence over these
relationships.
Assessing In-The-Moment Drinking and Minority-Stress Events
The field has developed a limited understanding of alcohol use disparities among the
LGBTQIA+ population, but reasons for drinking and coping motives are less clearly elucidated
in the literature. The majority of previous research has examined the relationship between
minority-stressors and alcohol use within retrospective timeframes (e.g., lifetime, past year, 30
days, etc.,) but less research has examined how minority-stress events (e.g., experiences of
discrimination or prejudice; microaggressions) directly relate to in-the-moment escalations of
alcohol use. In addition, more research is needed to expand our currently limited knowledge
about how non-heterosexual individuals construe these experiences and interpret the causal
factors surrounding their own alcohol use and related problems. Examining these relationships
using simulated events in a controlled environment allows for in-the-moment assessment, of the
kind we turn to next.
Simulated Situations Research

Exploring Minority-Stress and Alcohol Use 11
One way to conduct a study in this manner is by utilizing the Articulated Thoughts in
Simulated Situations (ATSS) paradigm. ATSS is an approach to cognitive assessment that
enables researchers to obtain think-aloud information from individuals while they are involved in
imagined situations where they are the participant, witness, or observer (Davison, Robins, &
Johnson, 1983). The participant articulates their thoughts in reaction to brief segments of an
imaginal situation. This paradigm not only provides an opportunity to assess qualitative data
from the participants' in-the-moment reactions to the ATSS segments, but also enables the
simulated situation to serve as an experimental independent variable. This allows researchers to
capture affective and cognitive responses that occur almost simultaneously in response to the
simulated event. Over 40 years of research using the ATSS paradigm confirm its validity and
reliability in assessing a wide variety of thoughts and feelings, including but not limited to anger
and aggression, hate crimes, social anxiety, depression, and fear of flying (Davison, Navarre, &
Vogel, 1995; Zanov & Davison, 2010). One study conducted by Rayburn & Davison (2002)
explored sexual identity-related issues using ATSS. The researchers used ATSS to investigate
college students’ articulated thoughts about anti-gay hate crimes and found that the hate crimes
versus non-hate crimes resulted in more intent to be aggressive toward the perpetrator (Rayburn
& Davison, 2002). These studies demonstrate the feasibility of using the ATSS paradigm to
investigate reactions to anti-gay scenarios.
No research to date has investigated alcohol or substance use related research questions
using the ATSS paradigm, but other “talk aloud” and simulated situation research has been
demonstrated to be feasible to assess substance use related decision-making. Cloutier et al.
(2021), for example, constructed a simulated party to examine the effects of social anxiety and
rejection on acute willingness to consume alcohol or cannabis using a simulated party situation,

Exploring Minority-Stress and Alcohol Use 12
Similarly, Anderson et al. (2014) and Anderson et al. (2013) examined youths’ willingness to
accept offers of alcohol and marijuana using audio and video simulations in the laboratory. Taken
together, this prior research indicates that laboratory simulated situations are an effective
methodological approach to assess both reactions to bias-related events and substance use
research questions.
The Present Study
Building upon previous research, the present study investigated the relationship between
minority-stress and in-the-moment escalations of alcohol use among sexual minority participants
using the ATSS paradigm. The study examined the ways that gender, sexual orientation, alcohol
expectancies, drinking motives, and other variables of interest relate to these associations. In
addition, participants tracked their data for one week after their participation in the study to
assess the prevalence of minority-stress events in their daily lives. This initial proof-of-concept
study lays the foundation for future research outside of the laboratory in ecologically valid
conditions. It also serves to expand our understanding of how minority stressors relate to
in-the-moment escalations of drinking, how queer individuals construe their own drinking
motives, and furthers our knowledge of the internalizing pathway to alcohol use problems in the
sexual minority population. Our study builds upon previous ATSS research by adapting and
streamlining the paradigm to reduce researcher burden. The specific aims, confirmatory
hypotheses, and exploratory hypotheses of the study are outlined below.
Specific Aims
1. To describe LGBTQIA+ individuals' reaction to a minority-stress event.
2. Explore how reactions to a minority-stress event relate to alcohol use motives and
expectancies and daily heterosexist experiences.

Exploring Minority-Stress and Alcohol Use 13
3. To develop and test these ATSS scenarios in terms of both the feasibility and
acceptability of both the content and methodology.
4. To examine how experiencing a minority-stress event relates to anxiety, negative affect,
minority-stress, and in-the-moment alcohol cravings.
Confirmatory Hypotheses
1. Participants who are in the minority-stress event condition versus the control condition
will be more willing to drink and crave alcohol more.
2. Participants who are in the minority-stress event condition versus the control condition
will experience elevated levels of anxiety, negative affect and minority-stress/otherness.
Exploratory Aims
1. To examine the incidence of minority-stress events over the course of one week using
ecological momentary assessment (EMA) daily assessments.

Exploring Minority-Stress and Alcohol Use 14
Chapter Two: Method
Design Overview
The present study was mixed methods, utilizing a phenomenological approach for
qualitative components and adapting both a within-subjects and between-subjects approach for
quantitative analyses using ATSS, EMA, and an active control/experimental paradigm. The
recruitment methods, procedures, and measures are described below. This research was approved
by the University of Southern California Institutional Review Board (IRB) under
#UP-22-00625-AM001.
Participants
Participants were recruited via social media (Instagram), as well as flyers in designated
areas on the USC campus. Posts were shared by the researcher's account and reposted by
community queer event-organizing platforms. N = 225 participants completed the screening
questionnaire.
Of N = 78 eligible participants, N = 34 participants consented to participate and
completed the initial survey. Written and informed consent was obtained from all participants.
The gender demographics of our sample were 15% men, 67% women, 6% non-binary, 3%
gender fluid, and 9% other gender/prefer not to answer. All participants identified as LGBTQIA+
(23% lesbian; 12% gay; 30% bisexual; 6% pansexual and 10% queer). The sample was 53%
non-Hispanic white (3% Black; 3% Asian American; 25% Hispanic/Latinx; 13% Biracial,
Mixed, or Other). One participant identified as transgender (97% cisgender). 20% of participants
were current college students. In terms of self-identified religion, participants were 56% Atheist
or Agnostic, 3% Christian, 9% Jewish, and 32% other or prefer not to answer.

Exploring Minority-Stress and Alcohol Use 15
Participants were compensated $50.00 for their participation in the study via their
preferred digital payment method (Venmo, CashApp, or Zelle).
Procedure
Screening Survey
A screening survey on Qualtrics asked participants to report their age, sexual orientation,
and whether or not they had consumed alcohol at least four times in the past month. Participants
reported their gender, age, ethnicity, and sexual orientation. Participants younger than 21 years
old or older than 30 years old, consumed alcohol less than four times per month, did not live in
Los Angeles County, or were not LGBTQIA+ identified were not eligible for the study. Eligible
participants were notified that they would receive a follow-up from the research team. Initial
Zoom
Participants filled out the screener survey. After confirming their eligibility, they were
sent a Google Calendar link to schedule a Zoom meeting with a trained research assistant. In this
appointment, participants verified their age and location via a State or Government-issued ID.
The consent form was reviewed by a trained research assistant and written informed/consent was
obtained from all participants at this time via DocuSign. Participants received a copy of their
consent form. The participants were then sent a link to the “Initial Survey” via email and
instructed to complete it as soon as possible. They were told that it would take between 15-30
minutes to complete.
Initial Survey Measures
Participants filled out the initial survey, which included a variety of demographic and
survey questionnaires. These included age, gender, sexual orientation, racial/ethnic identity,
biological sex, trans/cisgender identity, religion, education status, and college student status.

Exploring Minority-Stress and Alcohol Use 16
Participants were also asked to rank the salience on a scale of 1-10 of their sexual, racial, and
gender identity and to identify their preferred pronoun. Measures of social anxiety, daily
heterosexist experiences, alcohol expectancies, motives for alcohol use, and coping self-efficacy
were assessed. These measures are expanded upon below.
Social Anxiety. The Leibovitz Social Anxiety Scale (Leibovitz et al., 2006) assessed
participants' social anxiety. This scale asks participants about their anxiety and avoidance across
a variety of social contexts (e.g., making phone calls). Participants ranked their anxiety and
avoidance on a rating scale (1 = Mild, 2 = Moderate, 3 = Severe).
Coping Self-Efficacy. The Coping Self Efficacy (CSE) scale provides a measure of a
person's ability to cope with life challenges (see Chesney et al., 2006). The CSE is a 26-item
measure that asks participants “When things aren’t going well for you, or when you’re having
problems, how confident or certain are you that you can do the following.” Each item describes
behaviors important to coping, which participants rank on an 11-point scale (0 = cannot do at all,
to 10 = certain can do).
Alcohol Expectancies. Alcohol expectancies are beliefs that individuals hold about the
outcomes and consequences of using alcohol. Participants' expectations about their alcohol use
were measured using the Alcohol Expectancy Questionnaire (Brown et al., 1987). This 100-item
questionnaire assesses perceived outcomes of alcohol use such as positive change, impairment,
and relaxation-tension reduction. Participants ranked their agreement with items using a rating
scale (e.g., “drinking makes me feel good”; 1 = disagree strongly, to 5 = agree strongly).
Alcohol Use Motives. The 28-item Modified Drinking Motives questionnaire (Grant et
al., 2007) was used to capture participants' reasons for drinking. The scale includes motives such
as anxiety-coping, depression-coping, social motives, enhancement motives, and conformity

Exploring Minority-Stress and Alcohol Use 17
considerations. Participants ranked their agreement with items using a rating scale (1 = almost
never, to 4 = almost always).
Minority-Stress. To assess daily experiences of discrimination, prejudice, and anti-gay
messages elevate minority-stress among sexual minority individuals. Balsam et al. (2013)
developed the Daily Heterosexist Experiences Questionnaire (DHEQ). This 50-item
questionnaire uses a rating scale ranked from 1 = it happened, and it bothered me NOT AT ALL
to 5, = it happened, and it bothered me EXTREMELY.
After completing the initial survey, participants were sent a follow-up link to schedule
their ATSS Zoom.
Articulated Thoughts in Simulated Situations (ATSS) Protocol and Measures
ATSS Scenarios. The ATSS paradigm involves participants being instructed to respond
to audio segments by thinking aloud and articulating their thoughts, feelings, and reactions
in-the-moment in 30-second response intervals. The control and experimental scripts were
written by the first author and were adapted from Mullane & Davison’s (2014) dissertation study
on anti-gay hate speech. The experimental ATSS condition describes an incident where the
participant is at a party with friends and hears former acquaintances make microaggression-like
comments about their sexuality (see Appendix C & D). The active control condition describes an
identical scenario; however, instead of homophobic comments, the former acquaintances
negatively gossip about the host of the party and her boyfriend, and the participant overhears
them (see Appendix B). Both the experimental and control scenarios have nine segments.
The scripts were piloted with members of the LGBTQIA+ community. A survey was
shared with research assistants and acquaintances via Qualtrics that asked individuals to provide
feedback about the scenarios. The scenarios were adapted based on their feedback. Three

Exploring Minority-Stress and Alcohol Use 18
research assistants and one volunteer voice actor recorded their respective character lines in each
script. These audios were compiled by the first author and input into Mixcraft 6 and edited to
include royalty-free music and background noise to simulate the environment of a house party.
These audios were then input into PowerDirector video editing software to include on-screen
instructions and a timer visual for participants to listen and speak to automate the data collection
process. Each video lasted approximately 5-8 minutes. The protocol was practiced, piloted, and
refined by multiple research assistants.
Participants completed the control (n = 27) and experimental (n = 26) for a
within-subjects design. Six participants did not follow up after the initial survey, and one
participant’s data was corrupted for the experimental condition. Two versions of the
experimental script were created to include both she/her and he/him pronouns. Participants were
assigned to the He/Him or She/Her pronoun version of the script based on what locker room they
were reported to have been assigned to in high school, given that the script references high
school interactions.
Baseline Zoom Procedure. Participants joined Zoom with a trained research assistant.
The research assistant instructed the participants to fill out a Baseline Survey sent in the Zoom
chat via Qualtrics, which asked them to rank their positive and negative affect ratings as
measured by the Positive and Negative Affect Schedule (PANAS; Crawford & Henry, 2004).
The scale contained twenty questions, ten which capture positive affect and ten that capture
negative affect. Each question was rated using a rating scale (1 = very slightly or not at all, to 5 =
extremely). Participants also filled out the Alcohol Craving Questionnaire (ACQ-NOW;
Singleton et al., 1995) questionnaire. The ACQ-NOW is a 47-item measure of acute alcohol
craving. The scale captures in-the-moment alcohol cravings via multiple subscales: Urges and

