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

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

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Minority Stress and Intersectionality: How are Identity, Discrimination, and Biological Stress
related to Depression and Suicidality Among Multiple Minority Subgroups?
Sylvanna M. Vargas, MA, MPH

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)

August 2021

Copyright (2021) Sylvanna Maria Vargas

ii

Dedication

Para mi abuela Mireya y mi madre Isidra.
For my grandmother Mireya and my mother Isidra.

iii
Acknowledgements
The research described in this dissertation was supported by the Ford Fellowship
Foundation, the American Psychological Foundation/ Council for Graduate Departments of
Psychology, and the University of Southern California Department of Psychology and Graduate
School. I am appreciative to these organizations for providing me financial support, training, and
academic community to develop this dissertation.
I am incredibly grateful to my dissertation committee co-chairs, Drs. Jeanne Miranda and
Stanley Huey and the remaining members of my committee, Drs. Jeremy Goldbach, Richard
John, and Darby Saxbe. Thank you for the many hours of consultation, advice, and helping me
sort out my ramblings related to this project and topic. I am also grateful to the members of my
research lab at USC and my research team at UCLA, in particular the graduate students in my
USC lab(s), and Dr. Bowen Chung, Krystal Griffith, HSS community partners and many other
RADD study team members at UCLA and LSU who have supported me in this research and in
my professional development. I would like to extend my gratitude also to my co-authors on the
manuscripts involved in this dissertation, especially my step-lab sister Vanessa Calderon, Dr.
Luis Parra, Clarence Williams, and my spectacular Research Assistants, Wilmer Rivas, Sinan
Payat, and Roxanne Mistry.
To my research advisors Stan and Jeanne: I feel incredibly fortunate to have been
mentored by you both. I admire you both greatly as scholars and as people. I am infinitely
grateful that you took me under your wing 4 years ago when I was lost, and have guided and
encouraged me so kindly, respectfully, and unwaveringly over that time. Thank you for teaching

iv
me about equity, research, true mentorship, clinical work, and compassion. I hope to look
forward to many more years of collaborations and friendship.
I would like to acknowledge others who have indirectly contributed to this dissertation
through their significant impact on my professional development and thinking: Drs. Andrew
Ryder, Steven López, Joan Asarnow, Roberto Lewis-Fernández, and Jerry Davison. Similarly,
my long-distance intellectual and TCK soulmates, (soon to be Drs.) Aya Williams and Megan
Ramaiya, who are always willing to talk excitedly about my ideas –no matter how variable the
quality-, provide daily encouragement, accountability, distraction, and remind me there is more
to life than work.
Finally, with immense humility I reflect on the many generations of intelligent women in
my family who had to abandon their ambitions of pursuing a degree, due to cultural, financial, or
political barriers. Thank you to my mother and grandmother for showing me what tenacity looks
like, and encouraging me –often counterintuitively- to be hard-headed about my career. Thank
you to my father and my siblings for not fostering overly limiting beliefs and your support along
my career path. I especially appreciated all the jokes about my depreciating salary. Thank you, to
my husband Jordi, for being my biggest cheerleader and shapeshifting supporter –whether it be
encouraging me to (re-)apply to graduate school and reading my essays when I applied from
Costa Rica, moving to another country, sticking it out at your job, cooking, taking me out when I
needed it, encouraging me to take time off, or agreeing that I obviously could not survive a PhD
without two puppies and millions of plants– I would not have done it without you.

Table of Contents

Dedication .............................................................................................................................. ii
Acknowledgements ................................................................................................................ iii
List of Tables ........................................................................................................................ vii
List of Figures ...................................................................................................................... viii
Dissertation Abstract ............................................................................................................. ix
Introduction ........................................................................................................................... 1
Study 1: .................................................................................................................................. 6
Abstract .......................................................................................................................................... 7
Introduction .................................................................................................................................... 8
Methods ........................................................................................................................................ 10
Results .......................................................................................................................................... 12
Discussion ..................................................................................................................................... 14
Conclusion .................................................................................................................................... 18
References ..................................................................................................................................... 20
Study 2 ................................................................................................................................. 31
Abstract ........................................................................................................................................ 33
Introduction .................................................................................................................................. 34
Method .......................................................................................................................................... 38
Results .......................................................................................................................................... 41
Discussion ..................................................................................................................................... 43
References ..................................................................................................................................... 48
Study 3 ................................................................................................................................. 62
Abstract ........................................................................................................................................ 64
Introduction .................................................................................................................................. 65
Method .......................................................................................................................................... 68
Results .......................................................................................................................................... 71
Discussion ..................................................................................................................................... 76
References ..................................................................................................................................... 82
Discussion ............................................................................................................................ 95

vi
Comprehensive References ................................................................................................... 99

vii
List of Tables

STUDY 1
Table 1: Participant Characteristics for Overall Sample and by Sexual Orientation……...25
Table 2: Models reporting clinical depression by sexual orientation in overall sample, controlling
for income……………………………...…………………………………………………..29
Table 3: Stratified multivariate models reporting clinical depression among race by sexual
orientation………………………………………………….…………………………..…..30
STUDY 2
Table 1: Participant demographic characteristics……………………………………….....53
Table 2: Correlation matrix of all model variables with standard errors in parentheses…..55
Table 3: Indices of model fit and suicide risk variance explained…………………………57
Table 4: Structural regression model showing predictors of suicide risk……………….....58
STUDY 3
Table 1: Study Protocol Adaptation…………………………….…….…………………....86
Table 2: Participant characteristics………………………….……………………………..89
Table 3: Rater agreement across themes……………….……………………………….….91
Table 4: Themes Across Study: Facilitators for Participating in a Hair Cortisol Study…...92

viii
List of Figures
STUDY 2
Figure 1: Conceptual model……………………………………………..………………...60
Figure 2: Model showing gender and discrimination interaction and simple slopes…..….61
STUDY 3
Figure 1: Study engagement and recruitment flow chart……….……………………..…..94

ix
Dissertation Abstract
Minority stress theory (MST) suggests that mental health disparities occur partly due to
excess the social stress (e.g., discrimination, victimization) associated with belonging to a
stigmatized minority group. While empirical support exists for MST, less is known about how
MST applies to multiple minority groups, such as sexual minority people of color, or women of
color. While some scholars suggest that multiple minority groups might experience incremental
risk related to minority stress, intersectionality scholars indicate that risks may vary by specific
subgroups. The current three studies use an intersectionality framework to assess the relationship
between depression/suicidality and three concepts implicated in MST: minority identity,
discrimination, and biological stress. In particular, the manuscripts examine: 1) how
intersectional identities are associated with depression; 2) how intersectional characteristics (e.g.,
gender and ethnicity) contribute to the relationship between minority stressors and suicide risk;
and 3) how to engage understudied, intersectional groups in biological stress research. Results
from the studies indicate that minority stress may confer different mental health risks across
intersectional groups. In combination, these studies support intersectionality frameworks, by
suggesting that subgroups, and their mental health risk, should be examined separately. More
research is needed to continue extending components of the MST examining diverse
intersectional groups.

1
Introduction
Minority stress theory (MST) posits that belonging to a stigmatized minority group
exposes people to chronic social stress associated with marginalization (e.g., interpersonal
discrimination, internalized stigma), which contributes to poor health (Meyer, 2003). The theory
was developed to provide an explanation for health disparities among sexual minority (SM)
groups, but its application to people of color (POC), particularly SM-POC, has not been well
studied. Extensions of MST include research on the added burden of holding multiple
marginalized identities (Meyer, Schwartz, & Frost, 2008), suggesting that multiply marginalized
individuals, such as SGM-POC, may experience more discrimination and consequently worse
health than singly marginalized persons. However, few empirical studies have examined how
MST can be applied to multiply marginalized groups (Meyer, Schwartz, & Frost, 2008).
MST relies on three key concepts that come together to impact mental health (Meyer,
2003). First, MST highlights minority status. The theory provides an explanation for mental
health disparities among SM people, first pointing to the relationship between minority status
and mental health problems. Second, MST emphasizes the role of minority stress experiences,
such as interpersonal discrimination, in contributing to health disparities. The theory suggests
that belonging to a marginalized minority status exposes people to social stressors such as stigma
and prejudice, which are collectively referred to as minority stress. MST proposes minority stress
is related to mental health problems. For example, MST suggests that SM persons are exposed to
stigma associated with being a SM, such as heterosexism and other experiences, and this
minority stress explains why higher rates of mental health problems exist among SM groups.
Finally, MST relies on a stress-health pathway, emphasizing the role of biological stress. The

2
theory provides that minority stress is a type of chronic stress. Chronic stress is known to affect
allostatic load and wear-and-tear in the body, which ultimately negatively impacts mental health
(Saxbe, 2008; Sapolsky, Romero, & Munck, 2000). This chronic, biological minority stress that
minority groups endure is therefore believed to account for disparities in mental health problems.
Therefore, three core concepts to understanding mental health disparities emerge from MST:
minority status, experiences of minority stress (e.g., interpersonal discrimination), and biological
stress.
The existing literature provides mixed empirical support for the MST model (Meyer,
Schwartz, & Frost, 2008). This may in part be due to the limited attention to intersecting
identities that individuals hold. For example, a study relying on an SM sample to test MST may
under-attend to other minority identities including race, gender, and SES background. Studies
show that holding multiple marginalized identities is associated with experiencing more and
multiple kinds of discrimination (e.g., racism and heterosexism; Grollman, 2012), and this in turn
is associated with worse mental health (Vargas, Huey, & Miranda, 2020). Therefore, multiple
minority statuses may be relevant to testing and refining MST. Studying multiple minority
groups may clarify understanding of how status exposes people to minority stressors, how
minority stressors may differently impact mental health, and how multiple minority stressors
contribute to biological stress. In sum, attention to multiple minority statuses in refining MST is
warranted.
Given that MST relies on explanations about minority status and stress, one way to
extend the theory towards multiple minority groups is to suggest that each minority status
confers incremental exposure to stress (Cyrus, 2017). This extension is applied to the three
components of MST described above. In relation to the first of the three components of MST,

3
this would suggest that the more disadvantaged statuses a person has, the worse their mental
health (Meyer, Schwartz, & Frost, 2008). In terms of minority stress, multiple minorities may
experience more kinds and greater frequency of minority stressors (Grollman, 2012), or a larger
effect on mental health than individuals holding a single minority identity (Vargas, Huey, &
Miranda, 2020). This would indicate that multiple minorities therefore experience greater
biological stress as a result of these numerous minority stressors. While some studies have begun
to examine these issues, several conceptual issues remain. These primarily center around the
question of whether diverse minority statuses all confer the same degree of risk and exposure to
minority stressors.
Intersectionality scholars warn against assuming that all minority statuses contribute
equally to stress and resilience (Bowleg, 2008). Given that minority status and experiences are
directly impacted by historical and structural oppression, diverse minority groups are
differentially affected by factors that contribute risk and resilience. Furthermore, intersectionality
scholars indicate that intersectional minority statuses cannot be separated from one another –
pointing to the impossibility of deconstructing Black women’s experiences as a simple
combination of “women’s” and “Blacks’” experiences. Instead, intersectionality frameworks
propose that subgroup experiences may be partly a combination of multiple categories (i.e.,
shared experiences related to being Black and to being a woman), along with unique experiences
that cannot be summed up by separate, ambiguous categories (i.e., unique experiences to being a
Black woman). Therefore, according to this framework, the relationship between minority
statuses, minority stress, and mental health outcomes may vary by subgroup.
More research is needed to understand how MST can be applied to intersectional groups.
Using an intersectionality framework to evaluate components of MST means examining

4
subgroup differences, rather than relying on differences based on overly-inclusive groups (e.g.,
grouping all sexual minorities together). This approach may allow an opportunity to evaluate and
refine MST.
The current set of studies broadly use an intersectionality framework to assess the three
key MST components highlighted above. Given that MST and intersectionality frameworks have
largely been examined separately, these studies provide an initial opportunity to examine how
these two related models can be integrated and refined. The three studies yielded initial results on
how to integrate intersectional groups to test components of MST among diverse minority
subgroups.
Manuscript 1: Intersectional Identities and Depression
Study 1: “Depression at the Intersection of Race/Ethnicity, Sexual Minority, and Low-
Income Status” examines the first component of MST. The study focuses on differences in
depression based on intersectional minority identities. The study sample is comprised of low-
income, racially diverse and predominantly SGM subgroups. Although some studies have
compared rates of depression among SGM-POC vs. SGM Whites, the existing evidence is
mixed. Some work suggests these mixed results are due to variable methodologies across studies
examining within vs. between group differences. The current study therefore compares
differences in depression based on racial minority subgroups (e.g., Black, Hispanic, White,
Other) in combination with sexual minority subgroups (e.g., Gay/lesbian, heterosexual, bisexual,
queer and questioning). This paper was currently under peer review.
Manuscript 2: Discrimination, Depression and Suicide Risk among Intersectional Groups
Study 2: “Worse for Girls?: Gender Differences in Discrimination as a Predictor of
Suicide Risk among Latinx Youth” examines the second component of MST. The study explores

5
intersectional differences in the relationship between discrimination (i.e., minority stressor) and
suicide risk among Latinx youth, by examining gender as a moderator. While research has
examined gender differences in suicidality, few studies have explored differences in how
minority stress confers risk using an intersectional framework. This paper was accepted by the
Journal of Adolescence.
Manuscript 3: Engaging Intersectional Groups in Biological Stress Studies
Study 3: “Using Community-Based Partnerships to Engage Sexual and Gender Minority
People of Color in a Hair Cortisol Study” describes different methods used to engage a sample of
low-income, racially diverse, predominantly SGM adults in a biomarker study aimed at
examining the relationship between discrimination, stress, and depression. Intersectional SGM-
POC are underrepresented in biomarker research, and POC in general are less likely to
participate in research involving biological samples. The current study therefore reports different
strategies employed to engage individuals in a biomarker study. Additionally, the current study
conducted qualitative interviews to examine participants’ motivators for and barriers to
providing biomarker samples. This paper is currently under peer review.