Exploring Minority-Stress and Alcohol Use 19
desires to use alcohol, intent to use alcohol, the anticipation of a positive outcome, anticipation
of relief from withdrawal OR other negative outcomes, and lack of control over use. Participants
ranked their agreement with each question using a rating scale (1 = strongly disagree, 5 =
strongly agree). Lastly, participants ranked their subjective units of distress (SUDS) on a scale of
1-100 for their desire to drink alcohol, their anxiety, and feelings of otherness to capture
minority-stress.
Control Zoom Procedure and Pre-Test Survey. After completing the baseline survey,
participants completed the control condition ATSS scenario. Trained research assistants read the
following script to participants:
“Now, we are going to do an activity together. You will listen to an audio recording for
about 5-8 minutes. There will be multiple segments. After each segment, you will
respond with your thoughts and feelings as if you were in the situation that is being
described. Respond freely and think-aloud your natural thoughts and feelings as you
would if this were happening to you. You will not be interrupted. You will have 30
seconds to respond to each segment. You will see a timer on the screen with this
countdown. When the timer reaches 0, you will listen to the next segment. You may or
may not be asked to fill out ratings about your feelings in between each segment as well.
The RA will show you how to do this and tell you when to do this. Do you have any
questions?”
Participants then listened to the audio scenario and responded in thirty-second intervals. After
completing the audio scenario, participants were asked to fill out the “Pre-Test” survey, which
included the ACQ-NOW, PANAS, and SUDS ratings. In addition, participants were asked to

Exploring Minority-Stress and Alcohol Use 20
rank the realism of the scenario, indicate whether or not it had happened to them in the past, and
provide open-ended feedback about the content and methodology.
Experimental Zoom Procedure and Post-Test Survey. After completing the pre-test
survey, participants completed the experimental condition ATSS scenario. Trained research
assistants read the following script to participants:
“Now, we are going to do an activity together. You will listen to an audio recording for
about 5-8 minutes. There will be multiple segments. After each segment, you will
respond with your thoughts and feelings as if you were in the situation that is being
described. Respond freely and think-aloud your natural thoughts and feelings as you
would if this were happening to you. You will not be interrupted. You will have 30
seconds to respond to each segment. You will see a timer on the screen with this
countdown. When the timer reaches 0, you will listen to the next segment. You may or
may not be asked to fill out ratings about your feelings in between each segment as well.
The RA will show you how to do this and tell you when to do this. Do you have any
questions?”
Participants then listened to the audio scenario and responded in thirty-second intervals. After
completing the audio scenario, participants were asked to complete the “Pre-Test” survey, which
included the ACQ-NOW, PANAS, and SUDS ratings. In addition, participants were asked to
rank the realism of the scenario, indicate whether or not it had happened to them in the past, and
provide open-ended feedback about the content and methodology.
“Now, we are going to do the same activity again. If you would like the instructions to be
reviewed again to you, you can say that now. Otherwise, tell me when you are ready to
move forward. If you have any questions, you may ask them now or at any time.”

Exploring Minority-Stress and Alcohol Use 21
Participants listened to the second audio scenario and responded in thirty-second intervals. After
completing the audio scenario, participants were asked to fill out the “Post-Test” survey, which
included the ACQ-NOW, PANAS, and SUDS questions. In addition, participants were asked to
rank the realism of the scenario, indicate whether or not it had happened to them in the past, and
provide feedback about the content and methodology. At the end of the Zoom call, participants
provided their contact and payment information. They were then signed up to receive the Daily
Assessment Survey.
Daily Assessment Field Data Collection
Participants were informed that they would receive a text message with a link to complete
a Daily Assessment Qualtrics survey every day for seven days at 7:00 P.M. beginning the day
following their ATSS Zoom call for seven days. Participants provided their phone numbers to be
entered into the Remind application from the IOS App Store, which automatically sends text
notifications. Participants consented to receive messages from Remind via an automated text
message. When prompted, participants completed a survey assessing whether or not they had
experienced a minority-stress event that day, to describe that event if it had occurred, whether or
not they had consumed alcohol, and to provide their SUDS anxiety, otherness, and alcohol
craving ratings on a scale of 0-100.
Coding Procedure
For ATSS we used a deductive coding approach and developed codes based on the
theoretical concepts and variables we sought to capture as they related to alcohol use,
minority-stress, anxiety, and other emotional constructs. These included Anxiety, Social Anxiety,
Minority-Stress, Internalized Homophobia, Anger, Sadness, Desire to Drink, and Alcohol
Coping Motives. A codebook with descriptions and examples of these codes can be found in

Exploring Minority-Stress and Alcohol Use 22
Appendix A. Research assistants were extensively trained to identify these codes throughout a
variety of Zoom training and applied practice activities. Each transcript was coded by two
trained research assistants using Atlas.Ti qualitative analysis software.

Exploring Minority-Stress and Alcohol Use 23
Chapter Three: Results
Specific Aim 1: Describe LGBTQIA+ individuals' reaction to a Minority-Stress Event
Inter-Coder Reliability
Ten randomly generated control and experimental transcripts coded in Atlas.TI were
selected for an inter-coder agreement analysis. The percent agreement coefficient was 94%.
Control Condition
Of our total sample, all N = 27 participants successfully completed the control condition
ATSS scenario. The rank order of the most frequently occurring codes in the control condition
can be found in Table 1.
Experimental Condition
Of our total sample, N = 26 participants successfully completed the experimental
condition scenario. The 27th participant completed the control condition scenario, but their data
was corrupted due to an error with the Zoom recording. The rank order and rates of codes from
the experimental condition (microaggression) scenario can be found in Table 1. The themes that
emerged in the experimental transcript are further described below in order of prevalence.
Thematic Analysis of Codes
Anger. Anger was the most common reaction expressed by participants in the
microaggression ATSS scenario. The anger that was expressed was primarily directed towards
the perpetrators, with participants expressing that the anti-LGBTQIA+ sentiments made them
angry. In an instance where one of the perpetrators expressed that they might “think [the
participant] has a crush on them,” a participant expressed the following:

Exploring Minority-Stress and Alcohol Use 24
“Ohh my god I would be so mad, at this point I probably would be like... The person in
this scenario has a lot more control than me. I feel like I would have said something
already, and uh. Yeah, I would be like really mad.” [36]
This highlights how participants were angered by both the microaggression that suggests
romantic attraction without provocation–a common LGBTQ+ stereotype– as well as the
perceived power dynamics of the situation. Among participants who identified as women,
expressions of anger were described to be more elevated when they were in relation to a
masculine-voiced perpetrator: “Oh my God! AH OK guys, who say that, I feel like I'd get even
more mad. [36] Another subdomain that emerged within the theme of anger was with regard to
the fact that no one in the simulated party event spoke up for the participant or openly defended
them. Participants took offense to this aspect of the scenario in particular.
Another relevant aspect of the anger expressed by participants was that it was often laden
with surprise. Participants indicated that they were “shocked” that the group of individuals in the
simulated party would express anti-LGBTQ+ sentiments in this day and age:
“Honestly, at this point I'm probably thinking like, who the hell still would like think like
this? In 2022 and wherever I am. And my anger and annoyance might also have a tinge of
like surprise and amusement. Like, just that there are people who think like that.”
These reactions of amusement and shock were common throughout the sample. In addition,
participants expressed anger that was both modulated and with an outward desire to act on their
anger. This latter theme was separated into its own category and is further expanded upon in the
confrontation desire section.

Exploring Minority-Stress and Alcohol Use 25
Anger rarely emerged in the control condition scenario. When anger was expressed, it
was typically in response to defending their assumed friend who was hosting the party against
the people who were gossiping about them.
Escape Response. Escape response was the second-highest-ranked theme among
participants in the microaggression scenario. Escape response captures incidents where
participants express desired avoidance behaviors, such as going to another part of the party or
exiting the room that the perpetrators were in. Some participants expressed that they would
attempt to engage with other persons at the party in order to avoid hearing more homophobic
sentiments. Participants noted that they would “leave the conversation” or “just leave [the party]
[20] Overall, escape responses tended to begin as soon as the homophobic sentiments began to
be expressed by the perpetrators, and not before, indicating that avoidance may have been
prompted by the homophobic rhetoric.
Escape responses were less so prevalent in the control condition scenario. When
participants expressed a desire to leave the party, it was typically associated with the discomfort
surrounding overhearing a private conversation. “I would feel kind of uncomfortable and would
probably want to go” [20]. In other cases, participants expressed a desire to go to another area of
the party or to interact with other individuals in order to avoid further interaction with the
gossiping group “I’d kind of slink away.” [17]
Anxiety. Another common theme in response to the microaggression scenario was
anxiety. Descriptions of anxiety included physical descriptions of the symptoms that participants
might experience (e.g., stuttering or shaking) as well as feelings of nervousness, fear, and
uncertainty. In addition, anxiety was coupled with the escape response theme in some instances–

Exploring Minority-Stress and Alcohol Use 26
However, participants expressed that their nervousness would prevent this. Anxiety was directly
linked to the presence of the perpetrators, with many of the participants who expressed anxiety
noting that they felt relieved when the perpetrators exited the party.
Anxiety was one of the primary themes in the control condition. Participants expressed a
general anxiety and discomfort associated with being at the party. “I’d be nervous about the
people I do know and the people I don’t know.” [36] This happened based entirely on the
context, independent of any conversation occurring around them: “I have anxiety, so I would feel
pretty anxious,” [17] expressed one participant. Anxiety expressions also became elevated when
the gossip conversation began to escalate. Participants noted their discomfort and uneasiness
surrounding overhearing the perpetrators gossiping, as well as a fear that they might call them
out for listening in on their conversation.
Confrontation Desire. The desire to confront the perpetrators was a very prevalent
theme among our sample. This occurred when participants felt as if they were not being
defended by the other individuals at the party, or when they wanted to express themselves.
Participants also noted a desire to embarrass or shame the perpetrators for their sentiments, as
well as redirect the attention from them onto the others:
“I’m kinda getting ready to publicly humiliate these people. I have pretty thick skin and
don’t really care but I would love for them to feel all the attention on them and maybe,
uh, get them kicked out of the party or something? Oh and they were being nasty to the
host, weren’t they?” [33]
Humiliating or embarrassing the perpetrators was a wish shared by many of the participants in
our sample. On the other hand, an alternative motivation for confrontation desires were related to
an urgency to educate the perpetrators about how offensive their language was: “I would say

Exploring Minority-Stress and Alcohol Use 27
yeah, like what you're saying is like extremely hurtful and offensive and you need to think about
your actions, something short like that and leave the party and like tell my friends about it. I
guess that's tough.”[17] As the segments progressed and the initial subtlety of the queerphobic
rhetoric was dismissed, participants expressed more desire to tell off, educate, or shame the
perpetrators for their behavior.
In the control condition, it was somewhat common for participants to express a desire to
confront the individuals gossiping. This was often in relation to a desire to defend their friend. In
some cases, participants may have assumed that the gossiping group was speaking about them,
and they expressed a desire to confront the participants for talking about them.
Minority-Stress & Internalized Homophobia. Minority-stress, or stress experienced
related to one’s sexual identity, also emerged. Minority-stress was not always so overtly
expressed, but rather manifested in feelings of otherness. For example, participants noted that
homophobic comments caused them to feel alienated and uncomfortable at the party: “Um, yeah,
I would be really uncomfortable…that was like a homophobic comment, so I would just be like
really uncomfortable at a party… surrounded by them.” [10]. Moreover, participants directly
expressed feelings of otherness: “Yeah, there's just a sense of otherness and like. That straight
people are scared of you.” [19]
Minority-stress also took the form of self-doubt about who was “right” in the situation,
uncertainty about one’s behavior, or embarrassment. “I would be stressed out like…was I doing
anything wrong?” [10] noted one participant, expressing confusion and doubt about why they
were being attacked and wondering if they did something to provoke it. “I feel like it would feel
like embarrassed because that's just like … there's almost no reasoning with someone like that
who thinks it's a lifestyle choice” [36] another participant noted. Generally, expressions of

Exploring Minority-Stress and Alcohol Use 28
minority-stress were coupled with a sense of hopelessness about the situation–the idea that they
had no control over the situation and would have to endure the feelings of alienation. In sum,
participants were left with “a bunch of shame” [37].
Minority-stress was only expressed once in the control condition. Expressions of
internalized homophobia–that is, overt negative attitudes or ideas towards the self–were rarely
expressed in either condition. However, this theme exclusively occurred in the experimental
condition and did not emerge in the control condition.
Social Anxiety. The sub-category of social anxiety was generated due to the fact that
some expressions of anxiety were specifically in relation to the fact that the perpetrators
appeared to be talking about the participant directly, rather than expressing general homophobic
sentiments: “Seems like they’re definitely talking about me which is making me, really, kind of
like nervous and anxious.” [38] Social anxiety also tended to mitigate confrontation desires:
“I think I would... in my like imagination I would want to like go up, and tell her off and
have this, like, amazing snide comment. I think in reality, I'd probably like stutter over
my words and feel nervous and end up just walking away rather than confronting it like I
would actually want to do.” [37]
Interestingly, social anxiety was more prevalent in the control scenario. As such, it is somewhat
difficult to disentangle anxiety and social anxiety with relation to the microaggression
scenario–however, broadly speaking, participants who expressed social anxiety were concerned
with the judgment or negative evaluation of the perpetrators. These reactions centered around a
sense of worry that participants might be judged for spying or listening in on the dramatic
conversation. “I’d be concerned that people saw me overhearing him” [19] noted one participant.
“I’d probably get another little anxiety spike because I made eye contact with this girl that was

Exploring Minority-Stress and Alcohol Use 29
gossiping” [14] noted another. Among some participants, social anxiety emerged as soon as they
were made aware of the context of the audio scenario being a party.
Sadness. Sadness was somewhat prevalent as a response in our sample in the
microaggression scenario. “I would just feel hurt.” [37] Participants expressed sadness in regard
to many aspects of the situation, with a common link being the fact that they were being targeted
by individuals at the party. “I would be... so upset! Like just so, disheartened.” [36] Participants
sometimes expressed that they would excuse themselves to experience emotional reactions
related to sadness: “ I would go like, cry about it in secret.” [10]. Another dimension of sadness
was linked to the disbelief surrounding the fact that individuals would be expressing these sorts
of sentiments in the first place. A pattern that emerged was a sense of upset and hopelessness
about the fact that individuals would be holding homophobic views and expressing them so
openly.
Sadness was uncommon in the control condition. When sadness was expressed, it was in
relation to the individuals talking badly about someone that they know, or if they misinterpreted
the scenario as being about themself. Some participants expressed sadness coupled with anger or
embarrassment: “I’d be feeling so anxious and sad and mad and embarrassed.”[36]
Desire to Drink & Alcohol Coping Motives. Participants expressed both a desire to
drink alcohol and a desire to drink alcohol for the purposes of coping with the distress that they
were experiencing as part of the microaggression scenario. Some expressions were general, with
participants noting that alcohol would be helpful to tolerate the effects of the situation: “Well,
first of all, um, I don’t even have a drink yet it sounds like so I’m not, I’m nowhere near drunk
enough for any of this” [38] In other cases, participants described how they would take the
opportunity to replace the distress of the situation with “fun,” aided by the use of alcohol:

Exploring Minority-Stress and Alcohol Use 30
“I’d force myself to have fun, like, vibe out, do my own thing, whatever, because I’m not
gonna, like, put energy towards that. Um, you know, hit my vape, drink, get another drink
or something—oh I don’t have a drink. I’ll find a drink, like I’ll find it myself like
[unintelligible] taking forever, I dunno.” [30]
In many cases, participants noted that they would have a drink to “forget about [the situation]”
[36]. Across our sample, among those who expressed a desire to drink and/or use alcohol to
cope, the motives expressed centered around forgetting, tolerating, or taking away from distress.
In the control condition, alcohol coping motives and desires to drink were even more so
common than in the experimental condition. However, the reasons for drinking varied.
Participants in the control condition frequently expressed a desire to drink with regard to the
context of being in a social gathering: “Yeah my initial thought is just like I would immediately
want to start drinking too and I’d be nervous.” [36]. In addition, drinking to cope with the
anxiety associated with being at a social gathering was frequently expressed. Sometimes, this
was in conjunction with a desire to be more socially competent and mingle more with other
people at the gathering: “I would need a drink at a party that big and that loud to just sort of like
calm the nerves and like be a little more social with everybody which is kinda what you’re
supposed to do at a party.” [36]
Correlations Among Codes In The Experimental Condition
To further contextualize the data, bivariate correlations between all codes in the
experimental condition were examined. Minority-stress was positively correlated with anxiety (r
= .55, p =.004) and social anxiety (r = .41, p =.04). Sadness was positively correlated with
internalized homophobia (r = .65, p < .001) and anger (r = .53, p =.005). Desire to drink was
positively correlated with anger (r =.48, p =.01) and alcohol coping motives (r = .54, p =.004).

Exploring Minority-Stress and Alcohol Use 31
Confrontation desires were positively associated with anger (r =.50, p =.01) and escape
responses (r =.58 p =.02).
Specific Aim 2: Explore how reactions to a minority-stress event relates to alcohol use
motives and expectancies and daily heterosexist experiences.
Specific aim 2 explored survey data and ATSS dependent variables for the experimental
microaggression ATSS scenario (N = 26). ATSS categorical codes were coded into frequency
variables by trained research assistants using Atlas.TI, Excel, and SPSS. Regressions predicting
frequency scores of anger, internalized homophobia, alcohol coping motives, anxiety,
confrontation desires, desire to drink, escape responses, minority-stress, sadness, and social
anxiety were run covarying for demographic variables (gender identity, racial identity, sexual
orientation, religion, education level, trans/cisgender status), coping self-efficacy scores, and
social anxiety scores. Distress scores from daily heterosexist experiences in the past twelve
months, alcohol coping motives scores, and alcohol relaxation/tension expectancies were run as
predictors in the model. Higher distress scores of daily heterosexist experiences predicted higher
frequencies of desire to confront homophobic perpetrators with B(SE) =1.33(.49) and p = .02 No
other predictive relationships were significant.
Specific Aim 3: To examine how experiencing a minority-stress event relates to anxiety,
negative affect, minority-stress, and in-the-moment alcohol cravings.
Specific aim 3 was investigated in confirmatory hypotheses one and two.
Confirmatory Hypothesis 1: Participants who are in the minority-stress event condition versus
control condition will be more willing to drink and crave alcohol more.
Within-subjects analyses of Covariance (ANCOVAs) tested confirmatory hypothesis 1 to
examine whether anxiety, negative affect, feelings of otherness (minority-stress), and

Exploring Minority-Stress and Alcohol Use 32
in-the-moment alcohol cravings for N = 26 participants. Ratings of 0-100 desire to drink alcohol,
as well as scores on the ACQ-NOW were included in the models as dependent variables. Scores
from baseline (prior to the control condition), pre-test (after the control condition and before the
experimental condition), and post-test (after the experimental condition) were compared while
covarying for demographic variables (gender identity, racial identity, sexual orientation, religion,
education level, trans/cisgender status), coping self-efficacy scores, and social anxiety scores. No
differences were found between baseline, pre-, or post-test scores for any measures.
Confirmatory Hypothesis 2: Participants who are in the minority-stress event condition
versus control condition will experience elevated levels of anxiety, negative affect, and
minority-stress/otherness.
Within-subjects analyses of Covariance (ANCOVAs) tested Confirmatory Hypothesis 2
to examine whether anxiety, negative affect, feelings of otherness (minority-stress), and
in-the-moment alcohol cravings for N = 26 participants varied across conditions. Ratings of
0-100 on anxiety, and otherness, as well as scores on the PANAS and the ACQ-NOW were
included in models as dependent variables. Scores from baseline (prior to the control condition),
pre-test (after the control condition and before the experimental condition), and post-test (after
the experimental condition) were compared while covarying for demographic variables (gender
identity, racial identity, sexual orientation, religion, education level, trans/cisgender status),
coping self-efficacy scores, and social anxiety scores. No significant differences were found
between baseline, pre-, or post-test scores for any measures. See Figures 1-5 for a display of all
confirmatory hypothesis results.
Exploratory Aims
Examine the relationships through an intersectional lens

Exploring Minority-Stress and Alcohol Use 33
No significant interactions were detected at p <.01 across any of our models. As such,
quantitative analyses were not split by demographic covariates. However, the prevalences of
qualitative themes varied somewhat by demographic identity groups. The frequency of themes
across gender, racial identity, sexual orientation, and age can be found in Tables 2-5. A
qualitative analysis of the trends of theme variability across demographic groups in the
experimental condition is described below.
Gender. Anxiety and social anxiety reactions in response to the microaggression scenario
were far more prevalent among women compared to men- and non-binary/gender-variant
participants. The same is true of minority-stress, internalized homophobia, and anger. Sadness
did not emerge among participants who identified as men.
Racial Identity. Across all demographic racial groups (white, Black, Asian,
Hispanic/Latino, and Biracial/Other), all themes occurred at higher rates among white
participants compared to other racial groups. Among minority-racial groups, anxiety–but not
social anxiety– was most frequent in the Black and Hispanic/Latino samples. Minority-stress was
most common among White and Hispanic/Latino samples, and internalized homophobia was
expressed by all racial groups except Black and Asian. Among the minority-identified
participants, sadness most commonly was expressed within the Hispanic/Latino-identified group.
Desire to drink was not expressed by Asian participants, and alcohol coping motives were not
expressed among Asian and Black participants.
Sexual Orientation. Bi- and pansexual participants expressed more anxiety than all other
sexual orientation groups, as well as minority-stress and sadness. Gay-identified individuals did
not express alcohol coping motives. Escape responses were most common among Lesbians, and
confrontation desires were most common among queer-identified individuals.

Exploring Minority-Stress and Alcohol Use 34
Age Group. Between youth (21-25) and adult (26-30) groups, anger was most common
among the older age group, as well as desire to drink and alcohol coping motives.
Examine the incidence of minority-stress events over the course of one week using Daily
Assessments.
Compliance with our daily assessment protocol was high. N = 27 participants were
instructed to complete one daily assessment per day for seven days (189 total assessments). 180
daily assessments were completed, yielding a 95% compliance rate.
Microaggressions. Of N = 180 total daily assessments, only two participants reported
that they had experienced a microaggression based on their sexual orientation. One participant
only reported the location of the event (Boulder Colorado), while another participant reported
that a facialist had assumed that they had a boyfriend, rather than a girlfriend
Specific Aim 4: Develop and test these ATSS scenarios in terms of both the feasibility and
acceptability of both the content and methodology.
Specific aim 4 investigated participant feedback from the ATSS events with qualitative
and quantitative methodologies in the control and experimental conditions. The questions were
administered in the pre- and post-test surveys.
Control Condition
Participants (N = 27) reported their feedback about the control condition scenario. 48% of
participants reported that the simulated event had happened to them in real life (52% no/hadn’t
happened). When asked how realistic the scenario was, 74% reported that it was realistic (26%
maybe). Participants offered qualitative feedback about the realism of the scenario as well as
suggestions for improvement, which are expanded upon below.