6
Study 1: Depression at the Intersection of Race/Ethnicity, Sexual Minority, and Low-Income
Status

Sylvanna M. Vargas, MA, MPH ,
1,2
Olivia K. Sugarman, MPH,
3,4
Lingqi Tang, PhD,
2
Jeanne
Miranda, PhD,
2,5
& Bowen Chung, MD
2,6

1
Departments of Psychology and Preventive Medicine, University of Southern California, Los
Angeles, California
2
Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and
Human Behavior, University of California, Los Angeles, Los Angeles, California

3
Center for Healthcare Value and Equity and Section of Community and Population Medicine,
Department of Internal Medicine, LSU Health Sciences Center – New Orleans, New Orleans,
Louisiana
4
Department of Behavioral and Community Health Sciences, School of Public Health, LSU
Health Sciences Center – New Orleans, New Orleans, Louisiana
5
Department of Health Policy and Management, Fielding School of Public Health, University of
California, Los Angeles, Los Angeles, California
6
Los Angeles County Department of Mental Health, Harbor-UCLA Medical Center, Los
Angeles, California

Corresponding author: Sylvanna M. Vargas, MA, MPH; Departments of Psychology and
Preventive Medicine, University of Southern California; Department of Psychiatry and
Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of
California, Los Angeles; Postal address: 10920 Wilshire Blvd., Suite 300, Los Angeles, CA,
USA 90024; Email: sylvannv@usc.edu; Phone: 305-761-4632

7
Abstract
Purpose: The current study uses an intersectional framework to examine subgroup differences in
the prevalence of depression among a community sample of predominantly low-income,
racial/ethnic and sexual minority adults. Methods: Between May 2017-June 2018, participants
(N=1753) were recruited from and screened for depression in community organizations that
serve sexual minority clients based in Los Angeles, California and New Orleans, Louisiana.
Results: Twenty-six percent of people screened for study eligibility met criteria for depression
(Patient Health Questionnaire-8≥10). As is true in higher-resourced populations, bisexual (Odds
Ratio; OR: 1.50; 95% Confidence Interval; CI: 1.08, 2.09) and queer/questioning (OR: 1.86;
95% CI: 1.08, 3.19) individuals were more likely to be depressed than heterosexual and lesbian/
gay individuals. These differences remained even when accounting for income. No differences in
depression were observed between lesbian/gay and heterosexual adults. In terms of racial
differences, bisexual Black (OR: .47; 95% CI: .22, 1.03) and Hispanic (OR: .51; 95% CI: .23,
1.12) adults were marginally less likely to be depressed than bisexual White adults. No racial
differences emerged across other sexual orientations. Conclusion: Rates of depression may be
higher among low-income, racial/ethnic sexual minority adults than in the general population.
Further, differences across some sexual minority subgroups may be race-specific, suggesting that
intersectional frameworks may be the best way to understand how multiple marginalization
affects different subgroups.
Keywords: Bisexuality, depression, intersectionality, racial/ ethnic minorities, sexual
minority

8
Introduction
Depressive symptoms and disorders are common health conditions. Studies of the general
U.S. population estimate that the prevalence rate of current depression is 8.6% to 9.2% among
adults.
1,2
Sexual minority (SM) adults, including those who identify as lesbian, gay, bisexual,
queer or questioning, are more likely than heterosexual people to be depressed currently,
3,4
in the
past year, or in their lifetimes. Rates of past depression among SM adults are up to two times
higher than their heterosexual counterparts.
5
Studies that disaggregate sexual minorities show
that bisexual people experience the greatest risk of current, past year, and lifetime depression.
6,7

For example, a 2018 meta-analysis suggested that bisexuals are 40% more likely to exhibit
current depression than lesbian and gay, and 138% more likely than heterosexual adults.
7

However, it is unclear to what extent income contributes to these differences, since bisexual
persons generally have lower-incomes than lesbian and gay people,
7
and prior work has shown
that bisexual vs. lesbian/gay differences in physical health are largely accounted for by
socioeconomic status.
8
Studies examining other sexual orientation identities, such as questioning
adults, have yielded mixed results about their depression rates, and less is known about
individuals who identify as queer.
6
Very little is known about low-income SM adults, despite
evidence that rates of current depression among those with low-incomes are higher,
9,10
with
some studies reporting prevalence estimates from 11%
11,12
to 15.8%.
13

The minority stress theory (MST) provides a conceptual framework for the disparity in
depression risk among SM groups.
14
This theory proposes that minorities experience unique
social stressors such as prejudice and stigma, leading to greater mental health burden. Extensions
of the minority stress theory and the intersectionality framework suggest that individuals who
experience social stress related to multiple marginalized statuses, such as SM adults who are also

9
racial/ethnic minorities, may be at even greater risk for mental health problems
15
and are an
important understudied group.
16
Consistent with the minority stress theory, initial work shows
that multiple discrimination (e.g., heterosexism and racism) is associated with worse
depression
17
than is one-dimensional discrimination. Yet studies examining the rates of
depression among sexual and racial/ethnic minority adults show mixed results.
18

Contrary to MST, racial/ethnic minority, particularly Black and Latinx, adults show
lower or similar lifetime, past year, and current rates of depression as do White persons.
19,20

Studies examining depression rates among racial/ethnic minority people who are also SM have
yielded mixed findings, with some producing evidence in favor of
18
or against
21–23
heightened
rates of depression among this group. However, most of these studies assessed depression in the
past year or lifetime. Few studies appear to measure the prevalence of current depression among
racial/ethnic SM adults, including subgroup differences between gay/lesbian, bisexual, and
queer/questioning individuals. Finally, very little is known about how income contributes to
these patterns, despite racial/ethnic minority and bisexual individuals generally having lower
incomes.
7
In sum, more research is needed to understand how depression affects lesbian, gay,
bisexual, and queer racial/ethnic minority communities, particularly among low-income samples.
The Resilience Against Depression Disparities (RADD) study is a community-partnered
participatory research study that assessed the rates of depression among predominantly low-
income, racial/ ethnic SM adults. Our study had two aims: 1) examine rates of depression by
sexual orientation among a low-income, diverse sample; 2) examine racial differences in rates of
depression within subgroups based on the sexual orientation of low-income adults.

10
Methods
Between May 2017 and June 2018, 2080 clients were approached and 1787 English- or
Spanish- speaking adults (18 years and above) provided written consent to participate in a brief
screening to determine eligibility for the RADD clinical trial (NCT02986126), for which
recruitment strategy and study procedures are described elsewhere.
24
. Of 1787 who agreed to
participate, 1753 completed the screening. The RADD study was an intervention using
community health workers to deliver cognitive behavioral therapy skills to improve depressive
symptoms among low-income, sexual and gender minority (SGM) and racial/ethnic minority
adults. The current study focuses only on differences in depression in our sample based on self-
reported sexual orientation.
For the RADD study, we did not create any inclusion/exclusion criteria around self-
reported sexual orientation, gender identity, or racial/ ethnic identity. We did this to allow
participants who may not be comfortable identifying publicly as SGM
18
to self-select into the
study and not have to publicly disclose their status during the study screening. To ensure that we
enrolled SGM individuals, we purposely recruited from 26 organizations that serve
predominantly low-income, racial/ethnic SGM adults. Organizations were identified by asking
community partners where members of the community sought support for emotional distress.
These included healthcare organizations (primary care, mental health, and alcohol/ substance
abuse programs), community-based agencies (faith-based, homeless-serving, and those providing
advocacy or social services), and other community-trusted locations (LGBTQ-friendly bars,
gyms) in Los Angeles, CA and New Orleans, LA.
During screening, participants were asked to report the following: sex assigned at birth,
current gender identity, US-born status, race/ ethnicity (re-coded into Black/ African American,

11
Hispanic, White, and Other), sexual orientation (heterosexual/ straight, lesbian/gay/homosexual,
bisexual, or queer/questioning), language spoken, highest level of education, current marital
status, number of children, current health insurance coverage, employment status, current living
situation, income related to work, number of people supported by income, current assistance
from government program, general self-rated health, depression symptoms, and past diagnosis of
schizophrenia. Depressive symptoms were measured using the 8-item Patient Health
Questionnaire (PHQ-8).
1
Participants who scored a 10 or higher were considered depressed. The
RADD study was reviewed and approved by the Institutional Review Board at UCLA, with
reliance agreements and local reviews by partnering institutions.
Data Analyses
We conducted univariate analyses to describe the sample and bivariate analyses to
compare self-reported sexual orientation (heterosexual/ straight, lesbian/gay/homosexual,
bisexual, or queer/questioning) for social demographics factors and clinical characteristics. We
present means with standard deviation for continuous variables and percentage for categories
variables. Chi-square tests were used to analyze differences in categorical variables, and one-way
analysis of variance for continuous variables. Logistic regressions were utilized to analyze the
impact of sexual orientation on depression for overall sample controlling for income. Racial
effects (Hispanic, Black/ African American, White/ Caucasian) on depression were stratified by
sexual orientation group using exact logistic regressions. For missing data, we used an extended
hot-deck multiple imputation based on the predictive mean matching method.
25,26
We used five
imputed data sets, averaged results and adjusted standard errors for uncertainty due to
imputation.
27,28
The rates of missing data among the 21 variables we collected were: <5% (14

12
variables), <10% (3 variables), 18-27% (4 variables). Analyses were conducted using SAS
software version 9.4.
Results
Participants’ demographic characteristics are reported in Table 1. Results are provided for
the overall sample and by sexual orientation. A majority of participants identified as gay, lesbian,
or homosexual (LG; 43.0%) or straight/ heterosexual (40.8%), with the remainder identifying as
bisexual (12.5%) or queer/questioning (3.7%). Participants in our sample were on average 40.7
years of age. A majority (73.4%) were assigned male sex at birth, and identified as men (68.7%),
while 25.5% identified as women, 1.5% as transgender men, 2.1% as transgender women, and
2.2% are genderqueer or gender non-conforming. Participants identified as Hispanic (39.3%),
Black or African American (27.8%), White/ Caucasian (25.2%), or another race (7.7%). As
anticipated, participants in our sample were predominantly low-income and many lived below
the poverty line, with 35.2% reporting an annual household income of $10,000 or less.
Participants reported a range of levels of education, with approximately 19.0% completing less
than a high school degree. Nearly half were unemployed (28.2% not looking for work, 17.9%
looking for work). Half of participants lived in a rented unit (52.7%). A majority (60.6%) were
single and never married. Approximately a third (32.5%) described their health as good. Finally,
twenty-six percent of participants in our total sample met criteria for current depression (PHQ-8
≥ 10).
We examined whether differences across demographics existed based on sexual
orientation (Table 1). Differences emerged in most demographic characteristics, except for
language, health insurance coverage, and general self-rated health. Overall, 26% of heterosexual-
and 22.2% of LG people were depressed, whereas 34.6% of bisexual- and 39.4% of

13
queer/questioning- identifying people were depressed. Our results showed that even among a
low-income sample, income differences emerged across sexual orientation groups. Given our
conceptual interest in income, we included this in future models.
We then examined rates of depression by sexual orientation in our low-income sample
(Table 2). To do this, we first compared rates of depression across sexual orientation groups in
our overall sample. We compared rates of depression by running separate models with
straight/heterosexual adults (Model 1), and LG individuals (Model 2) as the reference group.
Results from Model 1 show that in comparison to straight/ heterosexual adults, bisexual
individuals were 50% (Odds Ratio; OR=1.50, 95% Confidence Interval; CI 1.08-2.09) and
queer/questioning adults were 86% (OR=1.86, 95% CI 1.08-3.19) more likely to be depressed.
There were no significant differences between heterosexual and LG adults. In Model 2, we found
that in comparison to LG adults, bisexual individuals were 89% (OR=1.89, 95% CI 1.33-2.59)
and queer/ questioning were 129% (OR=2.29, 95% CI 1.33-3.93) more likely to be depressed.
These findings indicate that bisexual and queer/questioning individuals exhibited heighted rates
of depression in comparison to both heterosexual/ straight and LG individuals, but no differences
between straight/ heterosexual and LG persons.
Since our overall bivariate findings showed that people with lower income were more
likely to be depressed, we examined whether differences in rates of depression across SM
participants were accounted for by income. When controlling for income, bisexual and
queer/questioning individuals exhibited greater odds of depression when compared to
straight/heterosexual (Model 3; bisexual: OR=1.59, 95% CI 1.14-2.21; queer: OR=2.04, 95% CI
1.17-3.55) and LG (Model 4; bisexual: OR=1.72, 95% CI 1.22-2.42; queer: OR=2.21, 95% CI
1.27-3.85) adults. These findings suggest that even when accounting for differences in income

14
among a low-income sample, bisexual and queer/questioning individuals are at heightened risk
for depression.
Next, we examined whether racial differences existed in depression rates within sexual
orientation subgroups. To do this, we compared differences based on race for each sexual
orientation group (Table 3). Among heterosexual participants, we found no differences in odds
of depression among Hispanic or Black in comparison to White individuals (Model 1). These
findings remained even when accounting for income, which was a significant predictor of
depression (Model 2). A similar finding emerged among LG (Models 3 and 4), and
queer/questioning individuals (Models 7 and 8). However, a marginal racial difference was
found among bisexual persons. When controlling for income, bisexual Black were 53%
(OR=0.47, 95% CI 0.22-1.03) and bisexual Hispanic were 49% (OR=0.51, 95% CI 0.23-1.12)
less likely to be depressed than bisexual White participants (Model 6). This indicates that, in
comparison to other bisexual racial groups and when accounting for differences in income,
bisexual White adults may be at greatest risk for depression.
Discussion
Our study compared the rates of depression among a diverse sample of predominantly
low-income, racial/ethnic SM community adults. Twenty-six percent of our sample met criteria
for current depression, a vastly higher rate than the 8.6-9.2% prevalence rate of current
depression in the general population and 11-15.8% among low-income populations.
Furthermore, our results showed that even within our low-income sample, those with lower
income were more likely to be depressed. We found that overall, there were no differences in
depression among heterosexual and LG individuals. However, bisexual and queer individuals
had higher rates of depression when compared to heterosexual and LG persons. These findings

15
remained when we accounted for differences in income, suggesting that in our low-income
sample, elevated rates of depression among bisexual in comparison to LG, or heterosexual
persons cannot be attributed to differences in income. Furthermore, we found initial evidence
suggesting that bisexual ethnic/racial minority adults may be protected against depression, in
comparison to bisexual White individuals.
Ours is the first study we know of that has examined rates of current depression in a
community sample of low-income, ethnically/racially diverse SM subgroups. Over a quarter of
our participants met criteria for depression. This rate is higher than those found in prior studies
of low-income samples, and in prior studies showing heightened depression among SM persons.
Our study screened participants in settings where they were likely to be seeking support, which
possibly contributed to the heightened rates of depression. A past study conducted by our
research team screened low-income ethnic/racial minority individuals for depression in similar
kinds of organizations, and yielded comparable rates.
29
This study did not assess sexual
orientation, so it is impossible to compare the two study samples. Nevertheless, the high rate of
depression in our sample may reflect that our participants overall were likely very socially
marginalized.
Our results expand on the well-documented finding that bisexual groups exhibit higher
rates of depression than LG and heterosexual persons,
7
given our focus on a low-income
population. Prior scholars have indicated it is unclear to what extent this finding may be, at least
in part, related to income disparities characterized by lower income among bisexual individuals.
7

Although we are unable to answer whether income contributes to depression differences among
SM persons in the general population, our findings indicate that income alone does not explain
heightened rates of depression among low-income bisexual and queer/questioning individuals.

16
Even when accounting for differences in income, bisexual and queer/questioning individuals
were more likely to be depressed than LG or heterosexual persons in our low-income sample.
Some work has suggested that heightened rates of depression may be related to compounded
discrimination and marginalization of bisexual and non-conforming people from both
heterosexual and LG communities.
7
Future work should examine mechanisms contributing to
this disparity.
Our data surprisingly suggests that among a low-income, racially/ ethnically diverse
sample, LG individuals were not more likely to be depressed than heterosexual persons. In the
general population, it is well documented that LG adults have higher rates of depression.
7
It is
not clear why this was not the case in our sample of racially/ethnically diverse adults. One
possibility may be that racial/ethnic minority status may be protective and confer resilience
towards mental health. This interpretation is in line with literature based on the general
population showing that racial/ethnic minority persons may have lower rates of depression than
White individuals, but experience unmet needs due to poorer access to quality care.
19
Some
scholars have suggested that social support around ethnic identity may be partly contributing to
improved mental health.
30–32

Although bisexuals and queer/questioning individuals in our sample did have overall
heightened rates of depression, our follow-up analyses suggest this finding may be driven by
higher rates of depression among Whites. Among our low-income sample, bisexual Black and
Hispanic adults had lower odds of depression than bisexual Whites. To establish whether the
bisexual depression disparity finding is actually unique to bisexual Whites, more studies
examining racial differences among bisexuals are needed. Future research with larger

17
representative samples should examine how rates of depression are patterned among ethnically
diverse bisexual individuals.
Although our data suggests that racial/ethnic minority persons may be protected against
depression in comparison to Whites, depression rates in our overall sample were still very high
compared to population estimates.
1,2
Our data therefore suggests that low-income SM adults
overall had very high rates of depression, with some indication that racial/ethnic SM individuals
may be at lower risk for depression than their White counterparts. Studies should examine
potential protective or resilience factors that contribute to these lower odds of depression among
ethnic/racial SM persons.
Our results elucidate that differences in rates of depression are subtler and more nuanced
across SM subgroups than previously thought, particularly for low-income populations. This
provides support for intersectional frameworks that advocate for examining the health status of
subgroups separately.
16
Our results may also provide the opportunity to examine and refine
existing theories, such as the minority stress theory. Though the minority stress theory suggests
that SM persons experience higher rates of mental health problems like depression, our data
surprisingly suggests that among a low-income, racially/ethnically diverse sample, LG
individuals are not more likely to be depressed than heterosexuals. Our findings underscore the
importance of including racially/ethnically and socioeconomically diverse populations in
research.
Some study limitations should be noted. First, other characteristics which we did not
capture in the screening stage of our study may contribute to these results. For example, some
participants in the heterosexual group may be considered SM. Although variations exist across
all cultural groups, racial/ ethnic sexual minorities may not always self-identify with the lesbian,

18
gay, bisexual, transgender, and queer (LGBTQ) community.
18
In our baseline study assessment,
we discovered that 66% participants reported at least some same-sex sexual behavior, despite
identifying as straight. Since we did not assess sexual behavior in the screener stage, it is not
possible to know how differences in self-identification might impact our results. These factors
may have contributed to the nonsignificant differences between straight and LG individuals in
our sample.
Once we enrolled depressed participants into our study, we also discovered at baseline
that 46% of 225 participants were HIV-positive. HIV status may confer additional
marginalization throughout our sample and increase risk for depression,
33
which could influence
our results. However, we did not assess for HIV status during our study screening stage, so it is
not possible to examine this issue in our data. Similarly, gender may have played a role in our
findings. Prior studies on racial/ethnic SM adults have primarily focused on women.
23
Since our
study was comprised mainly of men, it is unclear how past findings relate to ours. Additionally,
we had too few transgender people in our study to examine transgender subgroups. Larger
sample sizes are needed to be able to examine how gender may contribute to within and across
race/ ethnicity and sexual orientation subgroup differences in depression. Finally, our study
relied on a community sample recruited from LGBTQ-friendly organizations. It is unclear how
depression affects racial/ethnic sexual minority individuals who are not connected to any LGBT
affirming organizations.
Conclusion
Altogether, our results provide initial evidence of how depression affects a vastly
understudied and multiply marginalized population. We use an intersectional lens to examine
subgroup differences in our sample, and ultimately provide initial evidence to help refine SM

19
mental health knowledge and theories. Furthermore, this work helps us begin to understand how
marginalization may affect mental health. In particular, our findings suggest that multiply
marginalized groups may not all be affected in the same way. Studies should continue to
examine how subgroups are affected by depression, and future work should explore potential risk
and protective mechanisms contributing to these subgroup patterns of depression.
Acknowledgments
The authors would like to thank the RADD study participants, RADD Executive Committee,
RADD Community Advisory Board, the County of Los Angeles Department of Mental Health,
and countless others whose involvement were essential to completing this study.
Disclaimer
The statements in this article are solely the responsibility of the authors and do not necessarily
represent the views of PCORI, its Board of Governors or Methodology Committee.
Author Disclosure Statement(s)
No competing financial interests exist.
Funding Information
This study was supported by the Patient-Centered Outcomes Research Institute (PCORI,
www.pcori.org), grant number: PPRND-1507-32173. SMV was supported through a Ford
Foundation Predoctoral Fellowship. JM was partly supported through a Substance Abuse and
Mental Health Services Administration grant (SM080041-01) and a National Institute of Mental
Health grant (P30MH058107-21). BC was also supported by the UCLA Clinical and
Translational Science Institute/ National Center for Advancing Translational Sciences grant
(UL1TR001881). RADD is registered on ClinicalTrials.gov, NCT02986126.

20
References
Bell, R., & McCaffey, D. (2002). Bias reduction in standard errors for linear regression with
multi-stage samples. Survey Methodology, 28(2), 169–182.
Bostwick, W. B., Hughes, T. L., Steffen, A., Veldhuis, C. B., & Wilsnack, S. C. (2019).
Depression and victimization in a community sample of bisexual and lesbian women: An
intersectional approach. Archives of Sexual Behavior, 48(1), 131–141.
https://doi.org/10.1007/s10508-018-1247-y
Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an
important theoretical framework for public health. American Journal of Public Health,
102(7), 1267–1273. https://doi.org/10.2105/AJPH.2012.300750
Brody, D. J., Pratt, L. A., & Hughes, J. (2018). Prevalence of depression among adults aged 20
and over: United States, 2013-2016. NCHS Data Brief, no 303.
Brondolo, E., Brady ver Halen, N., Pencille, M., Beatty, D., & Contrada, R. J. (2009). Coping
with racism: A selective review of the literature and a theoretical and methodological
critique. Journal of Behavioral Medicine, 32(1), 64–88. https://doi.org/10.1007/s10865-
008-9193-0
Centers for Disease Control and Prevention. (2010). Current depression among adults - United
States, 2006-2008. MMWR, 59(38), 1229–1235.
https://www.cdc.gov/mmwr/PDF/wk/mm5938.pdf
Chakraborty, A., McManus, S., Brugha, T. S., Bebbington, P., & King, M. (2011). Mental health
of the non-heterosexual population of England. British Journal of Psychiatry, 198(2), 143–
148. https://doi.org/10.1192/bjp.bp.110.082271
Gorman, B. K., Denney, J. T., Dowdy, H., & Medeiros, R. A. (2015). A new piece of the puzzle:

21
Sexual orientation, gender, and physical health status. Demography, 52(4), 1357–1382.
https://doi.org/10.1007/s13524-015-0406-1
Grant, J. E., Odlaug, B. L., Derbyshire, K., Schreiber, L. R. N., Lust, K., & Christenson, G.
(2014). Mental health and clinical correlates in lesbian, gay, bisexual, and queer young
adults. Journal of American College Health, 62(1), 75–78.
https://doi.org/10.1080/07448481.2013.844697
Institute of Medicine (US) Committee on Lesbian Gay Bisexual and Transgender Health Issues
and Research Gaps and Opportunities. (2011). The Health of Lesbian, Gay, Bisexual, and
Transgender People. National Academies Press. https://doi.org/10.17226/13128
Jeong, Y. M., Veldhuis, C. B., Aranda, F., & Hughes, T. L. (2016). Racial/ethnic differences in
unmet needs for mental health and substance use treatment in a community-based sample of
sexual minority women. Journal of Clinical Nursing, 25(23–24), 3557–3569.
https://doi.org/10.1111/jocn.13477
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., Rush, A. J.,
Walters, E. E., & Wang, P. S. (2003). The epidemiology of major depressive disorder.
JAMA, 289(23), 3095. https://doi.org/10.1001/jama.289.23.3095
King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008).
A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and
bisexual people. BMC Psychiatry, 8(1), 70. https://doi.org/10.1186/1471-244X-8-70
Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H.
(2009). The PHQ-8 as a measure of current depression in the general population. Journal of
Affective Disorders, 114(1–3), 163–173. https://doi.org/10.1016/j.jad.2008.06.026
Little, R. J. A. (1988). Missing-data adjustments in large surveys. Journal of Business and

22
Economic Statistics, 6(3), 287–296. https://doi.org/10.1080/07350015.1988.10509663
Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief Patient Health
Questionnaire Mood Scale (PHQ-9) in the general population. General Hospital Psychiatry,
28(1), 71–77. https://doi.org/10.1016/j.genhosppsych.2005.07.003
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–
697. https://doi.org/10.1037/0033-2909.129.5.674
Meyer, I. H., Dietrich, J., & Schwartz, S. (2008). Lifetime prevalence of mental disorders and
suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of
Public Health, 98(6), 1004–1006. https://doi.org/10.2105/AJPH.2006.096826
Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does
disadvantaged social statuses confer more stress and fewer coping resources? Social Science
& Medicine, 67(3), 368–379. https://doi.org/10.1016/j.socscimed.2008.03.012
Miranda, J., Chung, J. Y., Green, B. L., Krupnick, J., Siddique, J., Revicki, D. A., & Belin, T.
(2003). Treating depression in predominantly low-income young minority women: A
randomized controlled trial. JAMA: Journal of the American Medical Association, 290(1),
57–65. https://doi.org/10.1001/jama.290.1.57 U6 -
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=psyc4
&AN=2003-05836-001 M4 - Citavi
Miranda, J., McGuire, T. G., Williams, D. R., & Wang, P. (2008). Mental health in the context of
health disparities. American Journal of Psychiatry, 165(9), 1102–1108.
https://doi.org/10.1176/appi.ajp.2008.08030333
Miranda, J., Ong, M. K., Jones, L., Chung, B., Dixon, E. L., Tang, L., Gilmore, J., Sherbourne,

23
C., Ngo, V. K., Stockdale, S., Ramos, E., Belin, T. R., & Wells, K. B. (2013). Community-
partnered evaluation of depression services for clients of community-based agencies in
under-resourced communities in Los Angeles. Journal of General Internal Medicine,
28(10), 1279–1287. https://doi.org/10.1007/s11606-013-2480-7
O’Malley, A. S., Forrest, C. B., & Miranda, J. (2003). Primary care attributes and care for
depression among low-income African American women. American Journal of Public
Health, 93(8), 1328–1334. https://doi.org/10.2105/AJPH.93.8.1328
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-
analytic review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059
Plöderl, M., & Tremblay, P. (2015). Mental health of sexual minorities. A systematic review.
International Review of Psychiatry, 27(5), 367–385.
https://doi.org/10.3109/09540261.2015.1083949
Rabkin, J. G. (2008). HIV and depression: 2008 review and update. Current HIV/AIDS Reports,
5(4), 163–171. https://doi.org/10.1007/s11904-008-0025-1
Ross, L. E., Salway, T., Tarasoff, L. A., MacKay, J. M., Hawkins, B. W., & Fehr, C. P. (2018).
Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and
heterosexual individuals: A systematic review and meta-analysis. The Journal of Sex
Research, 55(4–5), 435–456. https://doi.org/10.1080/00224499.2017.1387755
Rubin, D. (1987). Multiple imputation for nonresponse in surveys. John Wiley & Sons.
Schafer, J. (1997). Analysis of Incomplete Multivariate Data. Vol 72: Chapman & Hall/CRC.
Taylor & Francis.
Smith, T. B., & Silva, L. (2011). Ethnic identity and personal well-being of people of color: A
meta-analysis. Journal of Counseling Psychology, 58(1), 42–60.

24
https://doi.org/10.1037/a0021528
Thomas, J. L., Jones, G. N., Scarinci, I. C., Mehan, D. J., & Brantley, P. J. (2001). The utility of
the Ces-D as a depression screening measure among low-income women attending primary
care clinics. The International Journal of Psychiatry in Medicine, 31(1), 25–40.
https://doi.org/10.2190/FUFR-PK9F-6U10-JXRK
Vargas, Sylvanna M., Huey, S. J., & Miranda, J. (2020). A critical review of current evidence on
multiple types of discrimination and mental health. American Journal of Orthopsychiatry,
90(3), 374–390. https://doi.org/10.1037/ort0000441
Vargas, Sylvanna Maria, Wennerstrom, A., Alfaro, N., Belin, T., Griffith, K., Haywood, C.,
Jones, F., Lunn, M. R., Meyers, D., Miranda, J., Obedin-Maliver, J., Pollock, M.,
Sherbourne, C. D., Springgate, B. F., Sugarman, O. K., Rey, E., Williams, C., Williams, P.,
& Chung, B. (2019). Resilience Against Depression Disparities (RADD): A protocol for a
randomised comparative effectiveness trial for depression among predominantly low-
income, racial/ethnic, sexual and gender minorities. BMJ Open, 9(10), e031099.
https://doi.org/10.1136/bmjopen-2019-031099

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31

Study 2: Worse for Girls?: Gender Differences in Discrimination as a Predictor of Suicide Risk
among Latinx Youth

Sylvanna M. Vargas, MA*
Department of Psychology
Department of Preventive Medicine
University of Southern California
Los Angeles, USA

Vanessa Calderon, MA*
Department of Psychology
Department of Preventive Medicine
University of Southern California
Los Angeles, USA

Christopher R. Beam, PhD
Department of Psychology
University of Southern California
Los Angeles, USA

Yolanda Cespedes-Knadle, PhD
Alliant International University

32
California School of Professional Psychology
Los Angeles, CA

Northeast Valley Health Corporation
Los Angeles, CA

Stanley J. Huey, Jr., PhD
Department of Psychology
Department of American Studies and Ethnicity
University of Southern California
Los Angeles, USA

*Denotes co-first authors

Funding: The research in this paper was funded in part by a grant from the American Foundation
for Suicide Prevention. The first authors were supported by the Ford Foundation Predoctoral
Fellowship (SMV) and APA Minority Fellowship Program fellowship (VC).

Corresponding author at: Sylvanna M. Vargas, Department of Psychology, University of
Southern California, 3620 S. McClintock Ave, SGM 501, Los Angeles, CA 90089-1061. E-mail:
sylvannv@usc.edu

33
Abstract
Introduction: Gender and ethnic differences exist in suicidal ideation, plan, and attempt among
adolescents in the US. However, limited research has used theoretically-informed approaches to
integrate how cultural and classic risk factors together account for suicide pathways among
vulnerable populations. The present cross-sectional study used the interpersonal theory of suicide
framework to examine gender differences in how a cultural (i.e., discrimination) and classic (i.e.,
depressive symptoms) risk factor contribute to suicidality among Latinx youth. Method: A total
of 390 Latinx adolescents (ages 13-18; 50% female) attending a high school in the U.S.
completed a series of questionnaires that included measures of depressive symptoms, suicide
risk, perceived discrimination, and demographics. Results: We found that discrimination is
associated with increased suicide risk among Latinx adolescents and this association is stronger
for girls versus boys. Girls who experienced higher levels of discrimination were at highest risk
for suicide. Additionally, the moderation effect remains when statistically controlling for
covariates and depressive symptoms. Conclusions: These findings indicate that in terms of
suicide risk, discrimination may be more detrimental to Latinx girls than boys. This study also
highlights the importance of drawing on theory-driven and culturally informed work in the study
of suicide risk pathways among diverse subpopulations.