Exploring Minority-Stress and Alcohol Use 35
Realism. Overall, participants reported that the scenario was fairly realistic. They noted
that the scenario felt “normal” and like something that could feasibly happen to them. Realism
was primarily reported to be diminished by the way that participants were described to have
behaved in the scenario–for example, one participant noted that they would have acted
differently, and as such it seemed unlikely that they would remain a bystander. In addition, some
participants felt that the dialogue between the gossipers in the control scenario was not realistic
or “specific” enough. Overall, the participants had a very positive perception of the realism of
the control scenario.
Clarity. Some participants expressed confusion about the subjects of the gossip in the
scenario. “I felt confused by the situation; I wasn’t clear exactly what was happening,” reported
one participant. Another stated that more specific details in the dialogue to describe who the
perpetrators were talking about would be helpful.
Content. The participants offered several suggestions for the content of the scenario.
Interestingly, some participants expressed that they did not feel “invested” in the scenario
because a heterosexual couple was being described as the subject of the negative gossip. Some
participants noted that the comments felt immature, and thus they did not find the scenario as
relatable as they might have if they were in high school or middle school. Other participants
suggested that more details about their relationship to the host of the party, the perpetrators, or
other characters would help them better understand and/or relate to the scenario.
Methodology. Some participants suggested attention checks, such as a “quiz” to make
sure that they understood the situation at hand. They recommended that such measures be taken
in the future to ensure the sustained attention of participants.
Experimental Condition

Exploring Minority-Stress and Alcohol Use 36
Participants (N = 27) reported their feedback about the experimental condition scenario.
19% of participants reported that the event had previously happened to them in their real life
(82% no). When asked the question “Did you feel as though the event was realistic?” 48% of
participants indicated ‘yes’ as their answer (48% maybe; 4% prefer not to answer). Qualitative
feedback about the realism and suggested changes were collected. from the participants
illuminated several areas of feedback, both positive and suggestive of future improvements to the
audio scenario in terms of both the content and methodology.
Realism. While feedback was mixed and some participants reported experiencing similar
behavior in the past, multiple participants expressed that they found trouble believing that the
scenario could realistically happen. One participant reported that they “Could not imagine” [23]
this scenario happening to them, particularly at an acquaintance's household. Another participant
expressed that they could feasibly see the conversation happening over social media, but
definitely not in “real life.” [40] Some participants expressed that it is possible that this event
could happen, and rather, it may be aspects about them as an individual and/or their personal
context that affect their ability to relate to the situation: “I think I’ve been in a bubble where I
experience less ignorance and hate than a lot of the world, so the way people talked about gay
people felt foreign to me.” [25] Clearly, a widespread disbelief about the homophobic content
was prevalent throughout the sample.
Clarity. Various participants expressed that aspects of the scenario were unclear to them.
For example, one participant noted that they had trouble understanding why they did not take
action throughout the scenario and found this confusing, supplemented by another who
expressed that a choose your own adventure storyline would make more sense to them. Another
expressed that an improvement of the storytelling would benefit the scenario: “Some of the

Exploring Minority-Stress and Alcohol Use 37
storytelling could be improved - I was confused about who was being talked about at times and
what the relationship was between me and the people gossiping.” [40] Overall, issues with
identifying characters in the story, understanding their own perceived behavior in the scenario,
and their relationship with members of the friend groups described were identified as areas of
improvement for the clarity of the scenario.
Content. The participants generally reported that they found the content upsetting and
annoying. However, suggestions were made for the content of the microaggressions themselves.
One participant expressed that the comments made by the perpetrators were “not very modern
sounding” [15] and could be updated to reflect more modern insults. Another noted that the
covertness of the homophobic sentiments were not true to reality: “I feel like there would have
been more derogatory language used. Like the guys would have been calling me a dyke or
something, rather than just talking about me.” [27] Others indicated that they would have
preferred a different context for the event to occur in, rather than a friend/acquaintance's home.
Overall, participants expressed that updating the language and context would improve the
content of the scenario.
Accessibility. Some participants noted that the audio was a little hard to hear over the
music and that the audio quality could be increased. Moreover, one participant noted that our
ATSS scenario was not accessible to deaf and hard-of-hearing people, stating: “Be more mindful
of deaf/Hoh people, maybe body language or facial expressions could be included.” [19] Clarity
of the audio quality, subtitles, or other aspects of delivery that increased accessibility were
important to participants.

Exploring Minority-Stress and Alcohol Use 38
Chapter Four: Discussion
Our pilot-study study demonstrates a proof-of-concept for assessing the relationship
between identity-related stress and alcohol use in real-time, as well as our ability to investigate
these associations using the ATSS paradigm. Furthermore, our study demonstrates the utility,
feasibility, and acceptability of using a novel virtual methodology to employ ATSS with
decreased researcher burden. Lastly, our findings expand upon our understanding of how
LGBTQIA+ individuals react to microaggression scenarios and how this relates to alcohol use
and motives to cope with identity-based stress. The implications, contextual factors, and
limitations of the findings are discussed below.
Describing LGBTQIA+ Individuals Reaction to a Minority-Stress Event
Anger and Desire to Confront Perpetrators
Reactions of shock, anger, and disbelief were extremely common in our sample during
the microaggression scenario. This is consistent with findings from Rayburn and Davison (2002),
which investigated sexual minority reactions to hate crime and non-hate crime scenarios. There
may be several reasons that this was the most common reaction among members of our sample.
First, the microaggression scenario presented several “cliche” and stereotypical transgressions
that may be made by heterosexual individuals against the LGBTQIA+ community. This may
have provoked frustration in light of the juvenile statements that the perpetrators made. Second,
there was a high amount of disbelief that was paired with expressions of anger. Even with
shifting attitudes in our sociopolitical context towards the LGBTQIA+ community in 2023, these
kinds of statements may still be perceived as jarring in the United States. In an even more
specific context, all of our sample live in Los Angeles, California, which is considered to be a
welcoming location for queer individuals. Our sample may have been more biased to harbor

Exploring Minority-Stress and Alcohol Use 39
disbelief about homophobic sentiments due to a lack of exposure to these kinds of interactions in
their current living context. Moreover, this may explain the high prevalence of a desire to
confront the perpetrators, which was also paired with anger. Our sample, which was
predominantly white and educated, expressed a desire to tell the perpetrators why they were
wrong–a motive which may also be specific to our sample. In addition some participants hoped
to “shame” the perpetrators–a motive that plausibly suggests a certain level of comfortability in
one’s identity is needed to engage in this behavior. It is plausible to suggest that overall, anger is
a response specific to identity-related stress rather than social distress overall, given the rare
emergence of these themes in our control condition scenario. Furthermore, the fact that desire to
drink and alcohol coping motives were positively associated with anger might suggest that some
participants drink to cope with anger, rather than anxiety. It also may suggest that results align
with affect intensity theory, versus regulation theory (see Tovmasyan et al., 2022). Future studies
should investigate the role of anger and confrontation in diverse samples in alternate geographic
contexts in the U.S., such as more rural or conservative communities, as participants may be less
willing or compelled to confront individuals making stigmatizing comments in these contexts,
and anger may have variable relationships to their alcohol use and motives.
Social Anxiety, Anxiety, Escape Response
While expressions of elevations of anxiety, social anxiety, and escape responses were
prevalent across both conditions, the context in which they emerged varied. In the control
condition, these anxiety and avoidance-related themes were expressed in response to arriving at
the party or overhearing gossip. However, in the minority-stress/experimental condition,
participants expressed their anxiety in response to the perpetrators' anti-LGBTQ+ statements.
This suggests that when homophobic sentiments are expressed, it may be common for sexual

Exploring Minority-Stress and Alcohol Use 40
minorities to experience elevations in anxiety. In addition, the judgment and negative evaluation
targeting their sexual identity may produce distress and discomfort. Moreover, physically
removing oneself from the situation and avoiding further interactions with perpetrators to reduce
distress may be an alternative coping response (viz., drinking alcohol). Future studies may
investigate other alternative coping responses. Our results are consistent with the literature, as
internalizing psychological problems have been found to be associated with sexual
identity-based stigma and discrimination (see Cochran & Mays, 2003; Hatzenbuehler et al.,
2010).
Minority-Stress and Internalized Homophobia
Identity-related stressors emerged in the experimental condition, and rarely–if at all–in
the control condition scenario. This demonstrates the distinctness of identity-based stressors from
general anxiety and social anxiety in these contexts; however, minority-stress was also positively
associated with anxiety and social anxiety, and it is difficult to disentangle whether these
internalizing problems might occur as an outcome of minority stressors or precede them. Our
results indicate that feelings of shame, embarrassment, and otherness can emerge in response to
homophobic microaggressions, even when they are less overt (e.g., homophobic slurs, violence).
This expands our knowledge of how experiences of discrimination and stigma relate to outcomes
of psychological distress. However, identity-based stressors were less prevalent in our sample
compared to other themes, especially internalized homophobia (cf. anger, anxiety). This too may
be related to the fact that our sample resides in a predominantly left-leaning and progressive
metropolitan city, where LGBTQIA+ community support and resources are robust and prevalent.
Future studies may investigate these phenomena in more rural, diverse, and conservative
communities to further our understanding of how minority-stress manifests in-the-moment.

Exploring Minority-Stress and Alcohol Use 41
Drinking Desire and Alcohol Coping Motives
Participants expressed a desire to drink alcohol, as well as a desire to drink alcohol
specifically to reduce tension or distress, in response to the microaggression scenario. This
manifested in the form of a desire to drink to “forget” the situation, to relax, and reduce
nervousness. These findings add a valuable contribution to the literature on both minority-stress
and developmental models of alcohol use problems. Prior studies have tended to focus on the
effects of chronic minority-stress as it relates to drinking outcomes over time (e.g., Hamilton &
Malik, 2009) rather than how alcohol use may escalate in-the-moment as a result of experiencing
a stigmatizing event. Moreover, many of our measures in the field focus on more overt, violent,
and unambiguous experiences with anti-LGBTQIA+ bigotry, such as hate crimes (e.g., Rayburn
& Ravison, 2002). These findings also provide proof-of-concept for a conceptual model of
minority-stress, anxiety, and alcohol use problems among sexual minorities via the negative
affect regulation pathway. In sum, these findings provide initial evidence that alcohol may be
used to cope with distress surrounding more subtle anti-gay expressions. However, similarly
drinking to cope was not a highly prevalent theme in our sample during the microaggression
scenario, likely due to the aforementioned contextual factors. In addition, the within-subjects
design may have contributed to these findings–it is possible that because participants
experienced anxiety as a result of the control condition, they had habituated to their anxiety or
already expressed their urges to drink by the time of the microaggression scenario. However, the
frequency of alcohol coping motives and a desire to drink across both conditions is consistent
with literature suggesting that in a broader, general sense, LGBTQIA+ identified individuals are
more likely to develop problematic alcohol use and drink to cope with stress (see Romano et al.,
2021; Fish & Baams, 2018; Moody et al., 2020). Future research should investigate these

Exploring Minority-Stress and Alcohol Use 42
relationships in real-world, ecologically valid contexts, across diverse samples, and with
qualitative and quantitative analytic approaches.
Specific Aim 2: How reactions to a minority-stress event relates to alcohol use motives and
expectancies and daily heterosexist experiences
Our statistical analyses for Specific Aim 2 identified one predictive relationship. Elevated
levels of daily heterosexist experiences in the past year as measured by the DHEQ were also
related to heightened frequencies of expressing a desire to confront homophobic perpetrators.
This may suggest that cumulative experiences of distress due to minority-stress create conditions
in which anger becomes increasingly difficult to modulate. However, our sample size for this
statistical analysis was very small (N = 26 participants). Future studies should examine these
relationships in large samples to test these associations with more statistical power.
Specific Aim 3: To examine how experiencing a minority-stress event relates to anxiety,
negative affect, minority-stress, and in-the-moment alcohol cravings.
Confirmatory hypotheses one and two predicted that individuals in the minority-stress vs.
control condition would experience elevated alcohol cravings, anxiety, negative affect, and
otherness. We did not find any significant differences on any of these measures. However, trends
in our data indicate that while non-significant, feelings of otherness and desire to drink increased
over conditions from baseline through post-test. Given that our comparison groups were fairly
small (n = 26 in each condition) participants, our sample sizes may be too small for statistically
significant differences to emerge. Furthermore, our findings are further limited by the fact that
our scenarios were not counterbalanced, which may have produced carry-over effects. Future
research should examine baseline and post-test ratings in larger sample sizes to determine
whether or not differences emerge, with counterbalancing and other methodological changes.

Exploring Minority-Stress and Alcohol Use 43
Examine the relationships through an intersectional lens
Gender Identity
Our quantitative analyses were not split by demographic groups due to the fact that
significant interactions were not detected. However, the frequency of themes in our qualitative
data was split by demographic groups to examine these relationships via an intersectional lens.
Anxiety and social anxiety reactions were more common among women and other gendered
participants than men, which aligns with trends in the literature that suggest that the negative
affect regulation pathway is more common in women than in men and that sexual minority
women are at higher risk for problem alcohol use compared to sexual minority men (see Sher et
al., 2005; Cerezo et al., 2019). Identity-related stress variables were also more common among
women and non-cisgender folks. Moreover, sadness did not emerge among participants who
identified as men, further aligning with the literature suggesting that drinking to cope occurs
more among non-men (see Sher et al., 2005). It may be the case that more externalizing
responses and drinking motives are common among men, rather than the negative affect and
anxiety reduction motives observed among women. However, our sample size was
disproportionately women and gender-nonconforming individuals, with only N = 4 men in our
final sample. Future studies may examine these relationships with more equivalent groups to
determine whether or not the same patterns emerge.
Racial Identity
Emotion, affective, and stress-related themes were more common among white
participants while coping and avoidance methods (e.g., alcohol coping motives, desire to drink,
and escape response) were more common among non-white participants. Moreover,
minority-stress and internalized homophobia were more common in the white and

Exploring Minority-Stress and Alcohol Use 44
Hispanic/Latino groups, versus The Black and Asian participants. This might align with the
theories of skin-deep resilience–that is, that African Americans often have fewer psychological
diagnoses, but experience worse outcomes in terms of both the severity and chronicity of
psychological problems as well as negative physical health outcomes (Rodriguez-Seijas et al.,
2019; Meyer et al., 2008). However, it is also worth noting that our sample was composed of
primarily white and Hispanic/Latino participants with n = 1 Black participant and n = 1 Asian
participant. Future studies may expand upon the intersections of racial identity with sexual
orientation based stigma with larger and more equivalent sample sizes to further our
understanding of how these differences might manifest.
Sexual Orientation
Bi- and pansexual participants expressed the most anxiety compared to other sexual
orientation groups. While they comprise the majority of our sample, it is also notable that
bisexual individuals experience elevated stressors from both non-heterosexual and heterosexual
communities. As such, minority-stress is often disproportionately high in this population, and it
is feasible that in the instance of a microaggression scenario, non-monosexual individuals will be
most susceptible to distress as is consistent with our current understanding of Bi+ mental health
disparities (see Cerezo et al., 2019). Moreover, individuals who identified as gay did not express
alcohol coping motives. This could be due to the fact that all individuals identified as gay also
identified as men, and sexual minority men have been found to be at less risk for alcohol use
problems compared to sexual minority women (see Amadio et al., 2008).
Age Group
There were a few differences that emerged between our age groups. However,
expressions of anger were more common in the older (26 -30) age group, as well as desires to

Exploring Minority-Stress and Alcohol Use 45
drink and alcohol coping motives. The former may be a cohort effect, as older participants have
likely experienced a different interpersonal and systemic cultural context surrounding
LGBTQIA+ issues (e.g., coming out preceding marriage equality laws). In addition, drinking to
cope is more prevalent among older populations, and as such drinking to reduce minority-stress
may be more common at this developmental stage (see Gilson et al., 2017).
Examine the incidence of minority-stress events over the course of one week using Daily
Assessments.
Our high compliance rate (95%) with our daily assessment protocol indicates that it is a
feasible approach to collect data among LGBTQIA+ participants. Incidences of minority-stress
were low in our sample, with only two participants reporting one microaggression scenario
throughout the entire course of our study. As such, using this approach with another sample in a
less socially liberal environment outside of Los Angeles may provide more informative data on
the relationship between experiencing microaggressions in the real world under ecologically
valid conditions.
Specific Aim 4: Develop and test these ATSS scenarios in terms of both the feasibility and
acceptability of both the content and methodology.
Participants provided informative feedback about their experiences participating in the
ATSS scenarios. Generally, the realism of both scenarios was high, suggesting that the scenarios
are plausible. Improvements should be made to the clarity of the scenarios in order to mitigate
confusion, and attention checks may be beneficial to increase the attention and awareness of the
participant to evoke authentic responses to the simulated situations. Because the behavior of the
participants in the simulated scenarios was reported to deviate substantially from their imagined
behavior, it may be beneficial to investigate the feasibility of a “choose your own adventure”

Exploring Minority-Stress and Alcohol Use 46
approach to ATSS, wherein participants are able to have agency over their behavior in the
imagined scenario. This could also provide data related to decision-making, in addition to the
data obtained via cognitive assessment, but would change the method beyond the purview of
what ATSS traditionally captures. Accessibility was also an important consideration that
emerged in the study. Adaptations should be made for hard of hearing/deaf participants, such as
subtitles, as well as captioned tonal descriptions to encapsulate the mood of the scenarios.
Overall, our findings demonstrate a proof-of-concept for an online, automated version of ATSS
that reduces researcher burden.
Limitations and Conclusions
There are several important limitations to our study. First, our sample size is appropriate
for qualitative analyses (N = 27) but provides little statistical power for quantitative analyses. In
addition, the lack of counterbalancing of our scenarios may limit the conclusions we can draw
from our experimental data. Second, our study is an analog design and the generalizability of our
ATSS findings may be limited. Lastly, as previously mentioned, the cultural and social
environment of Los Angeles in terms of LGBTQIA+ life is very liberal. These findings may vary
substantively in other communities across the United States that are more rural, for example.
Nonetheless, our study adds several important contributions to the literature. First, it
enhances our understanding of how LGBTQIA+ participants react to microaggressions
in-the-moment, and how these events may relate to alcohol use motives to cope in real-time
among various demographic groups within the sexual minority community. Second, our study
presents a proof-of-concept for a novel virtual approach to the ATSS cognitive assessment
paradigm and contributes novel scenarios that simulate homophobic microaggressions in a
context where alcohol use is likely to occur. Continuing to investigate these relationships has the

Exploring Minority-Stress and Alcohol Use 47
potential to enhance our understanding of how alcohol use problem disparities manifest in this
population, and build toward developing approaches to culturally sensitive and
intersectionality-informed interventions to reduce negative health and behavioral outcomes in
this uniquely marginalized community. With increases in homophobia and transphobia across the
United States in 2023, it is now more important than ever that researchers seek to conduct studies
with the potential to enhance psychological well-being in this population.

Exploring Minority-Stress and Alcohol Use 48
References
Amadio, Adam, T., & Buletza, K. (2008). Gender differences in alcohol use and alcohol-related
problems: do they hold for lesbians and gay men? Journal of Gay & Lesbian Social
Services, 20(4), 315–327. https://doi.org/10.1080/10538720802310717
Anderson, K. G., & Parent, S. J. (2007). Adolescent decision-making about substance use: A
video-based assessment. In N. Galwye (Ed.), Progress in educational psychology research
(pp. 3–21). Nova Science Publishers.
Anderson, K.G., Ramo, D.E. & Brown, S.A. (2006). Life stress, coping, and comorbid youth: an
examination of the stress-vulnerability model for substance use. Journal of Psychoactive
Drugs, 38(3), 255-262. doi: 10.1080/02791072.2006.10399851
Anderson K.G., Duncan K., Buras M., Packard C.D., Kennedy, C. C-SIDE: drinking simulation
for college students. Journal of Studies on Alcohol and Drugs. 2013;74:94–103.
https://doi.org/10.15288/jsad.2013.74.94
Anderson, K. G., Brackenbury, L., Quackenbush, M., Buras, M., Brown, S. A., & Price, J.
(2014). A-SIDE: video simulation of teen alcohol and marijuana use contexts. Journal of
Studies on Alcohol and Drugs, 75(6), 953–957. https://doi.org/10.15288/jsad.2014.75.953
Armeli, S., Carney, M. A., Tennen, H., Affleck, G., & O'Neil, T. P. (2000). Stress and alcohol
use: A daily process examination of the stressor–vulnerability model. Journal of
personality and social psychology, 78(5), 979. doi: 10.1037//0022-3514.78.5.979
Arulkadacham, L. J., Richardson, B., Staiger, P. K., Kambouropoulos, N., O’Donnell, R. L., &
Ling, M. (2017). Dissociation between wanting and liking for alcohol and caffeine: a test
of the incentive sensitization theory. Journal of Psychopharmacology, 31(7), 927-933.
doi: 10.1177/0269881117711711
Balsam, K. F., Beadnell, B., & Molina, Y. (2013). The daily heterosexist experiences
questionnaire: measuring minority stress among lesbian, gay, bisexual, and transgender
adults. Measurement and evaluation in counseling and development: the official
publication of the Association for Measurement and Evaluation in Counseling and
Development, 46(1), 3–25. https://doi.org/10.1177/0748175612449743
Beard, C., Rodriguez, B. F., Moitra, E., Sibrava, N. J., Bjornsson, A., Weisberg, R. B., & Keller,
M. B. (2011). Psychometric properties of the Liebowitz social anxiety scale (lsas) in a
longitudinal study of African Americans with anxiety disorders. Journal of anxiety
disorders, 25(5), 722–726. https://doi.org/10.1016/j.janxdis.2011.03.009
Boyle, S. C., LaBrie, J. W., Costine, L. D., & Witkovic, Y. D. (2017). “It's how we deal”:
Perceptions of LGB peers' use of alcohol and other drugs to cope and sexual minority
adults' own coping motivated substance use following the Pulse nightclub shooting.
Addictive Behaviors, 65, 51-55. doi: 10.1016/j.addbeh.2016.10.001

Exploring Minority-Stress and Alcohol Use 49
Brown, S. A., Christiansen, B. A., & Goldman, M. S. (1987). The Alcohol Expectancy
Questionnaire: an instrument for the assessment of adolescent and adult alcohol
expectancies. Journal of studies on alcohol, 48(5), 483-491. doi:
10.15288/jsa.1987.48.483
Butler, R. M., Horenstein, A., Gitlin, M., Testa, R. J., Kaplan, S. C., Swee, M. B., & Heimberg,
R. G. (2019). Social anxiety among transgender and gender nonconforming individuals:
The role of gender-affirming medical interventions. Journal of Abnormal Psychology,
128(1), 25. doi: 10.1037/abn0000399
Cerezo, A., & Ramirez, A. (2021). Perceived discrimination, alcohol use disorder, and
alcohol-related problems in sexual minority women of color. Journal of Social Service
Research, 47(1), 33-46. https://doi.org/10.1080/01488376.2019.1710657
Chesney, M. A., Neilands, T. B., Chambers, D. B., Taylor, J. M., & Folkman, S. (2006). A
validity and reliability study of the coping self-efficacy scale. British journal of health
psychology, 11(Pt 3), 421–437. https://doi.org/10.1348/135910705X53155
Cochran, S. D., Sullivan, J. G., & Mays, V. M. (2003). Prevalence of mental disorders,
psychological distress, and mental health services use among lesbian, gay, and bisexual
adults in the United States. Journal of consulting and clinical psychology, 71(1), 53. doi:
10.1037//0022-006x.71.1.53
Cotton, N. S. (1979). The familial incidence of alcoholism: a review. Journal of Studies on
alcohol, 40(1), 89-116. doi: 10.15288/jsa.1979.40.89
Coulter, R. W., Blosnich, J. R., Bukowski, L. A., Herrick, A. L., Siconolfi, D. E., & Stall, R. D.
(2015). Differences in alcohol use and alcohol-related problems between transgender-and
nontransgender-identified young adults. Drug and alcohol dependence, 154, 251-259.
doi: 10.15288/jsa.1979.40.89
Courtney, & Russell, M. A. (2021). Testing affect regulation models of drinking prior to and
after drinking initiation using ecological momentary assessment. Psychology of Addictive
Behaviors, 35(5), 597–608. https://doi.org/10.1037/adb0000763
Cloutier, R. M., Blumenthal, H., Trim, R. S., Douglas, M. E., & Anderson, K. G. (2019).
Real-time social stress response and subsequent alcohol use initiation among female
adolescents. Psychology of addictive behaviors: journal of the Society of Psychologists in
Addictive Behaviors, 33(3), 254–265. https://doi.org/10.1037/adb0000454
Cloutier, R. M., Anderson, K. G., Kearns, N. T., Carey, C. N., & Blumenthal, H. (2021). An
experimental investigation of peer rejection and social anxiety on alcohol and cannabis
use willingness: Accounting for social contexts and use cues in the laboratory.
Psychology of addictive behaviors: journal of the Society of Psychologists in Addictive
Behaviors, 35(8), 887–894. https://doi.org/10.1037/adb0000711