Keywords: discrimination, suicidal risk, Latinx, adolescents, culture

34
Introduction
Suicide rates in the U.S. have been increasing over the past decade (Kann et al., 2018),
and suicide is now the second leading cause of death among adolescents and emerging adults
aged 15-24 (CDC, 2018). Yet, predicting suicide is no better today than it was 50 years ago
(Franklin et al., 2017). One potential explanation for the limited progress may be that much of
the extant research has drawn on different suicide theories without adequately evaluating their
accuracy and whether they apply to different populations (Duarté-Vélez, Jones, & Spirito, 2018).
Furthermore, it is likely that different pathways to suicide risk exist among diverse
subpopulations (Duarté-Vélez & Bernal, 2007; Franklin et al., 2017). However, the suicide risk
literature has been largely informed by the European American culture (Leong & Leach, 2010).
Given that rates are increasing among ethnic minority youth (Plemmons et al., 2018), greater
attention to understanding suicide risk among these subgroups is needed.
Gender and racial/ethnic differences in suicidality
Rates of suicidal ideation, plan, and attempts among adolescents differ based on gender
and ethnicity (Kann et al., 2018). Compared to males, females report higher suicidal ideation
(22.1% vs. 11.9%), past suicidal plan (17.1% vs. 9.7%), or previous suicidal attempt (9.3% vs.
5.1%; Kann et al., 2018). When compared to Latino males, adolescent Latinas are twice as likely
to report suicidal ideation (22.2% vs. 10.8%), prior suicidal plan (17.2% vs. 9.9%), and suicide
attempt during the past year (10.5% vs. 5.8%; Kann et al., 2018). Moreover, prior studies
document heightened risk of suicidal ideation, plan, and attempts among Latinas in comparison
to White or African American girls (Eaton et al., 2010), although a recent epidemiological study
using national data no longer reports significant differences between Latina and White or Black

35
youth (Kann et al., 2018). Nevertheless, it is possible that Latinx girls and boys experience
distinct pathways to suicide risk.
It is unclear why these gender and racial/ethnic differences in suicidality exist. Some
studies have shown that examining classic risk factors may not be sufficient to understanding
Latinx’s suicidal behaviors. Classic risk factors refer to standard risk constructs for suicidal
behaviors, such as hopelessness, depression, or substance use (Chu, Robinett, Ma, Shadish,
Goldblum, & Bongar, 2019). For example, one study drawing on the 2007 Youth Risk Behavior
Survey found that risk factors including feeling sad or hopeless, lifetime marijuana or cigarette
use, and being in a physical altercation were more strongly associated with suicidal ideation in
White girls than Latinas (Eaton et al., 2011). Despite the difference in magnitude, none of the
risk factors differentially predicted suicidal ideation for Latina versus non-Latina youth. This
may suggest that examining classic risk behaviors is insufficient to understanding Latinx’s
suicidality. Some initial work on cultural risk and protective factors has shown that minority
stress, such as experiences of interpersonal discrimination, account for variance above and
beyond classic risk factors for suicidality among diverse young adults (Chu et al., 2019).
Examining cultural, in combination with classic, risk factors may help better understand suicide
pathways among Latinx youth. However, no study we know of has examined whether gender
differences exist in how cultural and classic risk factors contribute to suicidality.
The interpersonal theory of suicide and discrimination
The interpersonal theory of suicide (ITS; Joiner, 2005) provides a theoretical framework
to understand the role of discrimination and potential interplay with gender in suicide risk
pathways. This theory proposes that two constructs contribute to suicidal desire: thwarted
belongingness (TB), or feeling alienated and disconnected from others particularly with regards

36
to a valued group; and perceived burdensomeness (PB), or the belief that one is a burden to
others. According to ITS, suicidal behavior results when there is also acquired capability, which
ultimately lowers a person’s fear of death or bodily harm and increases the chance they will
engage in suicidal behaviors (Van Orden et al., 2010). Specific cultural risk factors may fit
within this broader existing theoretical framework for why suicide occurs. For example, although
discrimination is not itself one of the key constructs of the ITS, it is conceptually relevant to both
PB and TB. Discrimination can be conceptualized as a form of rejection, which directly relates to
TB. Experiencing discrimination can also result in feelings of shame (Matheson & Anisman,
2009), which in turn may contribute to feeling like a liability or burden to others (PB). Although
one study with Asian international students shows that TB, PB, discrimination, and suicide
ideation are related to each other (Wang, Wong, & Fu, 2013), no studies have examined these
relationships among Latinx youth. Discrimination may be a culturally-unique stressor that
contributes to TB or PB and therefore heightened suicidality among Latinx adolescents.
Gender and racial/ethnic differences in discrimination
Ethnic minorities are more likely than Whites to experience discrimination (Kessler,
Mickelson, & Williams, 1999), and discrimination is a risk factor for poor mental health
outcomes (Pascoe & Richman, 2009). In particular, Latinxs who report discrimination are at
higher risk for suicide (Kwon & Han, 2019; Perez-Rodriguez et al., 2014), and those who
experience racism are 2.5 more likely to have attempted suicide (Gomez et al., 2011). However,
most of these studies utilize adult and young adult samples (Cheref, Talavera, & Walker, 2018;
Gomez et al., 2011) and few have focused on adolescent Latinxs. Yet, a meta-analysis by
Schmitt and colleagues (2014) found larger effect sizes for the relationship between perceived
discrimination and psychological well-being in children versus adults. Examining the impact of

37
discrimination, among other cultural stressors, on youth may be especially important given that
they are likely to have fewer coping strategies based on their developmental trajectory (Duarté-
Vélez & Bernal, 2007).
It is also possible that discrimination affects girls and boys differently. There is some
evidence that components of the interpersonal theory of suicide affect suicidality among men and
women differently. A meta-analysis of ITS studies showed that the relationship between PB and
TB and suicidal ideation is moderated by sex, such that the effects are larger when samples are
comprised of fewer males (Chu et al., 2017). Women may perceive greater TB and PB due to the
greater value they place on close connections (Van Orden, 2010). By extension, since
discrimination may increase TB and PB, it is possible that discrimination may differently affect
suicide risk for Latinx girls and boys.
The current study
The first aim of the present study was to evaluate gender differences in the relationship
between discrimination and suicide risk in a sample of Latinx adolescents. Based on existing
literature, the directionality of the expected gender differences in the discrimination-suicidality
relationship is unclear. On the one hand, girls are more likely to be affected by interpersonal
stressors than boys (e.g., Shih, Eberhart, Hammen, & Brennan, 2006). Therefore, interpersonal
discrimination may be inherently more stressful for Latina girls and therefore put them at greater
risk for suicidality. On other hand, men are more likely to report experiencing discrimination
(Pérez, Fortuna, & Alegría, 2008) and gender socialization and expectations may deter them
from seeking social support as a coping strategy (Lamis & Lester, 2013). This may suggest that
boys have fewer resources to cope with experiences of discrimination, and therefore
experiencing discrimination may confer greater suicide risk for Latino boys. Given the limited

38
research in this area, we propose two competing hypotheses based on the theoretical arguments
described above: 1) the effect of discrimination on suicidality will be greater for Latinas; or 2)
the effect of discrimination on suicidality will be greater for Latino boys.
The second aim of this study was to examine how classic (e.g., depressive symptoms)
and cultural risk factors (e.g., discrimination) simultaneously contribute to suicide risk. Since
prior research has shown that both types of risk factors uniquely account for suicidality among
diverse youth, we hypothesized that both depressive symptoms and discrimination would
independently account for suicide risk in our sample.
Method
Participants and Procedures
Data were collected from 390 Latinx students enrolled in a large metropolitan high
school in Southern California, USA. Youth completed assent forms to indicate voluntary
participation in study procedures, and parents provided informed consent. Details about
procedure and list of measures are published elsewhere (Cespedes, 2008; Chithambo, Huey, &
Cespedes-Knadle, 2014). The current study focused on measures of discrimination, depressive
symptomatology, and suicidality.
5.2 Measures
Demographics. A demographics questionnaire assessed participants’ background
information. The current study utilized the following variables: participant age, gender (listed as
“female” or “male”), self-identified racial/ethnic background, and place of birth (re-coded as US-
born or non-US-born). For participants who were born outside the US, we calculated the
percentage of their life lived in the US (Alegría, 2009). Measures of socioeconomic status (SES)
included participants’ mothers’ level of education and total number of people living in the home.

39
Mother’s education was dummy coded to represent three categories: 8
th
grade education or lower
(reference group), 9
th
-12
th
grade, and some college or higher. Participants reported the total
number of people living in the home, including themselves.
Discrimination. The Everyday Discrimination Scale (EDS; Williams, Yu, Jackson, &
Anderson, 1997) was utilized to measure participants’ experiences with discrimination. The EDS
includes nine items asking about perceived daily mistreatment (e.g., “in your day-to-day life how
often do you receive poorer service than other people at restaurants or stores” or “are treated with
less courtesy than other people”). Participants used a six-point Likert-type scale ranging from 1
(“never”) to 6 (“almost every day”) to indicate how often these events occur in their lives. For
each participant, we summed responses for the nine items. For the current sample, internal
reliability for the scaled items was .99. In all analyses, discrimination was grand-mean centered.
Suicide risk. An abbreviated version of the Suicidal Behaviors Questionnaire for
Children was utilized (SBQ-C; Cotton & Range, 1993). The SBQ-C was adapted from the SBQ-
14 (Linehan & Nielsen, 1981) for use among children and has been validated as a single factor of
broad suicide risk (Nadorff, Nazem, & Fiske, 2011). The SBQ-C is comprised of four items
inquiring about suicidal ideation, attempts, and perceived likelihood: “Have you ever thought
about or tried to kill yourself?” (rated 0-6); “How often have you thought about killing yourself
in your whole life?” (rated 0-4); “Have you ever told someone that you were going to commit
suicide, or that you might do it, in your whole life?” (rated 0-2); and “What chance is there that
you will attempt suicide in your lifetime?” (rated 0-4). Composite reliability of the four SBQ-C
items was substantial, .83, and was estimated using McDonald's omega (McDonald, 1999).
Clinical cutoffs have not been established.

40
Depressive symptoms. The Reynolds Adolescent Depression Scale, 2
nd
Edition (RADS-
2; Reynolds, 2002) was utilized. The RADS-2 is a 30-item scale that measures four dimensions
of depression (i.e., dysphoria, anhedonia, negative self-evaluation, and somatic concerns).
Participants respond to the frequency with which they experience each item on a 4-point scale
ranging from “almost never” to “most of the time”, with scores ranging from 30 - 120. Internal
consistency in the present sample was .89.
Analytical Strategy
We first conducted correlations to show dependence between our variables of interest and
determine whether multicollinearity existed. We then conducted ordinary least squares
regression analysis in which youths’ SBQ-C sum scores were regressed onto their discrimination
scores, gender, and the interaction between their discrimination scores and gender.
As the four SBQ-C items are ordinal and severely skewed, multivariate analyses
consisted of structural regression models. As a first step, we estimated a 1-factor latent variable
model in which the four SBQ-C items served as ordered categorical indicators (Millsap, 2011).
The latent factor was scaled by fixing one factor loading in order to free the variance of the latent
SBQ-C factor and fit using weighted least squares mean variance (WLSMV) estimator. The 1-
factor latent variable model fit the data well (χ2 = 0.40, df = 2, p = .818), so we proceeded to use
the latent SBQ-C factor as the outcome in all structural regression models. The benefit of
estimating a latent SBQ-C factor is that the SBQ-C variable is unbiased by measurement error
and adjusts for item skew.
Finally, we fit a series of structural regression models to test the hypothesis that
perceived discrimination predicts suicidality in female Latinx youth more so than in male Latinx
youth, and to examine the additional contribution of depressive symptoms in differentially

41
predicting suicide risk. The first model (Model 1) only included the effect of perceived
discrimination on latent SBQ-C. The second model (Model 2) added gender into the model, and
the third model (Model 3) included the interaction effect between perceived discrimination and
gender. The fourth model (Model 4) included covariates, which consisted of mother’s level of
education, number of people living in the home, age (centered at age 13), and country of birth.
The fifth, and final, model additionally included depressive symptoms. Our conceptual model is
illustrated in Figure 1.
All structural regression and WLSMV analyses were estimated using Mplus 8.2 (Muthén
& Muthén, 1998-2017). Missing data were handled using a 4-step procedure in Mplus. First, for
missing SBQ-C item data, univariate probit regression of each item on the covariates was used
using all people with data on that u (and the x's). Second, bivariate probit regression of each pair
of items on the covariates was implemented using all available data. Third, a weight matrix was
then estimated based on maximum likelihood estimation in the first two steps. Finally, the model
was fit using weighted least squares estimation. The procedure is considered to be superior to
using pairwise present data, as it permits missingness to be accounted for by all covariates. As
traditional chi-square tests of nested models cannot be used with WLSMV, model comparisons
were made using the DIFFTEST option in Mplus. The procedure consists of 2-steps to obtain
chi-square distributed values to compare nested models, as WLSMV χ2 values are not χ2
distributed. Factor models fit with fewer parameters without significant loss of model fit were
preferred.
Results
Sample Characteristics

42
Descriptive statistics reflecting participant demographics and other study variables are
reported in Table 1. Half the participants were female, and on average they were 15.24 years of
age. A majority (76.2%) were US-born, and those who immigrated to the US had spent
approximately 44% of their lives in the United States. Nearly half the participants were of
Mexican origin. Over half of the participants were in ninth grade. A majority of participants’
mothers had a high school education or lower, with 42.5% reporting their mothers earned the
equivalent of 8
th
grade or lower level of education. Participants reported on average living in a
household of 5.52 persons, including the participant.
Regression and Moderation Analyses
Table 2 shows a correlation matrix of all variables in our models. Experiencing
discrimination was related to all four suicide risk items, and girls were more likely to endorse
suicidality. Boys were older than girls in our sample. Some differences emerged across the
suicide risk items. Older youth reported higher suicidality on the first two items, and youth who
reported that their mothers had at least a college degree endorsed lower risk on the first item
inquiring about prior SI or attempt. All four suicide risk items correlated highly with each other
(rs ranged from .57-.82).
Table 3 reports indices of model fit and suicide risk variance explained across our five
models. According to these indices, model 4 was our best fitting model, which included both
main and interaction effects, as well as several covariates. In terms of suicide risk attributed to a
cultural risk factor, discrimination only (Model 1) explained 14% of the variance. When we
included gender along with discrimination, this increased by 4% (Model 2). When we included
the moderation along with the two main effects, this increased to 22% of variance explained
(Model 3). Next, we included covariates and an additional 5% variance was captured. Lastly, we

43
included a robust classic risk factor of suicide to our cultural risk model. When combining
depressive symptoms with the other variables in our prior models, this explained 60% of the
suicide risk variance in our sample (Model 5).
We report the findings from structural regression models 3, 4 and 5 in Table 4. Model 3
indicated that frequent discrimination predicted greater suicide risk. Gender was also
significantly associated with suicide risk, indicating that girls were more likely to endorse
suicidal risk. We found a significant moderation effect, such that the relationship between
discrimination and suicide risk was significant for both groups but stronger for girls than for
boys. As is visible in Figure 2, the slope of the female group (dashed line) is steeper than in the
male group (solid line), suggesting that female Latinx adolescents who perceive higher levels of
discrimination are predicted to have highest suicide risk. In Model 4, we included relevant
demographic factors as covariates, including mother’s level of education, number of people
living in the home, age, and country of birth. Finally, in Model 5 we examined a classic risk
factor (i.e., depressive symptoms) in conjunction with a cultural risk factor (i.e., discrimination)
and covariates. We found an effect for depressive symptoms and age predicting suicide risk. We
continued to find significant main and moderation effects for gender on discrimination. This
suggests that even when accounting for the influence of depressive symptoms and
sociodemographic factors like foreign-born status, age, and SES indicators, girls continued to
endorse higher suicide risk when they reported experiences with discrimination.
Discussion
Little is known about how classic and cultural risk factors together contribute to Latinxs’
suicidality. The present study evaluated gender differences in the relationship between
discrimination and suicidality among Latinx adolescents. Our results showed that discrimination

44
is associated with increased suicide risk among Latinx adolescents, and this association is
stronger for girls versus boys even when controlling for covariates and a robust classic risk
factor, depressive symptoms. This suggests that discrimination is an important suicide risk factor
to consider for Latinx youth, and particularly Latinas.
Our findings may be understood using the interpersonal theory of suicide framework. It is
possible that discrimination is a unique cultural experience of a type of perceived
burdensomeness and thwarted belongingness, which are two subjective states that put people at
risk for suicide. Some initial work supports this idea (Wang et a., 2013). For example, one study
of LGB young adults who were predominantly Latinx showed that those who endorsed perceived
or anticipated rejection due to their sexual orientation were more likely to report PB, which was
associated with greater suicidal ideation (Hill & Pettit, 2012). Thus, one potential explanation for
our findings is that Latinxs may exhibit suicidal behaviors because they experience PB and TB
through their exposure to discrimination. Alternatively, discrimination could interact with
experiences of PB and TB to produce increased suicidal risk.
We offer a few potential explanations for our finding that the relationship between
discrimination and suicide risk is stronger for adolescent girls. Our result is consistent with prior
literature showing that the effect of PB and TB on suicidality is larger in samples with fewer men
(Chu et al., 2017), indicating that women’s suicidality may be more strongly affected by PB and
TB. In one of the few studies with Latinxs, PB was associated with increased suicidal ideation
regardless of a cultural protective factor (i.e., familism) among Mexican American women
(Garza & Pettit, 2010), emphasizing the impact of interpersonal stressors for Latinas. Given that
the study only included Latina women, it is unclear if PB affected Latino men differently. Future