Exploring Minority-Stress and Alcohol Use 50
Cooper, Russell, M., Skinner, J. B., Frone, M. R., & Mudar, P. (1992). Stress and alcohol use:
moderating effects of gender, coping, and alcohol expectancies. Journal of Abnormal
Psychology (1965), 101(1), 139–152. https://doi.org/10.1037/0021-843X.101.1.139
Crawford, J. R., & Henry, J. D. (2004). The positive and negative affect schedule (PANAS):
construct validity, measurement properties, and normative data in a large non-clinical
sample. British Journal of Clinical Psychology, 43, 245–265. doi:
10.1348/0144665031752934
Davison, G. C., Navarre, S. G., & Vogel, R. S. (1995). The articulated thoughts in simulated
situations paradigm: A think-aloud approach to cognitive assessment. Current Directions
in Psychological Science, 4(1), 29-33. doi: 10.1037//0022-006x.65.6.950
Davison, G. C., Robins, C., & Johnson, M. (1983). Articulated thoughts during simulated
situations: A paradigm for studying cognition in emotion and behavior. Cognitive
Therapy and Research, 7(1), 17-40. https://doi.org/10.1007/BF01173421
Demant, D., Hides, L., White, K. M., & Kavanagh, D. J. (2018). Effects of participation in and
connectedness to the LGBT community on substance use involvement of sexual minority
young people. Addictive behaviors, 81, 167-174. doi: 10.1016/j.addbeh.2018.01.028
Dermody, Cheong, J., & Manuck, S. (2013). An evaluation of the stress-negative affect model in
explaining alcohol use: the role of components of negative affect and coping style.
Substance Use & Misuse, 48(4), 297–308. https://doi.org/10.3109/10826084.2012.76171
Douaihy, A. & Daley, D. (2017). Alcohol use disorder. In A. Wenzel (Eds.), The sage
encyclopedia of abnormal and clinical psychology (Vol. 1., pp. 96-99). SAGE
Publications, Inc. doi: 10.4135/9781483365817.n39.
Duif, M., Thewissen, V., Wouters, S., Lechner, L., & Jacobs, N. (2020). Associations between
affect and alcohol consumption in adults: an ecological momentary assessment study. The
American Journal of Drug and Alcohol Abuse, 46(1), 88–97.
https://doi.org/10.1080/00952990.2019.1635606
Felner, J. K., Wisdom, J. P., Williams, T., Katuska, L., Haley, S. J., Jun, H. J., & Corliss, H. L.
(2020). Stress, coping, and context: examining substance use among LGBTQ young
adults with probable substance use disorders. Psychiatric services, 71(2), 112-120. doi:
10.1176/appi.ps.201900029
Fish, J. N., & Baams, L. (2018). Trends in alcohol-related disparities between heterosexual and
sexual minority youth from 2007 to 2015: findings from the youth risk behavior survey.
LGBT health, 5(6), 359–367. https://doi.org/10.1089/lgbt.2017.0212
Flentje, A., Heck, N. C., & Cochran, B. N. (2014). Experiences of ex-ex-gay individuals in
sexual reorientation therapy: reasons for seeking treatment, perceived helpfulness and

Exploring Minority-Stress and Alcohol Use 51
harmfulness of treatment, and post-treatment identification. Journal of Homosexuality,
61(9), 1242-1268. doi: 10.1080/00918369.2014.926763
Gilson, K. M., Bryant, C., & Judd, F. (2017). Understanding older problem drinkers: the role of
drinking to cope. Addictive behaviors, 64, 101-106. doi: 10.1016/j.addbeh.2016.08.032
Goodman, L. A., Corcoran, C., Turner, K., Yuan, N., & Green, B. L. (1998). Assessing traumatic
event exposure: General issues and preliminary findings for the Stressful Life Events
Screening Questionnaire. Journal of Traumatic Stress: Official Publication of The
International Society for Traumatic Stress Studies, 11(3), 521-542. doi:
10.1023/A:1024456713321
Grant, V. V., Stewart, S. H., O'Connor, R. M., Blackwell, E., & Conrod, P. J. (2007).
Psychometric evaluation of the five-factor Modified Drinking Motives
Questionnaire—Revised in undergraduates. Addictive behaviors, 32(11), 2611-2632. doi:
10.1016/j.addbeh.2007.07.004
Hamilton, C. J., & Mahalik, J. R. (2009). Minority stress, masculinity, and social norms
predicting gay men's health risk behaviors. Journal of Counseling Psychology, 56(1),
132-141. doi:http://dx.doi.org/10.1037/a0014440
Hatzenbuehler, M. L., McLaughlin, K. A., Keyes, K. M., & Hasin, D. S. (2010). The impact of
institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual
populations: A prospective study. American journal of public health, 100(3), 452-459.
doi: 10.1016/j.addbeh.2007.07.004
Hatzenbuehler, M. L. (2014). Structural stigma and the health of lesbian, gay, and bisexual
populations. Current Directions in Psychological Science, 23(2), 127-132.
https://doi.org/10.1177/0963721414523775
Hobbs, M., Remington, B., & Glautier, S. (2005). Dissociation of wanting and liking for alcohol
in humans: a test of the incentive-sensitization theory. Psychopharmacology, 178(4),
493-499. doi: 10.1007/s00213-004-2026-0
Hughes, T. L., Wilsnack, S. C., & Kantor, L. W. (2016). The influence of gender and sexual
orientation on alcohol use and alcohol-related problems: Toward a global perspective.
Alcohol Research: Current Reviews, 38(1), 121–132.
Kail, B. L., Acosta, K. L., & Wright, E. R. (2015). State-level marriage equality and the health of
same-sex couples. American Journal of Public Health, 105(6), 1101-1105. doi:
10.2105/AJPH.2015.302589
Keyes, K. M., & Hasin, D. S. (2008). Socio‐economic status and problem alcohol use: the
positive relationship between income and the DSM‐IV alcohol abuse diagnosis.
Addiction, 103(7), 1120-1130. doi: 10.1111/j.1360-0443.2008.02218.x

Exploring Minority-Stress and Alcohol Use 52
Lewis, Romano, K. A., Ehlke, S. J., Lau-Barraco, C., Sandoval, C. M., Glenn, D. J., & Heron, K.
E. (2021). Minority stress and alcohol use in sexual minority women’s daily lives.
Experimental and Clinical Psychopharmacology, 29(5), 501–510.
https://doi.org/10.1037/pha0000484
Liebowitz, M. R., & Pharmacopsychiatry, M. P. (1987). Social phobia. New York, NY: Guilford
Publications.
McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T., & Boyd, C. J. (2010). The
relationship between discrimination and substance use disorders among lesbian, gay, and
bisexual adults in the United States. American journal of public health, 100(10),
1946-1952. doi: 10.2105/AJPH.2009.163147
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual
populations: conceptual issues and research evidence. Psychological bulletin, 129(5),
674. doi: 10.1037/0033-2909.129.5.674
Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color.
The counseling psychologist, 38(3), 442-454. doi: 10.1177/0011000009351601
Milosevic, I., & McCabe, R.E. eds. Phobias: The psychology of irrational fear: Abc-Clio, 2015.
Butler, R. M., Horenstein, A., Gitlin, M., Testa, R. J., Kaplan, S. C., Swee, M. B., & Heimberg,
R. G. (2019). Social anxiety among transgender and gender nonconforming individuals:
The role of gender-affirming medical interventions. Journal of Abnormal Psychology,
128(1), 25. doi: 10.1037/abn0000399
Moody, R. L., Savarese, E., Gurung, S., Rendina, H. J., & Parsons, J. T. (2020). The mediating
role of psychological distress in the association between harassment and alcohol use
among lesbian, gay, and bisexual military personnel. Substance Use & Misuse, 55(12),
2055–2063. https://doi.org/10.1080/10826084.2020.1790007
Mulia, Ye, Y., Zemore, S. E., & Greenfield, T. K. (2008). Social disadvantage, stress, and alcohol
use among Black, Hispanic, and white Americans: Findings from the 2005 U.S. National
Alcohol Survey. Journal of Studies on Alcohol and Drugs, 69(6), 824–833.
https://doi.org/10.15288/jsad.2008.69.824
Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental
health problems: A meta-analytic review. Clinical Psychology Review, 30, 1019 –1029.
http://dx.doi.org/10.1016/j.cpr.2010.07.003
Newcomb, Heinz, A. J., & Mustanski, B. (2012). Examining risk and protective factors for
alcohol use in lesbian, gay, bisexual, and transgender youth: A longitudinal multilevel
analysis. Journal of Studies on Alcohol and Drugs, 73(5), 783–793.
https://doi.org/10.15288/jsad.2012.73.783

Exploring Minority-Stress and Alcohol Use 53
O'Malley, P. M., & Johnston, L. D. (2002). Epidemiology of alcohol and other drug use among
American college students. Journal of Studies on Alcohol, supplement, (14), 23-39. doi:
10.15288/jsas.2002.s14.23
Pachankis, J. E., & Bränström, R. (2018). Hidden from happiness: Structural stigma, sexual
orientation concealment, and life satisfaction across 28 countries. Journal of Consulting
and Clinical Psychology, 86(5), 403-415. doi: 10.1037/ccp0000299
Park, C. L., Armeli, S., & Tennen, H. (2004). The daily stress and coping process and alcohol
use among college students. Journal of Studies on Alcohol, 65(1), 126-135. doi:
10.15288/jsa.2004.65.126
Palfai, T. P., & Ostafin, B. D. (2003). Alcohol-related motivational tendencies in hazardous
drinkers: Assessing implicit response tendencies using the modified-IAT. Behaviour
Research and Therapy, 41(10), 1149-1162. doi: 10.1016/s0005-7967(03)00018-4
Rayburn, & Davison, G. C. (2002). Articulated thoughts about antigay hate crimes. Cognitive
Therapy and Research, 26(4), 431–447. https://doi.org/10.1023/A:1016214632062
Reed, Prado, G., Matsumoto, A., & Amaro, H. (2009). Alcohol and drug use and related
consequences among gay, lesbian and bisexual college students: Role of experiencing
violence, feeling safe on campus, and perceived stress. Addictive Behaviors, 35(2),
168–171. https://doi.org/10.1016/j.addbeh.2009.09.005
Robinson, T. E., & Berridge, K. C. (1993). The neural basis of drug craving: an
incentive-sensitization theory of addiction. Brain research reviews, 18(3), 247-291. doi:
10.1016/0165-0173(93)90013-p
Rodriguez-Seijas, C., Eaton, N. R., & Pachankis, J. E. (2019). Prevalence of psychiatric
disorders at the intersection of race and sexual orientation: results from the national
epidemiologic survey of alcohol and related conditions-iii. Journal of Consulting and
Clinical Psychology, 87(4), 321. doi: 10.1037/ccp0000377
Ross, & Rosser, B. R. S. (1996). Measurement and correlates of internalized homophobia: A
factor analytic study. Journal of Clinical Psychology, 52(1), 15–21.
https://doi.org/10.1002/(SICI)1097-4679(199601)52:1
Schuler, M. S., Prince, D. M., Breslau, J., & Collins, R. L. (2020). Substance use disparities at
the intersection of sexual identity and race/ethnicity: Results from the 2015–2018
National Survey on Drug Use and Health. LGBT health, 7(6), 283-291. doi:
10.1089/lgbt.2019.0352
Sher, K., Grekin, E., & Williams, N. (2005). The development of alcohol use disorders. Annual
Review of Clinical Psychology, 1(1), 493–523. https://doi.org/10.1146/