45
studies should directly examine whether PB and TB differentially contribute to suicide risk
among Latinx girls versus boys.
Alternatively, it is possible that our finding reflects a different explanation. Latina girls
may be more strongly affected by discrimination due to experiencing prejudice and unfair
treatment based on multiple identities (i.e., ethnicity and gender). Prior research has indicated
that experiencing multiple types of discrimination is predictive of poor mental health outcomes
including depression and suicide, although these studies typically have not assessed the role of
sexism (Vargas, Huey, & Miranda, 2020). Therefore, it is possible that the heightened influence
of discrimination on Latinx girls’ suicidality may be related to their multiple minority statuses.
We were unable to explore the multiple discrimination hypothesis within our data. Future
research should examine to what extent Latina girls may be at increased risk for suicide because
they experience multiple types of discrimination.
The significance of discrimination in predicting suicidality among Latinx adolescents
adds to the evidence base of important cultural risk factors for suicide. Additionally, our results
indicated that discrimination is a significant predictor of suicide risk above and beyond a
commonly studied classic risk factor, depressive symptoms. In developing comprehensive
models of suicide risk for minority populations it is critical that we integrate both classic risk
factors and culturally relevant factors. Future studies should continue to evaluate relevant
sociocultural factors in the context of established theories of suicide, to further understand group
specific pathways to suicide risk.
7.1 Limitations
Our study has several limitations. While we propose that discrimination and other
cultural factors should be integrated into the study of extant theories, we did not assess the core

46
constructs of the interpersonal theory of suicide. Our study serves as an initial step to determine
the role of a conceptually related construct that is highly relevant for ethnic minority groups.
Prior studies have found that discrimination is indirectly associated with depression and suicidal
ideation through PB, and not TB, among LGB youth (Baams, Dubas, Russell, Buikema, & van
Aken, 2018; Baams, Russell, & Grossman, 2015). Further studies should directly assess PB and
TB constructs to determine the relationship with discrimination, suicidality, and gender among
Latinx adolescents. By incorporating cultural and classic risk factors in the context of established
theories we will further refine pathway models for suicide risk among vulnerable populations.
PB and TB are important predictors of suicide ideation, but according to the interpersonal
theory of suicide, lethal suicidal behaviors additionally involve the acquired capability for
suicide (Joiner, 2005). Our measure of suicide risk concurrently inquired about both suicidal
ideation and acts. Therefore, we were unable to disentangle how discrimination experiences may
impact suicidal ideation in comparison to suicidal behaviors. Future research should examine this
distinction more closely and explore potential protective factors, such as family cohesion and
self-compassion (Sun, Ren, Li, Jiang, Liu, & You, 2020) among at-risk youth.
Although our study examined suicidality in a less studied population, we did not
distinguish between Latinx subgroups. Efforts to refine pathways to suicide can benefit from
nuanced assessments of Latinxs (Duarté-Vélez & Bernal, 2007). Finally, several methodological
constraints are worth noting. All of our study measures relied on participant self-report, calling
into question concerns of common method variance. Future studies can further support our
findings by including different types of measures and information sources, such as parents’
reports, for the key constructs included in the present study. Additionally, given the cross-

47
sectional nature of our study, we are unable to draw conclusions regarding the directionality of
the relationship. Longitudinal research is needed in this area.
7.2 Conclusion
The present study examined a cultural risk factor for suicidality and potential pathway for
gender differences among Latinx adolescents. Our results indicate that discrimination is
associated with suicidality among adolescent Latinxs, particularly among girls. These findings
highlight the value of including cultural and classic risk factors in the development of potential
pathways to suicide for different vulnerable groups. Future studies should further assess other
relevant risk factors and more comprehensive models to predict suicide risk among Latinx youth.

48
References
Alegría, M. (2009). The challenge of acculturation measures: What are we missing? A
commentary on Thomson & Hoffman-Goetz. Social Science & Medicine, 69(7), 996-998.
doi:10.1016/j.socscimed.2009.07.006
Baams, L., Dubas, J. S., Russell, S. T., Buikema, R. L., & van Aken, M. A. (2018). Minority
stress, perceived burdensomeness, and depressive symptoms among sexual minority
youth. Journal of Adolescence, 66, 9-18.
Baams, L., Russell, S. T., & Grossman, A. H. (2015). Minority stress and mechanisms of risk for
depression and suicidal ideation among lesbian, gay, and bisexual youth. Developmental
Psychology, 51, 688–696.
Centers for Disease Control and Prevention. (2018). CDC WISQARS: Leading causes of death
reports, 1981–2018. Available from webappa. cdc. gov/sasweb/ncipc/leadcause. html.
Cespedes, Y.M. (2008). Evaluating a cultural process model of depression and suicidality in
Latino adolescents (Unpublished doctoral dissertation). University of Southern
California, Los Angeles, CA.
Chithambo, T., Huey, S.J., Jr., & Cespedes-Knadle, Y. (2014). Perceived discrimination and
Latino youth adjustment: Examining the influence of relinquished control, discrimination
attribution, nativity, and acculturation. Journal of Latino Psychology, 2(1), 54-66.
Cheref, S., Talavera, D., & Walker, R. L. (2019). Perceived discrimination and suicide ideation:
Moderating roles of anxiety symptoms and ethnic identity among Asian American,
African American, and Hispanic emerging adults. Suicide and Life‐Threatening
Behavior, 49(3), 665-677.

49
Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., ... &
Michaels, M. S. (2017). The interpersonal theory of suicide: A systematic review and
meta-analysis of a decade of cross-national research. Psychological Bulletin, 143(12),
1313.
Chu, J., Robinett, E. N., Ma, J. K., Shadish, K. Y., Goldblum, P., & Bongar, B. (2019). Cultural
versus classic risk and protective factors for suicide. Death Studies, 43(1), 56-61.
Cotton, C. R., & Range, L. M. (1993). Suicidality, hopelessness, and attitudes toward life and
death in children. Death Studies, 17(2), 185-191.
Duarté-Vélez, Y. M., & Bernal, G. (2007). Suicide behavior among Latino and Latina
adolescents: Conceptual and methodological issues. Death Studies, 31(5), 435-455.
Eaton, D. K., Foti, K., Brener, N. D., Crosby, A. E., Flores, G., & Kann, L. (2011). Associations
between risk behaviors and suicidal ideation and suicide attempts: Do racial/ethnic
variations in associations account for increased risk of suicidal behaviors among
Hispanic/Latina 9th-to 12th-grade female students?. Archives of Suicide Research, 15(2),
113-126.
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., ... & Nock,
M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50
years of research. Psychological Bulletin, 143(2), 187.
Garza, M. J., & Pettit, J. W. (2010). Perceived burdensomeness, familism, and suicidal ideation
among Mexican women: Enhancing understanding of risk and protective factors. Suicide
and Life-Threatening Behavior, 40(6), 561-573.
Gomez, J., Miranda, R., & Polanco, L. (2011). Acculturative stress, perceived discrimination,

50
and vulnerability to suicide attempts among emerging adults. Journal of Youth and
Adolescence, 40(11), 1465.
Hill, R. M., & Pettit, J. W. (2012). Suicidal ideation and sexual orientation in college students:
The roles of perceived burdensomeness, thwarted belongingness, and perceived rejection
due to sexual orientation. Suicide and Life‐Threatening Behavior, 42(5), 567-579.
Joiner, T. E. Why people die by suicide. Cambridge, MA: Harvard University Press; 2005.
Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., ... & Lim, C.
(2018). Youth risk behavior surveillance—United States, 2017. Morbidity and Mortality
Weekly Report: Surveillance Summaries, 67(8), 1-114.
Kwon, S., & Han, D. (2019). Discrimination, mental disorders, and suicidal ideation in Latino
adults: Decomposing the effects of discrimination. Journal of Immigrant and Minority
Health, 21(1), 143-150.
Lamis, D. A., & Lester, D. (2013). Gender differences in risk and protective factors for suicidal
ideation among college students. Journal of College Student Psychotherapy, 27(1), 62-
77.
Leong, F. T., & Leach, M. M. (Eds.). (2010). Suicide among racial and ethnic minority groups:
Theory, research, and practice. Taylor & Francis.
Linehan, M. M., & Nielsen, S. L. (1981). Suicidal behaviors questionnaire (SBQ). University of
Washington.
Matheson, K., & Anisman, H. (2009). Anger and shame elicited by discrimination: Moderating
role of coping on action endorsements and salivary cortisol. European Journal of Social
Psychology, 39(2), 163-185.
McDonald, R. P. (1999). Test theory: A unified treatment. Mahwah, NJ: Lawrence Erlbaum

51
Associates.
Muthén, L. K., & Muthén, B. O. (2011). Mplus User’s Guide. 1998–2011. Los Angeles,
California: Muthén and Muthén.
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-
analytic review. Psychological Bulletin, 135(4), 531.
Pérez, D. J., Fortuna, L., & Alegria, M. (2008). Prevalence and correlates of everyday
discrimination among US Latinos. Journal of Community Psychology, 36(4), 421-433.
Pérez-Rodriguez, M. M., Baca-Garcia, E., Oquendo, M. A., Wang, S., Wall, M. M., Liu, S. M.,
& Blanco, C. (2014). Relationship between acculturation, discrimination, and suicidal
ideation and attempts among US Hispanics in the National Epidemiologic Survey of
Alcohol and Related Conditions. The Journal of Clinical Psychiatry.
Reynolds, W. M. (2002). RADS-2: Reynolds adolescent depression scale. Psychological
Assessment Resources.
Schmitt, M. T., Branscombe, N. R., Postmes, T., & Garcia, A. (2014). The consequences of
perceived discrimination for psychological well-being: A meta-analytic review.
Psychological Bulletin, 140(4), 921.
Shih, J. H., Eberhart, N. K., Hammen, C. L., & Brennan, P. A. (2006). Differential exposure and
reactivity to interpersonal stress predict sex differences in adolescent depression. Journal
of Clinical Child and Adolescent Psychology, 35(1), 103-115.
Sun, R., Ren, Y., Li, X., Jiang, Y., Liu, S., & You, J. (2020). Self-compassion and family
cohesion moderate the association between suicide ideation and suicide attempts in
Chinese adolescents. Journal of Adolescence, 79, 103-111.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr,

52
T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575.
Vargas, S. M., Huey, S. J., & Miranda, J. (2020). A critical review of current evidence on
multiple types of discrimination and mental health. The American Journal of
Orthopsychiatry, advance online publication. https://doi.org/10.1037/ort0000441
Wang, K. T., Wong, Y. J., & Fu, C. C. (2013). Moderation effects of perfectionism and
discrimination on interpersonal factors and suicide ideation. Journal of Counseling
Psychology, 60(3), 367.
Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical
and mental health: Socio-economic status, stress and discrimination. Journal of Health
Psychology, 2(3), 335-351.

53
Table 1
Participant demographic characteristics (N=390)
Variable M(SD) N (%)
Female - 195(50)
Age 15.24(1.21) -
US-born - 297(76.2)
Age came to the US if non-
US-born
8.90(5.44) -
Percentage of life in the US if
non-US-born
43.98 (31.65) -
Ethnicity
Mexican - 179(45.9)
Salvadorian - 117(30)
Honduran - 8(2.1)
Other - 68(17.4)
Current grade
Ninth - 221(56.7)
Tenth - 30(7.7)
Eleventh - 98(25.1)
Twelfth - 27(6.9)
Mother’s education level
8
th
grade or lower - 166(42.5)
9
th
-12 grade - 126(32.3)

54
Some college or higher - 17(4.4)
Number of people living in
home
5.52(2.18) -
Depressive symptoms 58.20(13.89) -
Frequency of discrimination 19.50(9.31) -
Suicide risk 1.26(2.37) -

55

56

57

Table 3
Indices of model fit and suicide risk variance explained
Model # Model Description χ2 df χ2 df p R
2

1 Discrimination 464.04 73 - - - 0.14
2 Discr, Gender 456.47 72 11.80 1 .001 0.18
3 Discr, Gender,
Discr*Gender
457.81 71 7.54 1 .006 0.22
4 Discr, Gender,
Discr*Gender,
Covariates
526.50 66 10.89 5 .054 0.27
5 Discr, Gender,
Discr*Gender,
Covariates,
Depressive
symptoms
328.262 65 93.66 1 < .001 0.60

58

59

60
Figure 1
Conceptual model

*
*
SBQ
4
SBQ
1
SBQ
3
SBQ
2
SBQ
L
u
4
u
1
u
3
u
2
1
ƛ
2
*
Discrimination
ƛ
1
b
1
ƛ
3
*
*
Gender
b
2
Discrimination
x Gender
b
3
Covariates
b
k
d
L *

61
Figure 2
Model showing gender and discrimination interaction and simple slopes

−1
0
1
2
3
10 20 30 40 50
Discrimination
Latent SBQ
Gender
Male
Female

62

Study 3: Using Community-Based Partnerships to Engage Sexual and Gender Minority
People of Color in a Hair Cortisol Study

Sylvanna M. Vargas, MA, MPH
1, 2
, Luis A. Parra, PhD, MS
3
, Wilmer A. Rivas, BA
3
, Sinan
Payat
1
, Roxanne Mistry
1
, Clarence R. Williams, BA
4
, Diana Gamez, BA
5
, Krystal Griffith,
MPH
2
, Bowen Chung, MD
2
, Stanley J. Huey, Jr., PhD
1
, & Jeanne Miranda, PhD
2

1
Department of Psychology, University of Southern California, Los Angeles, California
2
Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and
Human Behavior, University of California, Los Angeles, Los Angeles, California
3
Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles,
California
4
Healthy African American Families, Los Angeles, California
5
Department of Anthropology, University of California, Irvine, Irvine, California

Word count: 5,022

Acknowledgements: The authors would like to thank the RADD study participants; RADD
Executive Committee; RADD Community Advisory Board; the County of Los Angeles
Department of Mental Health; Mariah Williams, BA; Jeremy Goldbach, PhD; Darby Saxbe,
PhD; Richard John, PhD; and countless others whose involvement were essential to completing
this study.

Funding information: This study was supported by the American Psychological Foundation and
Council of Graduate Departments of Psychology (Ruth G. and Joseph D. Matarazzo
Scholarship), the Patient-Centered Outcomes Research Institute (PCORI, www.pcori.org), grant
number: PPRND-1507-32173, and the University of Southern California Department of
Psychology and Graduate School. SMV was supported through a Ford Foundation Predoctoral

63
Fellowship. JM was partly supported through a Substance Abuse and Mental Health Services
Administration grant (SM080041-01) and a National Institute of Mental Health grant
(P30MH058107-21). BC was also supported by the UCLA Clinical and Translational Science
Institute/ National Center for Advancing Translational Sciences grant (UL1TR001881).

64
Abstract
Objective: This study explored: 1) how a community-partnered participatory research
(CPPR) model can be used to enhance research engagement for predominantly low-income,
sexual and gender minority people of color (SGM-POC) to provide hair cortisol samples; and 2)
participants’ motivations and concerns surrounding providing a hair sample. Methods: A CPPR
framework was employed to develop and implement a culturally-informed hair cortisol protocol.
Participants from a larger study were invited to provide hair samples and a brief acceptability
interview. Recruitment outcomes were systematically tracked and reported. Qualitative data from
the acceptability interview were then analyzed using thematic coding. Results: Seventy-one
percent of all 133 contacted participated in the current study, of whom 82% provided hair
samples. Several themes emerged from participants’ interviews, indicating that participants were
motivated to provide a hair sample due to internal and external factors, including a desire to learn
about their health. However, several concerns about providing a hair sample remained, such as
mistrust of research. Discussion: Using a CPPR model may enhance biomarker research
engagement among SGM-POC. Our results suggest that some participants may continue to
experience mistrust, but participate in a biomarker study if they perceive that the direct benefits
to themselves and to their communities outweighed the risks. Specific recommendations based
on recruitment techniques that emphasized the benefit to the participant and community are
provided. Conclusion: Collecting biospecimens in research with underserved groups requires
careful and intentional consideration of perceived benefits and risks to the individual and their
communities.
Keywords: community-based participatory research, sexual minority people of color, research
subject recruitment, hair cortisol

65
Introduction
A major challenge for biomedical research in the United States is the effective translation
of science to reduce racial/ethnic health disparities (IOM, 2003; IOM, 2013), such as by
improving the representation of historically understudied groups in research (Jackson & Gracia,
2014; Oh et al., 2015). Biospecimen research can help promote advances in basic science into
new public health approaches (ATSDR, 2011; IOM, 2013; NIH, 2013), such as through deeper
understanding of the physiological mechanisms implicated with health disparities. However,
people of color (POC), including Black and Latinx individuals, and sexual and gender minority
persons (SGM; e.g., who traditionally identify as lesbian, gay, bisexual, transgender, and queer)
are underrepresented in biospecimen studies (Lick et al., 2013). Moreover, sexual and gender
minority people of color (SGM-POC) are nearly absent from biospecimen research (Parra &
Hastings, 2018). One reason commonly cited reason is mistrust of researchers (Ford et al., 2016;
Graham et al., 2011), which is rooted in a history of structural racism (Bassett & Graves, 2018)
characterized by misconduct towards these under-resourced communities (e.g., Layman, 2009;
Novak et al., 2018). Increasing representation of low-income minorities is an NIH priority (Oh et
al., 2015).
A recommended approach for enhancing trust and community engagement is to rely on
community partnerships, such as through community-partnered participatory research (CPPR)
model (ASTDR, 2011; IOM, 2013). Although several CPPR studies have been conducted with
POC (Jones & Wells, 2007), little is known about how to employ a CPPR framework for
biospecimen collection among diverse SGM-POC. The current study used a CPPR model to
develop a culturally-adapted biospecimen study protocol for low-income, predominantly SGM-
POC.