Exploring Minority-Stress and Alcohol Use 54
Singleton, E. G. (1995). A brief version of the Alcohol Craving Questionnaire (ACQ-NOW):
Problems of Drug Dependence. In Proceedings of the 60th Annual Meeting, The College
on Problems of Drug Dependence, Inc (Vol. 2).
Spielberger, C. D. (1989). State-Trait Anxiety Inventory: Bibliography (2nd ed.). Palo Alto, CA:
Consulting Psychologists Press.
Swaim, Chen, J., Deffenbacher, J. L., & Newcomb, M. D. (2001). Negative affect and alcohol
use among non-Hispanic white and Mexican American adolescents. Journal of Child &
Adolescent Substance Abuse, 11(1), 55–75. https://doi.org/10.1300/J029v11n01_03
Tibboel, H., De Houwer, J., Spruyt, A., Brevers, D., Roy, E., & Noël, X. (2015). Heavy social
drinkers score higher on implicit wanting and liking for alcohol than alcohol-dependent
patients and light social drinkers. Journal of behavior therapy and experimental
psychiatry, 48, 185-191. doi: 10.1016/j.jbtep.2015.04.003
Tovmasyan, Monk, R. L., & Heim, D. (2022). Towards an affect intensity regulation hypothesis:
Systematic review and meta-analyses of the relationship between affective states and
alcohol consumption. PloS One, 17(1), e0262670–e0262670.
https://doi.org/10.1371/journal.pone.0262670
Turrisi, R., Mallett, K. A., Mastroleo, N. R., & Larimer, M. E. (2006). Heavy drinking in college
students: who is at risk and what is being done about it? The Journal of General
Psychology, 133(4), 401–420. https://doi.org/10.3200/GENP.133.4.401-420
Van Der Star, A., & Bränström, R. (2015). Acceptance of sexual minorities, discrimination,
social capital, and health and well-being: A cross-European study among members of
same-sex and opposite-sex couples. BMC Public Health, 15(1), 812–.
https://doi.org/10.1186/s12889-015-2148-9
Villarreal, Charak, R., Schmitz, R. M., Hsieh, C., & Ford, J. D. (2021). The relationship between
sexual orientation outness, heterosexism, emotion dysregulation, and alcohol use among
lesbian, gay, and bisexual emerging adults. Journal of Gay & Lesbian Mental Health,
25(1), 94–115. https://doi.org/10.1080/19359705.2020.1809588
Williams, E. C., Frost, M. C., Rubinsky, A. D., Glass, J. E., Wheat, C. L., Edmonds, A. T., Chen,
J. A., Matson, T. E., Fletcher, O. V., Lehavot, K., & Blosnich, J. R. (2021). Patterns of
alcohol use among transgender patients receiving care at the Veterans Health
Administration: overall and relative to nontransgender patients. Journal of studies on
alcohol and drugs, 82(1), 132–141. https://doi.org/10.15288/jsad.2021.82.132
White, H.R., Anderson, K.G., & Bechtol, J. (2018). Stress as a moderator of the effects of coping
motives on alcohol and marijuana use in young adulthood. Cannabis, 1(1), 1-13. doi:
http://dx.doi.org/10.26828/cannabis.2018.01.001

Exploring Minority-Stress and Alcohol Use 55
Zanov, & Davison, G. C. (2010). A conceptual and empirical review of 25 years of cognitive
assessment using the articulated thoughts in simulated situations (ATSS) think-aloud
paradigm. Cognitive Therapy and Research, 34(3), 282–291.
https://doi.org/10.1007/s10608-009-9271-9
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Exploring Minority-Stress and Alcohol Use 56
Table 1. Code Frequencies in the Control and Experimental Conditions
Code Control Frequency
(n = 27)
Experimental Frequency
(n = 26)
1. Anxiety 85 73
2. Social Anxiety 59 58
3. Escape response 39 83
4. Desire to Drink 33 13
5. Confrontation Desire 21 72
6. Anger 19 115
7. Alcohol Coping Motives 16 8
8. Sadness 7 43
9. Minority-Stress 1 63
10. Internalized
Homophobia
0 11

Exploring Minority-Stress and Alcohol Use 57
Table 2. Rates of Themes by Gender Identity in Experimental Condition
Man
(n = 4 )
Woman
(n = 18 )
Non-Binary & Other
(n = 4)
Anxiety .5x 3.5x 2x
Social Anxiety 2x 2.3x 1.75x
Minority-Stress 1x 2.4x 2.75
Internalized
Homophobia
.25x .5x .25x
Anger 3x 5.2x 2.25
Sadness - 2.3x .25x
Desire To Drink 1x .38x 1x
Alcohol Coping
Motives
.5x .22x .25x
Escape Response 5.25x 2.94x 2.25x
Confrontation Desire 3.5x 2.88x 2.5x

Exploring Minority-Stress and Alcohol Use 58
Table 3. Rates of Themes by Racial Identity In Experimental Condition
White
(n = 14 )
Black
(n = 1)
Asian
(n = 1)
Hispanic/Latino
(n = 6)
Biracial/Other
(n = 4)
Anxiety 3.07x 11x 3x 1.66x 1.5x
Social Anxiety 2.21x 2x 2x 2x 2.5x
Minority-Stress 2.64 4x 1x 2.66x 1.25x
Internalized
Homophobia
.42x - - .5x .5x
Anger 5x 17x 4x .83x 4.75
Sadness 27x 1x 1x 2x .5x
Desire To Drink 1.92x 3x - .33x .5x
Alcohol Coping
Motives
.14x - - .5x .75x
Escape
Response
2.43x 5x 4x .33x 3.25x
Confrontation
Desire
2.43x 7x 5x 1.5x 4.25x

Exploring Minority-Stress and Alcohol Use 59
Table 4. Rates of Themes by Sexual Orientation In Experimental Condition
Lesbian
(n = 6)
Gay
(n = 3)
Bi- & Pansexual
(n = 10)
Queer
(n = 7)
Anxiety 3.67x 0.67x 4.50x 2.00x
Social Anxiety 1.67x 2.00x 2.50x 2.43x
Minority-Stress 2.33x 1.33x 3.30x 1.71x
Internalized
Homophobia
- 0.33x 0.40x 0.86x
Anger 5.33x 0.67x 4.80x 4.71x
Sadness 1.00x - 2.20x 2.14x
Desire To Drink 1.17x 0.67x 0.20x 0.29x
Alcohol Coping
Motives
0.67x - 0.10x 0.43x
Escape Response 4.33x 5.33x 0.80x 2.71x
Confrontation
Desire
2.67x 2.33x 1.30x 3.71x

Exploring Minority-Stress and Alcohol Use 60
Table 5. Rates of Themes by Age Group (Youth/Non-Youth) In Experimental Condition
Age 21-25
(N = 9)
Age 26-30
(N = 17)
Anxiety 3.22x 2.59x
Social Anxiety 2.22x 2.24x
Minority-Stress 3.11x 2.06x
Internalized
Homophobia
0.33x 0.47x
Anger 3.78x 4.76x
Sadness 1.44x 1.76x
Desire To Drink 0.44x 0.53x
Alcohol Coping
Motives
0.22x 0.35x
Escape Response 3.56x 3.00x
Confrontation Desire 2.56x 2.88x

Exploring Minority-Stress and Alcohol Use 61
Figure 1. ACQ-NOW Scores On Baseline, Pre-Test, and Post-Test Surveys
Note. Group n = 26. Error bars represent the standard error of the mean.

Exploring Minority-Stress and Alcohol Use 62
Figure 2. PANAS Negative Affect Scores on Baseline, Pre-Test, and Post-Test Surveys
Note. Group n = 26. Error bars represent the standard error of the mean.

Exploring Minority-Stress and Alcohol Use 63
Figure 3. Desire to Drink 0-100 on Baseline, Pre-Test, and Post-Test Surveys
Note. Group n = 26. Error bars represent the standard error of the mean.

Exploring Minority-Stress and Alcohol Use 64
Figure 4. Anxiety 0-100 on Baseline, Pre-Test, and Post-Test Surveys
Note. Group n = 26. Error bars represent the standard error of the mean.

Exploring Minority-Stress and Alcohol Use 65
Figure 5. Otherness 0-100 on Otherness, Pre-Test, and Post-Test Surveys
Note. Group n = 26. Error bars represent the standard error of the mean.

Exploring Minority-Stress and Alcohol Use 66
Appendix A. Descriptive/Expression Codes
Code Name Description Example/Quotations
Anxiety Express general fear, worry “Really, kind of like nervous
and anxious.”
Social Anxiety Express fear/worry related to
social evaluation
“I’d be nervous about the
people I do know and the
people I don’t know”
Minority-stress express fear or worry related to
sexual identity
“I feel like I should have been
the one who should have left
first because I felt deeply
unsafe when they were there.
Like, I didn’t feel safe around
them so I’m glad they’re
leaving um.”
Internalized Homophobia express self-deprecation related
to sexual identity (e.g., I
deserve this, they’re right)
“It's like really hard not to feel
like, embarrassed or like you
want to like cringe at your own
self”
Anger Express anger/ rage or desire to
perform aggressive acts or
frustration
“Ohh my god I would be so
mad, at this point”
Sadness Expression of sadness, feeling
blue, being hurt.
“I would go like, cry about it in
secret. Uhm, but that is like
such a bad scenario for me.”
Desire to Drink Expression of wanting or
needing to drink alcohol
“I would immediately want to
start drinking”
Alcohol Coping Motives Intent to use alcohol to cope
(e.g., “take the edge off”)
“I’m definitely relieved I can
finally get a drink.”
“kinda be more nervous and
kind of just impatient to sort of
just have a drink I think so I can
leave”

Exploring Minority-Stress and Alcohol Use 67
Escape Response Desire to leave the situation or
party/ avoidant behavior to
cope
“ Um..I would just feel
awkward and feel like I wanna
leave..”
Confrontation Desire Desire to confront perpetrators “Um, But I feel like I would
confront them at that point if I
could like guarantee that they
were talking about me”

Exploring Minority-Stress and Alcohol Use 68
Appendix B. Control ATSS Scenario Script
Segment 1
Narrator: You arrive at a party that your friend invited
you to. It is a birthday party for her boyfriend. You
were hesitant to come because you don’t know him that
well, but your friend insisted that you have to stay at
least until cake is served. You agreed to that before you
came. There are a lot of people and it’s very crowded.
You recognize some people, but there are a lot of people
that you don’t know at all.
Segment 2
Narrator: You get in line to get a drink. The line is
very long. You make eye contact with an acquaintance you
recognize from high school. She smiles briefly and then
quickly looks away. You see her face her group of friends
and they continue talking. You can overhear them
gossiping in the line.
Girl 1: Really? That’s so crazy they are still together!
Narrator: You then see other members of the group quickly
shush them.
Segment 3
Narrator: The group continues to chuckle and chat amongst
themselves. You hope the line will move along more
quickly soon, and don’t want to lose your spot.
Segment 4
Narrator: The conversation is more audible now. You hear
your friend from high school continue on.
Girl 1: Oh my god guys! I’m not saying I think they
should break up, just that if that was me I wouldn’t stay

Exploring Minority-Stress and Alcohol Use 69
in that relationship.
Segment 5
Narrator: At this point, you turn away so that they won’t
think you are listening. The music gets louder. As the
noise fades again, you make out another member of the
group say:
Guy 1: Yeah I mean, I feel that. I can’t judge or
anything, but that’s messed up.
Girl 2: Yeah like? Honestly I’m kind of uncomfortable
being here, I don’t even know why they invited me.
Segment 6
Narrator: They continue talking and the music gets louder
again..
Segment 7
Narrator: You hear more members of the group continue:
Guy 2: It’s not even like she couldn’t do better.
Girl 2: [in a frustrated tone] How can you be the judge
of that? Maybe he’s a great guy and you just don’t know
him.
Segment 8
Narrator: You continue to hear the group going on.
The line for drinks isn’t moving at all.
Guy 1: Let’s not get too worked up about this we don’t
really know all the facts.
Girl 1: [loudly] Don’t tell me that I’m worked up!