66
The importance of representation of POC and SGM groups in research has been linked to
generalizability of study findings (Hussain-Gambles et al., 2004; Yancey et al., 2006), improving
the accuracy of subgroup analyses (Miranda et al., 2003; Satcher, 2001), and health equity and
disparities (Ford et al., 2016). Health disparities are a growing public health concern and national
priority (Jackson & Gracia, 2014). Numerous studies have highlighted the role of interpersonal
discrimination in contributing to poor health outcomes and disparities in under-resourced
communities (Lewis et al., 2015). The existing evidence points to minority stress-health pathways
(e.g., Meyer, 2003; Myers, 2009), suggesting that chronic discrimination may contribute to
dysregulations in the hypothalamic-pituitary-adrenal (HPA) axis and its production of cortisol, a
stress hormone, which in turn impact health (Busse et al., 2017). Experiencing race-based and anti-
SGM discrimination is associated with less adaptive HPA axis functioning and dysregulated
cortisol production (Busse et al., 2017; Lick et al., 2013). Furthermore, simultaneously
experiencing both forms of discrimination may contribute to worse mental health than does
experiencing a single kind of discrimination (Vargas et al., 2020). Since very few studies have
focused on SGM-POC, little is known about the biological underpinnings of this phenomenon and
the overall HPA functioning of this population (Parra & Hastings, 2018).
The underrepresentation of POC and SGMs in biospecimen research is a result of barriers
for both researchers and participants (George, Duran, & Norris, 2014), rooted in a history of
structural racism (Bassett & Graves, 2018) and heterosexism (Kline, 2001). For researchers, since
past studies have predominantly been conducted by and focused on White persons, the current
standards for research conduct may be culturally insensitive or ineffective for recruiting and
engaging participants from diverse backgrounds (George et al., 2014). For participants, people
from under-resourced communities may face numerous barriers in participating, including learned

67
mistrust towards researchers due to an extensive history of scientific abuses (George et al., 2014;
Hussain-Gambles et al., 2004). We provide a few illustrative examples of these abuses (see
Layman, 2009 for brief overview). The 1932 Tuskegee experiment failed to obtain clear informed
consent among Black male participants, who were deceptively left with untreated syphilis
(Layman, 2009). Furthermore, in California, Latina women were disproportionately at risk of
being sterilized under the state’s forced sterilization laws, which were aimed at preventing the
reproduction of individuals thought to be “feebleminded” or having undesirable hereditary
conditions (Novak et al., 2018). Homosexuality and transgender experiences were classified as
mental illnesses until 1973 and 2013, respectively (Pandya, 2014; Rodriguez, Granda, & Gonzalez,
2018). This history has consequently generated mistrust of the medical and research community.
While numerous studies have described how this history of abuses is related to participation
barriers in hypothetical or future research (Hussain-Gambles et al., 2004; George et al., 2014), less
is known about the motivations and concerns of participants who already engaged in biospecimen
research. This information may be useful for studies aiming to enhance recruitment by
incorporating clear motivators and addressing concerns within a tailored protocol. Additionally,
existing research on barriers and facilitators has focused primarily on POC, with SGM-POC adults
under-identified. Understanding the views of SGM-POC who participate in research is important
and can help inform future research methods.
Recommendations established by the National Academy of Medicine and NIH for
conducting research with underrepresented groups describe the need for community engagement
approaches (ASTDR, 2011; IOM, 2013). CPPR models, which rely on community partnerships
of shared power and community engagement, have been shown to increase research engagement
and trust, partly through the development of culturally-responsive research methods (Jones &

68
Wells, 2007). CPPR includes ongoing consultation and involvement of community partners in all
phases of the research process, with community partners treated as co-investigators. However,
little work has examined how to apply a CPPR framework to biospecimen research with
predominantly low-income, SGM-POC community adults.
The current study used a CPPR model to learn how to engage predominantly low-income,
SGM-POC in biospecimen research. The study also aimed to examine participants’ views to
understand why they were motivated to participate in biospecimen research. The study relied on
consultation from community partners and study participants to develop and pilot a cortisol study
protocol. Given the dearth of information about SGM-POC in biospecimen research, we also
descriptively explored racial subgroup patterns in their reported barriers and facilitators to
participating in the current study.
Method
Study Overview and Participants
The current cortisol study was conducted as a follow-up to the Resilience Against
Depression Disparities (RADD) project. The RADD study was a longitudinal comparative
effectiveness depression trial for low-income, predominantly SGM and POC adults (see Vargas et
al., 2019 for full study description). The cortisol study was developed using a CPPR framework,
which involved integrating feedback from community members to design the study’s aims and
culturally-adapt the study protocol. Former Los Angeles-based RADD study participants (n=133)
who had agreed to be contacted about future research opportunities were invited participate. Those
interested in the cortisol study were offered an in-person visit in which research staff collected hair
samples, conducted a brief interview, and administered questionnaires. Participants who were
unable to attend in-person visits or who did not wish to provide a hair sample were able to complete

69
the interview and questionnaires by phone. Participants were compensated, in cash, $35 for
providing a hair sample and $15 for completing the interview and questionnaire. The in-person
visits lasted 30-60 minutes.
Protocol Adaptation
Adaptations to the protocol were iterative and developed in consultation with community
partners and from initial study participants’ input (Table 1). Community partners were also
involved in the implementation of the RADD study. They did not participate in the cortisol study,
but were representatives of their communities. The cortisol study was developed as a result of
conversations with community partners during the RADD study, with the goal to examine the role
of biological stress in the relationship between discrimination and depression. Based on partners’
recommendations and a literature review (Russell et al., 2012), hair cortisol was identified as a
low-burden method for collecting a marker of chronic stress. An initial protocol was developed
and then adapted based on partner feedback on community needs, cultural sensitivity, and
feasibility. As part of the research aims, participants were interviewed about the acceptability of
the current research. Initial participants’ feedback was integrated into further protocol adaptations.
Participant Recruitment and Engagement
Several techniques were employed to enhance recruitment for the cortisol study (see
Table 1). These included a flexible and persistent contact and scheduling approach, which took
into consideration logistical and sociocultural barriers to participating. For example, participants
were contacted at different times of the day, week, and month to account for non-traditional
work schedules and variability in telephone access. All efforts were made to see any participants
who arrived in person for a study visit, regardless of whether they arrived at their scheduled
appointment time or date. Participants whose hair was too short for hair sampling were given the

70
option to complete part of the study and return when their hair had grown ³1.5cm or to provide a
sample of body hair (e.g., underarm; Russell et al., 2012). Participants who missed appointments
were actively rescheduled.
Although the beginning of the study visit involved formal consent documents, consent
was considered an ongoing process throughout the visit (George et al., 2014). Participants were
provided a clear explanation of how their hair samples would be handled, and assurances that
their samples would only be assayed for cortisol. Research staff then collected hair samples for
off-site cortisol assay. Next, participants completed a brief feasibility/acceptability interview and
survey. Based on participant feedback while piloting the protocol, staff reviewed and provided a
brief tip sheet for managing stress at the end of the study visit. These tips were based on
cognitive behavioral therapy and mindfulness principles. Once the study and analyses are
complete, participants will receive an additional copy of the tip sheet, along with a summary of
the study findings.
Measures
Demographics. During the RADD study, participants were asked to report the following
demographic characteristics: age, household income, current health insurance coverage, gender
identity, sexual orientation, current marital status, US-born status, current living situation, and
race/ethnicity. Information was collected using the HIPAA-complaint online platform, CHORUS
(Arevian et al., 2018).
Interview. The qualitative acceptability interview consisted of nine open-ended questions
concerning perceptions of biospecimen research (including hair, saliva and blood sample research;
Rodriguez-Madera et al., 2017), although for purposes of the current study only the responses
regarding hair samples were used. Interviews lasted an average of fifteen minutes. Interviews were

71
conducted in Spanish or English, depending on participant preference. Participants were asked
about their motivations and concerns related to participating in a hair cortisol study (e.g., “What
motivated you to provide a hair sample?”). Interviews were audio recorded.
Qualitative Analysis
A thematic analysis approach (Braun & Clarke, 2006) was used to capture participants’
responses on the acceptability interview. The analysis was primarily at the code level and
involved systematically rating the presence or absence of each code. The initial codebook was
developed by the first author who conducted a majority of the study interviews (SMV). The
codebook was developed using an inductive approach and open coding. During the coder
training and reliability phase, the codebook was considered a living document that could be
refined. Once coder reliability was established, the codebook was finalized.
Four coders (LP, WR, SP, RM) rated the 90 interviews included in the analysis. Coder
training involved independently coding 15 interviews and discussing consensus. Reliability was
then established based on 25 interviews, which all four raters coded (see Table 3). Two bilingual
Spanish-speaking coders additionally coded 6 Spanish interviews to ensure the codebook
reflected both Spanish and English cases. Coders then independently coded the remaining cases
(n=59; 14-15 cases per coder), including the first 15 coding training cases. All coding was
conducted using interview audio recordings, and ratings were entered in Excel. Reliability was
analyzed using SPSS.
Results
Participants
Participants (N=94) were English or Spanish speaking adults (M=43.29 years; SD=13.47;
Table 2). Most participants identified as men (76.4%) and were low-income, with 69.6% of

72
participants earning £$20,000, annually. Additionally, 42.0% identified as gay or lesbian, 37.5%
as heterosexual, 11.4% as bisexual, and 9.1% as Queer/questioning. The majority of participants
were Hispanic (43.7%), followed by Black (29.9%), White (19.5%), and Other (6.9%).
Study engagement and recruitment
The study team attempted to contact 133 people, but scheduled visits with only 104
(Figure 1). Of those who scheduled an appointment (n=104), 94 participated in the study.
Participants who ultimately enrolled were contacted on the telephone an average of 5.74 times
(SD=4.22). Nine were additionally mailed a letter or contacted via e-mail, and two were
contacted via a relative or friend. Through our recruitment strategy, the research staff was able to
engage 71% of participants in the current study. Of those who participated in the study, 82%
(n=77) completed the hair sampling, brief interview, and survey portion of the study. These
participants were scheduled an average of 1.62 times (SD=1.23). Additionally, seven of the 77
participants did not have long enough hair during their visit and provided a hair sample during a
follow-up appointment. On average, the participants who scheduled a follow-up appointment did
so 2.29 times (SD=2.05). An additional 17 participants only completed the interview portion of
the study. Therefore, a total of 94 participants completed an interview, but only 90 audio
recordings were analyzed due to participants not consenting to record (n=1) or technical failures
with the recorder (n=3).
Interview findings
Results from the interviews are separated into two sections: 1) Facilitators; and 2)
barriers of participation in the hair cortisol study. All codes are presented in Table 3.

73
Facilitators of participation in the hair cortisol study. Participants who provided a hair
sample described several factors that facilitated their participation in the hair cortisol study.
These broadly fell under two themes: internal motivators, and external motivators.
Internal motivators for participating. Participants described several personal reasons for
participating in our study, including: (1) curiosity about their own health and stress, (2) desire to
contribute to research, and (3) prior experience participating in research studies. Overall, 73% of
Hispanic, 85% of Black, 73.3% of White, and 83.3% of Other race people endorsed some
internal motivator that contributed to their decision to provide a hair sample.
Curiosity about their own health and stress. The majority of participants (66.3%) stated
that they provided a hair sample because they wished to learn about their personal stress and
impact this had on their health. Seventy-three percent of Hispanic, 65% of Black, 53.3% of
White, and 50% of Other race people endorsed this as a motivating factor for providing a hair
sample. Several participants described wanting to learn whether they experienced too much
stress, or to understand how events in their lives might be impacting their stress level. For
example, one participant stated that he participated “Because I was curious about how stressed I
am or how I can stress less and maybe my hair will grow back” (Cisgender man, Gay, Black).
Desire to contribute to research. Over half (55%) of participants reported providing a
hair sample because they wanted to contribute to research or knowledge. Nearly half of Hispanic
(48.6%) and Black (45%), three-quarters (73.3%) of White, and two-thirds (66.7%) of Other race
people described this reason for participating. While some described personally enjoying
participating in research (“Research generally…is all for the purpose of education and
enlightenment”, Cisgender man, Gay, Black), others stated that they participated as a way to help
other members of their community. For example, one participant stated that he participated

74
because, “…[of] wanting to help… out. Give something back in a way” (Cisgender man, Gay,
Hispanic).
Prior experience participating in research. Several participants (25%) cited their prior
experience participating in research studies, particularly participation in the RADD study, as a
motivator. A small minority of Hispanic (18.9%) and Black (15%) participants endorsed this
reason for providing hair samples, whereas a much larger percentage of White (46.7%) and
Other race (50%) people described this as a rationale. For example, one woman stated that “…I
really like the way that they conducted the study with the follow-ups and making sure that after
the interviews everyone was okay. If they needed any sort of help contacting [mental health]
resources [they would help link people to care]. I thought that was great” (Cisgender woman,
Queer, Black). Many others similarly expressed willingness to provide a hair sample due to their
appreciation that they were being continuously followed up with and linked to resources by the
RADD study, suggesting that they experienced a personal benefit from participating in prior
research.
External motivators for participating. Participants described a number of external
reasons for participating in the hair cortisol study, with most involving factors related to the
research team or study. These include: 1) monetary incentives, 2) study convenience, 3) clear
explanations concerning the research study, and 4) perceptions of receiving a service in return
from the study. Given that many of these factors are well documented in prior work (e.g.,
Friedman et al., 2015), we elaborate below only on a few, but all codes are described in Table 3.
Seventy-three percent of Hispanic, 85% of Black, 73.3% of White, and 83.3% of Other race
participants endorsed some external factor that motivated them to provide a hair sample.

75
Clear explanation about the study. Some participants (17.5%) noted their initial
hesitation to participate was eased by the clear and ongoing consent process that included an
explanation about the purpose of the study and clarity on how samples would be handled. Few
Hispanic (10.8%), some White (18.8%), and a quarter of Black (25%) and Other race (28.6%)
participants described this as a motivation to participate.
Perception of receiving a service in return. Some participants (18.8%) perceived
participating in the current study as receiving a clinical service, such as cost-free information and
testing about stress and stress management. Few Hispanic (13.5%) and White (12.5%)
participants endorsed this reason, whereas over a third (35%) of Black and over a quarter
(28.6%) of Other race participants reported this was a motivating factor. Several participants
expressed a desire to acquire this information to improve their health. For example, one
participant stated that he provided a hair sample to receive feedback that might help improve the
quality of his current medical care: “I came here for answers to things that I don’t think people
[like my physician] are taking a look at. So, I’m hoping that it’ll reveal something that I can take
with me to show someone. You know, to advocate for myself.” (Cisgender man, Heterosexual,
Black).
Barriers to participation in the hair cortisol study
All participants described concerns and barriers to participating. For some, these
concerns remained throughout the study visit, whereas others reported that their concerns were
assuaged during the visit. Overall, participants reported three types of engagement-related
barriers: (1) mistrust, (2) stigma, and (3) aesthetics.
Mistrust. One third (33.3%) of participants reported worrying about the safety and
confidentiality of their hair sample. Nearly forty percent (38.5%) of Hispanic and Black, a

76
quarter (23.5%) of White, and few (14.3%) Other race participants endorsed concerns around
mistrust. For example, some participants described concerns about what would happen with their
data, citing recent news stories about companies sharing or selling customer’s data. “I was a little
worried about, like, confidentiality stuff… part of me that is just like totally weirded out by
companies like 23andMe, who… can sell [your data] or they can analyze certain portions … and
you would never know” (Cisgender man, Bisexual, Other). Others described concerns that their
data could be mishandled and used to implicate people in crimes, “If somebody tries to frame
you for a crime or something. But then they got your hair, so... you know, it’s their word against
yours but they got a sample of your hair (Cisgender man, Gay, Black).”
Stigma. Very few (3.3%) participants voiced concerns about social stigma surrounding
participating in mental health research. No Hispanic or White, 3.8% Black, and 28.6% of Other
race participants discussed worries about stigma.
Aesthetic concerns regarding the quantity of hair clippings. Very few (7.3%)
participants expressed concern that the amount of hair collected may leave a visible collection
spot. Approximately five percent (5.1%) of Hispanic, 3.8% of Black, 17.6% of White, and 14.3%
of Other race participants endorsed this concern.
Discussion
The current study relied on a community-partnered participatory research model (Chung
et al., 2010) to develop a protocol for collecting hair samples among low-income, ethnically, and
sexually diverse adults. We utilized a variety of recruitment techniques to explore how to engage
participants, and interviewed participants to understand their motivations and concerns
surrounding providing a hair sample. Through a CPPR model, community partners informed the
research team of the existing stress and health concerns, and helped to design research questions

77
and methodology. Given discussions with community partners, a wide net of recruitment
strategies was used. These included persistent, flexible, and respectful scheduling; attention to
relationship rapport and offering support to participants; staff availability; and transparency
about the study’s aims.
Seventy-one percent of people originally contacted participated in the current study.
Participants were interviewed and asked which strategies contributed to their decision to provide
a hair sample. Participants who provided a hair sample reported several internal and external
factors that motivated them to provide a hair sample, such as wanting to learn more about their
own stress and health. All participants expressed barriers to providing biospecimens, such as
potential violations to their rights to privacy and confidentiality. Despite those concerns, 82% of
participants who enrolled in the study provided a hair sample. This high rate of participation may
suggest that participants perceived the benefits of this research as outweighing the potential risks.
It is plausible that participants’ concerns may have been mitigated through the research team’s
ability to work with the community to clearly establish how the research might benefit
participants and their community. Below is a summary of lessons learned and recommendations
for future biospecimen studies recruiting diverse populations.
The engagement strategies and protocol of the current study can best be understood
through two, interrelated approaches: (1) a broader framework motivating and guiding research,
and (2) specific technical recruitment strategies the research team employed. Weighing benefits
and risks to the community is a fundamental component of community-partnered work (Jones &
Wells, 2007). Throughout the study, our team aimed to indicate to participants a mutual
relationship, where the research team was not merely extracting information from the community

78
without providing resources in return. In order to do this, our study relied on a process of
consultation with community partners and study participants.
Across participants’ interviews, themes related to benefit and risk emerged, underscoring
the importance of emphasizing research as a larger benefit to the individual and their community.
Both participants who did and did not provide a hair sample discussed several concerns about
biological samples, including worries related to trust, confidentiality, and sample usage/storage.
It is notable that some participants discussed concerns about potential data breaches that were
reflected in current events. For example, several Black participants reported concerns that the
data extracted from their hair samples may be used to implicate them or someone they know in a
crime. At the time the current study took place, several news stories reported that ancestry testing
companies had shared customer data with law enforcement. This linked customers’ relatives,
who had not provided a biospecimen sample, to crime scenes (Fortin, 2018). Despite these and
other concerns, participants were still willing to engage in biospecimen research.
In general, the qualitative findings suggest that biospecimen research with underserved
communities requires commitment to developing relationships as part of a collective effort to
conduct research, such that the perceived benefits outweigh the concerns of participation.
Throughout their interviews, participants described a desire to receive a service for their
participation. For example, during the piloting phase, several participants asked for information
about how to manage stress. Based on this feedback, the study protocol was adapted to provide a
brief tip sheet based on CBT and mindfulness skills to manage stress. Additionally, some
participants described a mutual relationship during their prior participation with the RADD
study, where participants provided data and the research team provided resources including
linking them to mental health services as needed. In both examples, participants described a

79
desire for immediate personal benefit from participating in the study. Other themes emerged in
participants’ responses that reflected a need for the larger community to also benefit from the
current research study. For example, some participants described providing a hair sample in
order to help improve knowledge about health in their community. Most participants appeared to
view that these personal and community benefits outweighed the serious risks of participating.
The second engagement approach focused on technical recruitment strategies that had
been used in past studies by our CPPR team to facilitate participation for disenfranchised groups.
These strategies included systematically scheduled participant contacts, flexibility in scheduling,
and specific efforts to establish rapport and build trust. Overall, the contact and scheduling
approach used in the current study aimed to be culturally informed by adopting a method that
places accountability on research staff. For example, rather than expecting participants to follow
up, the research team employed several strategies to make sure participants who had been called
or scheduled were not unintentionally forgotten. Given that many participants had non-traditional
work schedules, numerous life stressors, and variability in access to a telephone, research staff
repeatedly attempted to contact participants about the study.
At the same time, we weighed ethical considerations about unintentional coercion (Garza
et al., 2017) or participant discomfort related to repeated calls. Therefore, research team-initiated
contact was spaced out and a system was developed to transition to participant-initiated contact
through alternative means of communication (e.g., sending emails or letters asking participants
to contact the research team). Similar considerations were adopted when participants missed a
scheduled appointment, and research staff were responsible for contacting participants to
reschedule. Flexibility and accessibility were emphasized throughout the recruitment process,
such as by allowing participants to arrive late if necessary, using study cell phones which could

80
be used for texting or speaking with participants who got lost or needed support arriving to the
study location, and issuing appointment reminders.
Several participants noted that different efforts by the research team contributed to their
decision to provide a hair sample. Research staff received extensive training on how to clearly
explain the study and obtain ongoing consent from participants, with the goal to demonstrate
transparency and clarity about the study process. Several participants remarked on the critical
role this consent process played in their decision to provide a hair sample. Participants’
narratives suggested that they were searching for signs of legitimacy (e.g., specific rationale for
hair samples and the role cortisol plays in stress) and of specificity about the parameters of the
study (e.g., only cortisol, but not DNA, would be measured; safe disposal of hair samples).
Through the acceptability interviews, participants discussed how the different recruitment
strategies described above contributed to their participation in the study, as well as their broader
view about hair cortisol research. Given the dearth of data on SGM-POC (Parra & Hastings,
2018), these results provide important initial data about a highly under-studied population.
Overall, participants endorsed multiple reasons for providing hair samples. Participants most
commonly discussed wishing to learn about their health and stress. Statistical comparisons by
race were not possible in this study due to small subsamples yielding insufficient power.
However, some descriptive patterns can be observed based on the frequencies. For example, a
greater proportion of Whites in our sample than Blacks and Hispanics described that contributing
to research motivated them to provide a hair sample for the current study. Future studies with
larger samples should examine this and other subgroup differences in perceived motivators and
barriers to participation in biomarker research.

81
Given that SGM-POC are largely missing from biospecimen research, greater culturally
informed efforts are needed to mitigate participation in biospecimen research by increasing the
benefits and minimizing risks. General recommendations, based on this study’s findings, are
provided below.
1. Researchers should develop longstanding relationships with community partners, which may
help enhance participant mistrust, identify potential concerns, and develop appropriate
procedures based on community needs, cultural sensitivity, and feasibility.
2. Participant and community benefit for the study should be clearly stated (see Table 1, “Study
Wrap up and Analysis” for examples).
3. Since logistical barriers can keep underserved people from participating in research, recruitment
efforts should be informed by participants’ realities and adapted to facilitate study engagement
(see Table 1, “Participant Recruitment and Contact & Scheduling Visits” for examples).
4. The consent process should begin when participants are first contacted about the study and
should continue throughout the scheduled visit (see Table 1, “Consent Process” for examples).
5. Offering cash payment and notifying participants that payments are in cash is an effective
recruitment tool (Chung et al., 2010; see Table 1, “Consent Process” for examples). Aside from
cash incentives, future studies may benefit from paying separately for cost of transportation.

82
References
Agency for Toxic Substances and Disease Registry (2011). CTSA community engagement key
function committee task force on the principles of community engagement (2
nd
. ed.)
Arevian, A.C., O’Hora, J., Jones, F., Mango, J., Jones, L., Willians, P., Booker-Vaughns, J.,
Jones, A., Pulido, E., Banner-Jackson, D., & Wells, K. (2018) Participatory technology
development to enhance community resilience. Ethnicity & Disease, 28(Supp), 493-502.
Bassett, M. T., & Graves, J. D. (2018). Uprooting institutionalized racism as public health
practice. American journal of public health, 108(4), 457.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology, 3(2), 77–101.
Busse, D., Yim, I. S., Campos, B., & Marshburn, C. K. (2017). Discrimination and the HPA axis:
Current evidence and future directions. Journal of Behavioral Medicine, 40(4), 539–552.
Chung, B., Jones, L., Dixon, E. L., Miranda, J., Wells, K., & Community Partners in Care Steering
Council. (2010). Using a community partnered participatory research approach to implement a
randomized controlled trial: Planning the design of community partners in care. Journal of
Health Care for the Poor and Underserved, 21(3), 780.
Ford, J. L., Boch, S. J., & McCarthy, D. (2016). Feasibility of hair collection for cortisol
measurement in population research on adolescent health. Nursing Research, 65(3), 249.
Fortin, J. (2018). In serial rape case that stumped police, genealogy database leads to arrest. New York
Times, 23.
Garza, M. A., Quinn, S. C., Li, Y., Assini-Meytin, L., Casper, E. T., Fryer, C. S., Butler III, J.,
Brown, N. A., Kim, K. H., & Thomas, S. B. (2017). The influence of race and ethnicity on

83
becoming a human subject: Factors associated with participation in research. Contemporary
Clinical Trials Communications, 7, 57–63.
George, S., Duran, N., & Norris, K. (2014). A systematic review of barriers and facilitators to
minority research participation among African Americans, Latinos, Asian Americans, and
Pacific Islanders. American Journal of Public Health, 104(2), e16–e31.
Graham, R., Berkowitz, B., Blum, R., Bockting, W., Bradford, J., de Vries, B., & Makadon, H.
(2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for
better understanding. Washington, DC: Institute of Medicine, 10, 13128.
Hussain-Gambles, M., Atkin, K., & Leese, B. (2004). Why ethnic minority groups are
underrepresented in clinical trials: A review of the literature. Health and Social Care in the
Community, 12(5), 382-388.
Institute of Medicine (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in
Health Care. Washington, DC: The National Academies Press.
Institute of Medicine (2013). The CTSA program at NIH: Opportunities for advancing clinical and
translational research. Washington DC: The National Academies Press.
Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: the role of a
diverse workforce and the social determinants of health. Public Health Reports, 129(1_suppl2),
57-61.
Jones, L., & Wells, K. (2007). Strategies for academic and clinician engagement in community-
participatory partnered research. JAMA, 297(4), 407–410.
Kline, W. (2001). Building a better race: Gender, sexuality, and eugenics from the turn of the century
to the baby boom. University of California Press.

84
Layman, E. J. (2009). Human experimentation: Historical perspective of breaches of ethics in US
health care. The Health Care Manager, 28(4), 354–374.
Lewis, T. T., Cogburn, C. D., & Williams, D. R. (2015). Self-reported experiences of discrimination
and health: scientific advances, ongoing controversies, and emerging issues. Annual Review of
Clinical Psychology, 11, 407-440.
Lick, D. J., Durso, L. E., & Johnson, K. L. (2013). Minority stress and physical health among sexual
minorities. Perspectives on Psychological Science, 8(5), 521–548.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual
populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697
Miranda, J., Nakamura, R., Bernal, G. (2003). Including ethnic minorities in mental health
intervention research: A practical approach to a long-standing problem. Culture, Medicine, and
Psychiatry, 27(4), 467-486.
Myers, H. F. (2009). Ethnicity- and socio-economic status-related stresses in context: An integrative
review and conceptual model. Journal of Behavioral Medicine, 32.
National Institutes of Health. Institutional Clinical and Translational Science Award (U54). 2013;
http://grants.nih.gov/grants/guide/rfa-files/RFA-TR-12-006.html.
Novak, N., Lira, N., O’Connor, K., Harlow, S., Kardia, S., & Stern, A. (2018). Disproportionate
sterilization of Latinos under California’s eugenic sterilization program, 1920-1945. American
Journal of Public Health, 108(5), 611-613.
Oh, S. S., Galanter, J., Thakur, N., Pino-Yanes, M., Barcelo, N. E., White, M. J., ... & Borrell, L. N.
(2015). Diversity in clinical and biomedical research: a promise yet to be fulfilled. PLoS
Medicine, 12(12), e1001918.

85
Pandya, A. (2014). Mental health as an advocacy priority in the lesbian, gay, bisexual, and
transgender communities. Journal of Psychiatric Practice, 20(3), 225–227.
Parra, L. A, & Hastings, P. D. (2018). Integrating the Neurobiology of Minority Stress with an
Intersectionality Framework for LGBTQ‐Latinx Populations. New Directions for Child and
Adolescent Development, 2018(161), 91–108.
Richter, K. P., et al. (2012). Using “warm handoffs” to link hospitalized smokers with tobacco
treatment after discharge: Study protocol of a randomized controlled trial. Trials, 13(1), 127.
Rodríguez, M. F., Granda, M. M., & González, V. (2018). Gender Incongruence is No Longer a
Mental Disorder. Journal of Mental Health and Clinical Psychology, 2(5), 6-8.
Rodríguez-Madera, S. L., Díaz, N. V., Pibernus, A. R., Padilla, M., Guzzi, A. V., Rodríguez, G. R., &
Bockting, W. (2017). Exploring the feasibility and acceptability of biomarker collection for HIV
infection and chronic stress among transwomen in Puerto Rico. Revista Puertorriqueña de
Psicología, 28(2), 268–281.
Russell, E., Koren, G., Rieder, M., & Van Uum, S. (2012). Hair cortisol as a biological marker of
chronic stress: Current status, future directions and unanswered questions.
Psychoneuroendocrinology, 37(5), 589–601.
Satcher, D. (2001). Mental health: culture, race, and ethnicity – A supplement to Mental Health: A
Report of the Surgeon General. US Department of Health and Human Services, NIH.
Vargas, S. M., Huey Jr, S. J., & Miranda, J. (2020). A critical review of current evidence on multiple
types of discrimination and mental health. American Journal of Orthopsychiatry.
Yancey, A., Ortega, A., & Kumanyika, S. (2006). Effective recruitment and retention of minority
research participants. Annual Review of Public Health, 27(1), 1-28.

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Table 2
Participant characteristics
Variable Total
N = 94
Age, mean (SD) 43.29 (13.47)
Work-related income in U.S. Dollars
0 – 10,000 44.9
10,001 – 20,000 24.6
20,001 – 25,000 13.0
25,001 – 30,000 4.3
30,001 – 35-000 4.3
35,001 – 40,000 8.7
Current health insurance coverage
Yes 89.3
Current Gender
Woman 19.1
Man 76.4
Transgender man/ transgender male/ female-to-male 1.1
Transgender woman/ transgender female/ male-to-female 0
Genderqueer/ Gender non-conforming 3.4
Sexual Orientation
Straight or heterosexual 37.5
Gay (lesbian) or homosexual 42.0
Bisexual 11.4
Queer/questioning 9.1
Marital Status
Now married 11.4
Widowed 2.3
Divorced or separated 11.4
Single, never married 68.2
Living with someone as though married 6.8
Born in U.S.
Yes 65.9
Current Living Situation
Own home or apartment 3.4
Rent home or apartment 55.7
Living with friends or family 28.4
Living in a supported housing program 5.7
Living in an emergency shelter 0

Homeless 6.8
Race
a

Hispanic 43.7
Black 29.9
White 19.5

90
Other 6.9
Note. Results are % unless otherwise specified.
a
Missing demographic data not shown

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Table 3
Rater agreement across themes
Theme Kappa
value
Strength of
agreement
Facilitators of participation in the hair cortisol study
Internal motivators for participating
Curiosity about their own health and stress .56 Moderate
Desire to contribute to research .67 Substantial
Prior experience participating in research .85 Almost perfect
External motivators for participating
Monetary incentive .65 Substantial
Study convenience .67 Substantial
Clear explanation about the study .57 Moderate
Perception of receiving a service in return .31 Fair
Barriers to participation in the hair cortisol study
Mistrust .36 Fair
Stigma .38 Fair
Aesthetic concerns regarding quantity of hair clippings .91 Almost perfect
Note. All kappa’s refer to averaged Cohen’s Kappa, based on pairs using all four coders

92

93

94
Figure 1
Study engagement and recruitment flow chart

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Discussion
Despite that MST is an influential theory in understanding how social stress impacts
health disparities, little is known about how the theory applies to intersectional groups, such as
SGM-POC and ethnic minority women (Meyer, Schwartz, & Frost, 2008). While some scholars
suggest that multiple minority groups might experience incremental risk related to minority
stress (Meyer, Schwartz, & Frost, 2008), intersectionality scholars indicate that risks may vary
by specific subgroups (Bowleg, 2008). Each of the three manuscripts in this dissertation examine
a core component of MST among diverse multiple minority groups, to evaluate: 1) how
intersectional identities are associated with depression; 2) how intersectional characteristics (e.g.,
gender and ethnicity) contribute to the relationship between minority stressors and suicide risk;
and 3) how to engage understudied, intersectional groups in biological stress research. The
current set of findings provide some support for intersectionality frameworks suggesting that
subgroups, and their mental health risk, should be examined separately. By extension,
generalizations about multiple minorities were not observed. More research is needed to
understand how MST can be applied to diverse communities.
The first study in this dissertation examined rates of depression among an ethnically
diverse sample of low-income, predominantly SGM adults. The study provided two important
contributions to the literature: First, even when controlling for differences in income, bisexual
people exhibited greater odds of depression than lesbian/gay or straight adults. These findings
are important given that little is known about low-income, SM populations. Additionally, while
the finding about heightened rates of depression among bisexual adults is well established, few
studies have explored how differences in income account for these depression disparities (Ross

96
et al., 2018). Second, the results show limited evidence in support of racial/ethnic differences in
depression by SGM status. In general, White, Black, and Hispanic adults had similar rates of
depression as their White sexual orientation counterparts. An exception arose among bisexual
adults, where marginal differences were noted. When accounting for differences in income, it
appeared that Black and Hispanic bisexual adults were somewhat less likely than White bisexual
adults to report symptoms of depression. Taken together, these findings suggest that more
attention to racial differences is needed in understanding the documented depression disparity
among bisexual adults. However, given that findings in this study are marginal, results should be
interpreted with caution. Nevertheless, this study does not appear to provide support of added
burden and poorer mental health among multiply marginalized SGM-POC.
Next, the second study explored gender differences in the association between
discrimination and suicidality. The study found that among Latinx youth, experiencing
discrimination was associated with greater self-reported suicide risk. Gender moderated this
relationship, such that the effect was significant for both girls and boys, but stronger for girls.
This finding was maintained even when controlling for depressive symptoms. These results
indicate that some minority stressors, such as interpersonal discrimination, may be more
detrimental to the mental health of girls relative to boys. In terms of intersectionality and MST,
this manuscript provides support for the overall theoretical model describing a relationship
between minority identity, minority stress, and mental health problems. However, the findings in
this manuscript indicate that intersectional identity may also impact the magnitude of the
relationship between minority stress and mental health problems, such that Latinx girls were
more affected by discrimination than Latinx boys. These results indicate that attention to

97
intersectional subgroups is important, particularly in how minority stressors may contribute to
mental health problems.
Finally, the third study was influenced by the stress-health pathway implicated in MST.
The study reported methodological strategies to promote engagement with biomarker research
among low-income, predominantly SGM-POC adults. The manuscript reports the methods
employed in a study collecting hair cortisol samples, for a study that will later examine the
relationship between discrimination, cortisol, and depression. The paper also describes results
from interviews focused on individuals’ views about study acceptability. In general, participants
reported several motivators and ongoing barriers, such as mistrust, related to providing a
biological sample. Results suggest a need to balance these concerns with benefits received for
the community and individual participants.
Overall, these studies provide initial data about how MST can be refined to extend to
intersectional groups. Taken together, the studies suggest that multiple minority identity alone is
not an adequate index for understanding how minority stress is related to health disparities
among intersectional groups. Greater attention should be placed on how identity interacts with
minority stress to contribute to mental health problems. Limitations are described for each
specific study above. Across all the studies, some common limitations arise. First, no single
study examined all three components of the MST together. Second, the studies focus on related,
but different, mental health outcomes. Third, insufficient attention has been paid to
understanding mechanisms associated with resilience and risk among the subgroups studied
(Vargas, Huey, & Miranda, 2020). For example, more research is needed to understand what
specific factors contribute resilience among bisexual POC. Future studies should also assess why
interpersonal discrimination may be more strongly related to suicide risk among Latinx girls vs.

98
boys. Fourth, the studies relied on diverse samples and intersectional groups. The sample in the
third study was a subgroup of the larger, first study. The second study relied on a completely
different sample. The intersectional groups of focus varied across studies, with two focused on
SGM adults and one focused on Latinx youth. While the purpose of the current dissertation was
to rely on different intersectional samples to examine components of MST, the findings from
these studies may be affected by these sampling issues. Finally, all the studies in this dissertation
relied on cross-sectional data. More longitudinal studies are needed to test and refine MST.
Nevertheless, the current research provides important initial evidence in support of
intersectional scholars and direction for extending MST. While MST was originally developed
for SGM populations, the theories about social stress linked with minority identity need to be
explored with other minority groups who also face stressors such as racism, sexism, and
internalized stigma. More information is needed about how these processes impact intersectional
groups’ mental health. The current studies suggest that future research should attend to diverse
intersectional identities, avoiding grouping large characteristics together (e.g., all women without
attention to race) in order to understand how social stress differently impacts understudied
subgroups.

99
Comprehensive References

Agency for Toxic Substances and Disease Registry (2011). CTSA community engagement key
function committee task force on the principles of community engagement (2
nd
. ed.)
Alegría, M. (2009). The challenge of acculturation measures: What are we missing? A
commentary on Thomson & Hoffman-Goetz. Social Science & Medicine, 69(7), 996-998.
doi:10.1016/j.socscimed.2009.07.006
Arevian, A.C., O’Hora, J., Jones, F., Mango, J., Jones, L., Willians, P., Booker-Vaughns, J.,
Jones, A., Pulido, E., Banner-Jackson, D., & Wells, K. (2018) Participatory technology
development to enhance community resilience. Ethnicity & Disease, 28(Supp), 493-502.
Baams, L., Dubas, J. S., Russell, S. T., Buikema, R. L., & van Aken, M. A. (2018). Minority
stress, perceived burdensomeness, and depressive symptoms among sexual minority youth.
Journal of Adolescence, 66, 9-18.
Baams, L., Russell, S. T., & Grossman, A. H. (2015). Minority stress and mechanisms of risk for
depression and suicidal ideation among lesbian, gay, and bisexual youth. Developmental
Psychology, 51, 688–696.
Bassett, M. T., & Graves, J. D. (2018). Uprooting institutionalized racism as public health
practice. American journal of public health, 108(4), 457.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology, 3(2), 77–101.
Busse, D., Yim, I. S., Campos, B., & Marshburn, C. K. (2017). Discrimination and the HPA axis:
Current evidence and future directions. Journal of Behavioral Medicine, 40(4), 539–552.

100
Bell, R., & McCaffey, D. (2002). Bias reduction in standard errors for linear regression with
multi-stage samples. Survey Methodology, 28(2), 169–182.
Bostwick, W. B., Hughes, T. L., Steffen, A., Veldhuis, C. B., & Wilsnack, S. C. (2019).
Depression and victimization in a community sample of bisexual and lesbian women: An
intersectional approach. Archives of Sexual Behavior, 48(1), 131–141.
https://doi.org/10.1007/s10508-018-1247-y
Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an
important theoretical framework for public health. American Journal of Public Health,
102(7), 1267–1273. https://doi.org/10.2105/AJPH.2012.300750
Brody, D. J., Pratt, L. A., & Hughes, J. (2018). Prevalence of depression among adults aged 20
and over: United States, 2013-2016. NCHS Data Brief, no 303.
Brondolo, E., Brady ver Halen, N., Pencille, M., Beatty, D., & Contrada, R. J. (2009). Coping
with racism: A selective review of the literature and a theoretical and methodological
critique. Journal of Behavioral Medicine, 32(1), 64–88. https://doi.org/10.1007/s10865-
008-9193-0
Centers for Disease Control and Prevention. (2010). Current depression among adults - United
States, 2006-2008. MMWR, 59(38), 1229–1235.
https://www.cdc.gov/mmwr/PDF/wk/mm5938.pdf
Centers for Disease Control and Prevention. (2018). CDC WISQARS: Leading causes of death
reports, 1981–2018. Available from webappa. cdc. gov/sasweb/ncipc/leadcause. html.
Cespedes, Y.M. (2008). Evaluating a cultural process model of depression and suicidality in
Latino adolescents (Unpublished doctoral dissertation). University of Southern California,
Los Angeles, CA.

101
Chakraborty, A., McManus, S., Brugha, T. S., Bebbington, P., & King, M. (2011). Mental health
of the non-heterosexual population of England. British Journal of Psychiatry, 198(2), 143–
148. https://doi.org/10.1192/bjp.bp.110.082271
Chithambo, T., Huey, S.J., Jr., & Cespedes-Knadle, Y. (2014). Perceived discrimination and Latino
youth adjustment: Examining the influence of relinquished control, discrimination attribution,
nativity, and acculturation. Journal of Latino Psychology, 2(1), 54-66.
Cheref, S., Talavera, D., & Walker, R. L. (2019). Perceived discrimination and suicide ideation:
Moderating roles of anxiety symptoms and ethnic identity among Asian American, African
American, and Hispanic emerging adults. Suicide and Life‐Threatening Behavior, 49(3), 665-
677.
Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., ... &
Michaels, M. S. (2017). The interpersonal theory of suicide: A systematic review and meta-
analysis of a decade of cross-national research. Psychological Bulletin, 143(12), 1313.
Chu, J., Robinett, E. N., Ma, J. K., Shadish, K. Y., Goldblum, P., & Bongar, B. (2019). Cultural
versus classic risk and protective factors for suicide. Death Studies, 43(1), 56-61.
Chung, B., Jones, L., Dixon, E. L., Miranda, J., Wells, K., & Community Partners in Care Steering
Council. (2010). Using a community partnered participatory research approach to implement a
randomized controlled trial: Planning the design of community partners in care. Journal of
Health Care for the Poor and Underserved, 21(3), 780.
Cotton, C. R., & Range, L. M. (1993). Suicidality, hopelessness, and attitudes toward life and
death in children. Death Studies, 17(2), 185-191.
Duarté-Vélez, Y. M., & Bernal, G. (2007). Suicide behavior among Latino and Latina
adolescents: Conceptual and methodological issues. Death Studies, 31(5), 435-455.

102
Eaton, D. K., Foti, K., Brener, N. D., Crosby, A. E., Flores, G., & Kann, L. (2011). Associations
between risk behaviors and suicidal ideation and suicide attempts: Do racial/ethnic
variations in associations account for increased risk of suicidal behaviors among
Hispanic/Latina 9th-to 12th-grade female students?. Archives of Suicide Research, 15(2),
113-126.
Ford, J. L., Boch, S. J., & McCarthy, D. (2016). Feasibility of hair collection for cortisol
measurement in population research on adolescent health. Nursing Research, 65(3), 249.
Fortin, J. (2018). In serial rape case that stumped police, genealogy database leads to arrest. New York
Times, 23.
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., ... & Nock,
M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50
years of research. Psychological Bulletin, 143(2), 187.
Garza, M. J., & Pettit, J. W. (2010). Perceived burdensomeness, familism, and suicidal ideation
among Mexican women: Enhancing understanding of risk and protective factors. Suicide
and Life-Threatening Behavior, 40(6), 561-573.
Garza, M. A., Quinn, S. C., Li, Y., Assini-Meytin, L., Casper, E. T., Fryer, C. S., Butler III, J.,
Brown, N. A., Kim, K. H., & Thomas, S. B. (2017). The influence of race and ethnicity on
becoming a human subject: Factors associated with participation in research. Contemporary
Clinical Trials Communications, 7, 57–63.
George, S., Duran, N., & Norris, K. (2014). A systematic review of barriers and facilitators to
minority research participation among African Americans, Latinos, Asian Americans, and
Pacific Islanders. American Journal of Public Health, 104(2), e16–e31.
Gomez, J., Miranda, R., & Polanco, L. (2011). Acculturative stress, perceived discrimination,

103
and vulnerability to suicide attempts among emerging adults. Journal of Youth and
Adolescence, 40(11), 1465.
Gorman, B. K., Denney, J. T., Dowdy, H., & Medeiros, R. A. (2015). A new piece of the puzzle:
Sexual orientation, gender, and physical health status. Demography, 52(4), 1357–1382.
https://doi.org/10.1007/s13524-015-0406-1
Graham, R., Berkowitz, B., Blum, R., Bockting, W., Bradford, J., de Vries, B., & Makadon, H.
(2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for
better understanding. Washington, DC: Institute of Medicine, 10, 13128.
Grant, J. E., Odlaug, B. L., Derbyshire, K., Schreiber, L. R. N., Lust, K., & Christenson, G.
(2014). Mental health and clinical correlates in lesbian, gay, bisexual, and queer young
adults. Journal of American College Health, 62(1), 75–78.
https://doi.org/10.1080/07448481.2013.844697
Hill, R. M., & Pettit, J. W. (2012). Suicidal ideation and sexual orientation in college students:
The roles of perceived burdensomeness, thwarted belongingness, and perceived rejection
due to sexual orientation. Suicide and Life‐Threatening Behavior, 42(5), 567-579.
Hussain-Gambles, M., Atkin, K., & Leese, B. (2004). Why ethnic minority groups are
underrepresented in clinical trials: A review of the literature. Health and Social Care in the
Community, 12(5), 382-388.
Institute of Medicine (2013). The CTSA program at NIH: Opportunities for advancing clinical and
translational research. Washington DC: The National Academies Press.
Institute of Medicine (US) Committee on Lesbian Gay Bisexual and Transgender Health Issues
and Research Gaps and Opportunities. (2011). The Health of Lesbian, Gay, Bisexual, and
Transgender People. National Academies Press. https://doi.org/10.17226/13128

104
Institute of Medicine (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in
Health Care. Washington, DC: The National Academies Press.
Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: the role of a
diverse workforce and the social determinants of health. Public Health Reports, 129(1