Exploring Minority-Stress and Alcohol Use 70
Segment 9
Narrator: You glance over and unintentionally make eye
contact with one of the girls in the group as the
conversation is escalating. She gives you a glaring look
and turns back to her friends.
Girl 2: and now everyone can hear us, I’m so over this.
Narrator: You catch the eye of your friend and her
boyfriend across the room and decide to walk over
there.

Exploring Minority-Stress and Alcohol Use 71
Appendix C. She Pronoun Experimental ATSS Scenario Script
Segment 1
Narrator: You’re still at the same birthday party. Cake
hasn’t been served yet, and you still haven’t gotten a
drink. Your friend and her boyfriend go to get you a
drink from upstairs, and tell you to wait for them. You
stand in a huddle with their friends.
Segment 2
Narrator: You look around and unintentionally make eye
contact with one of the girls from the group you heard
gossiping earlier. They are standing by the pool table.
You see her face her friends and notice him leaning in
close and whispering. You then hear laughter and pieces
of the conversation.
Girl 1: Really? Her? Wow, I never would have pictured her
with another girl. That’s so crazy!
Narrator: You then see other members of the group quickly
shush her.
Segment 3
Narrator: They are drunk, and likely do not realize that
you are within earshot. They continue to chuckle and chat
amongst themselves. You notice your former friend make
eye contact with you again and then turn back to the
group. You turn to the people you are standing with who
begin to notice that you keep looking in that direction.
They do not say anything and continue chatting. You turn
back to face the other group.
Segment 4

Exploring Minority-Stress and Alcohol Use 72
Narrator: It then appears that your former friend is
going to approach you. You see her hesitate and turn to
her friends for approval, before there is another
outburst of laughter and they push her in your direction.
Your former friend stumbles forward before immediately
turning around and returning back to his friends. You
hear her say:
Girl 1: [laughing] Oh my god guys, stoooppppp! I’m not
going to go and talk to her. Like, ugh, she might think
I’m hitting on her or something! Come on, don't make me
do that.
Segment 5
Narrator: At this point, you turn away so that they won’t
think you are listening. You hear the group continue to
chat and chuckle, but it’s unclear what they’re saying.
As the noise fades again, you then make out another
member of the group say:
Girl 2: Yeah I mean, I feel that. I totally always felt
like she had a crush on me in high school. The fact that
we were in the locker room together all the time? SO
creepy.
Girl 1: So true! No offense but isn’t it kind of weird
they just let those people in the locker room when they
could be looking at us? I seriously had no idea she was
into that.
Segment 6
Narrator: They continue laughing and talking and the
music gets louder again. You notice that your friends
must be hearing what they’re saying as well, even from
this distance. Still, none of them take any action.
Segment 7

Exploring Minority-Stress and Alcohol Use 73
Narrator: You hear more members of the group continue:
Guy 1: It’s not even like she's even that bad looking?
She could totally get a boyfriend if she tried.
Guy 2: Yeah, totally a waste...you feel me?
Segment 8
Narrator: You continue to hear the group going on about
you:
Girl 1: I just don’t get it, personally, it’s not for me.
It’s like choosing where to eat.
Girl 2: Totally! Like I don’t really know why she would
choose to be attracted to that. Definitely not for me.
Segment 9
Narrator: You glance over and see some of the group
members begin to put their jackets on. It looks like
they’re going to leave. As they begin to walk outside,
you hear pieces of their conversation continue.
Guy 2: I mean maybe I should have guessed? Did you see
her outfit?? She TOTALLY looks the part.
Guy 1: Bro, you’re so right. Even if you make that
lifestyle choice, at least try to look more feminine.
Girl 1: Yeah, let’s go outside… sorry, not to be a jerk
but I’m just kind of uncomfortable around those kinds of
people.
Narrator: They exit the party.

Exploring Minority-Stress and Alcohol Use 74
Now, we are going to do the same activity again. If you
would like the instructions to be reviewed again do you,
you can say that now. Otherwise, tell me when you are
ready to move forward. If you have any questions, you may
ask them now or at any time.

Exploring Minority-Stress and Alcohol Use 75
Appendix D. He Pronoun Experimental ATSS Scenario Script
Segment 1
Narrator: You’re still at the same birthday party. Cake
hasn’t been served yet, and you still haven’t gotten a
drink. Your friend and her boyfriend go to get you a
drink from upstairs, and tell you to wait for them. You
stand in a huddle with their friends.
Segment 2
Narrator: You look around and unintentionally make eye
contact with one of the guys from the group you heard
gossiping earlier. They are standing by the pool table.
You see him face his friends and notice him leaning in
close and whispering. You then hear laughter and pieces
of the conversation.
Guy 1: Really? Him? Wow, I never would have pictured him
with another guy. That’s so crazy!
Narrator: You then see other members of the group quickly
shush him.
Segment 3
Narrator: They are drunk, and likely do not realize that
you are within earshot. They continue to chuckle and chat

Exploring Minority-Stress and Alcohol Use 76
amongst themselves. You notice your former friend make
eye contact with you again and then turn back to the
group. You turn to the people you are standing with who
begin to notice that you keep looking in that direction.
They do not say anything and continue chatting. You turn
back to face the other group.
Segment 4
Narrator: It then appears that your former friend is
going to approach you. You see him look at you, hesitate
and turn to his friends for approval, before there is
another outburst of laughter and they push him in your
direction. Your former friend stumbles forward before
immediately turning around and returning back to his
friends. You hear him say:
Guy 1: [laughing] Oh my god guys, stoooppppp! I’m not
going to go and talk to him. Like, ugh, he might think
I’m hitting on him or something! Come on, don't make me
do that.
Segment 5
Narrator: At this point, you turn away so that they won’t
think you are listening. You hear the group continue to
chat and laugh, but it’s unclear what they’re saying. As
the noise fades again, you then make out another member
of the group say:
Guy 2: Yeah I mean, I feel that. I totally always felt
like he had a crush on me in high school. The fact that

Exploring Minority-Stress and Alcohol Use 77
we were in the locker room together all the time? SO
creepy.
Guy 1: So true! No offense but isn’t it kind of weird
they just let those people in the locker room when they
could be looking at us? I seriously had no idea he was
into that.
Segment 6
Narrator: They continue laughing and talking and the
music gets louder again. You notice that your friends
must be hearing what they’re saying as well, even from
this distance. Still, none of them take any action.
Segment 7
Narrator: You hear more members of the group continue:
Girl 1: It’s not even like he's even that bad looking? He
could totally get a girlfriend if he tried.
Girl 2: Yeah, totally a waste...you feel me?
Segment 8
Narrator: You continue to hear the group going on about
you:

Exploring Minority-Stress and Alcohol Use 78
Guy 1: I just don’t get it, personally, it’s not for me.
It’s like choosing where to eat.
Guy 2: Totally! Like I don’t really know why they would
choose to be attracted to that. Definitely not for me.
Segment 9
Narrator: You glance over and see some of the group
members begin to put their jackets on. It looks like
they’re going to leave. As they begin to walk outside,
you hear pieces of their conversation continue.
Girl 1: I mean maybe I should have guessed? Did you see
his outfit?? He TOTALLY looks the part.
Guy 1: Bro, you’re so right. Even if you make that
lifestyle choice, at least try to look more masculine.
Guy 2: Yeah, let’s go outside… sorry, not to be a jerk
but I’m just kind of uncomfortable around those kinds of
people.
Narrator: they exit the party.

Exploring Minority-Stress and Alcohol Use 79

Abstract (if available)

Abstract Sexual minority individuals are at an elevated risk for mental health and substance use problems. Limited research has examined how these experiences relate to alcohol use problems in-the-moment. Moreover, assessing minority-stress in real-time under naturalistic conditions can pose methodological difficulties. As such, the present study sought to expand upon prior research by using the Articulated Thoughts in Simulated Situations (ATSS) paradigm to describe sexual minority identified participants’ reactions to an anti-gay microaggression scenario. A novel method of administering ATSS virtually with the goal of streamlining administration and reducing researcher burden was piloted. Participants (N = 34) expressed anger, anxiety, avoidance, alcohol coping motives, and identity-related stress in response to the novel ATSS microaggression scenario. Participants reported finding the scenario realistic (48% yes; 48% maybe; 4% no), and offered feedback to improve the content, accessibility, and methodology. In addition, daily diary monitoring (once per day) was used to assess the frequency of sexual orientation microaggressions in the participants’ daily lives. Compliance was high, (95%) but microaggressions occurred infrequently (2). This research expands knowledge of the negative affect regulation model of problem alcohol use and furthers our understanding of why non-heterosexual individuals may drink to cope with discrimination in-the-moment. Moreover, this study demonstrates the feasibility and acceptability of a novel method of ATSS administration in terms of both the content and methodology and offers a proof-of-concept for ATSS administration that reduces researcher burden. These findings can inform future research that assesses these constructs across diverse samples and contexts.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Assessing therapeutic change mechanisms in motivational interviewing using the articulated thoughts in simulated situations paradigm

PDF

Measuring narcissistic cognitions in response to relationship threat using articulated thoughts in simulated situations

PDF

A longitudinal study of sexual minority stress and behavioral health in sexual minority adolescents

PDF

In-flight turbulence: an articulated thoughts in simulated situations (ATSS) paradigm investigation of air travelers ' experiences

PDF

Personalized normative feedback applied to undergraduates with problem drinking: a comparison with psychoeducation and an examination of cognitive-affective change mechanisms via the articulated ...

PDF

Minority stress and intersectionality: how are identity, discrimination, and biological stress related to depression and suicidality among multiple minority subgroups?

PDF

Complicated relationships: the prevalence and correlates of sexual assault, dating violence victimization, and minority stress among sexual minority adolescents throughout the United States

PDF

Memory, gender, and rumination in depression: recall of simulated situations with articulated thoughts and the Rivermead behavioral memory test

PDF

Examining the effects of personalized feedback about ALDH2*2, alcohol use, and associated health risks on drinking intentions and consumption: the role of self-efficacy and perceived threat

PDF

Age differences in jealousy: an ATSS examination of the role of attributions in the emotional reactions of older and younger adults in relationship-threatening situations

PDF

Reacting to the negative consequences of your decisions: an ATSS comparison of cognitive and affective reactions in older versus younger adults

PDF

Substance use disparities in adolescents of lower socioeconomic status: emerging trends in electronic cigarettes, alternative tobacco products, marijuana, and prescription drug use

PDF

Transgender patients’ perceptions of healthcare: A study of gender minority stress and resilience factors in predicting healthcare behavioral intentions

PDF

Breaking it down to make it stronger: examining the role of source credibility and reference group specificity in the influence of personalized normative feedback on perceived alcohol use norms a...

PDF

Friendship network position on adolescent behaviors: an examination of a broker position and the likelihood of alcohol and cigarette use

Asset Metadata

Creator Walden, Kyla-Rose (author)

Core Title Exploring experiences of minority-stress and alcohol use among sexual minorities using articulated thoughts in simulated situations: a proof of concept study

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Degree Conferral Date 2023-12

Publication Date 11/03/2023

Defense Date 04/28/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag alcohol use problems,articulated thoughts in simulated situations,bisexual,Gay,lesbian,minority-stress

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Luczak, Susan E. (committee chair), Davison, Gerald C. (committee member), John, Richard (committee member)

Creator Email itiskyla@gmail.com,kylarose@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113763577

Unique identifier UC113763577

Identifier etd-WaldenKyla-12451.pdf (filename)

Legacy Identifier etd-WaldenKyla-12451

Document Type Thesis

Format theses (aat)

Rights Walden, Kyla-Rose

Internet Media Type application/pdf

Type texts

Source 20231107-usctheses-batch-1105 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu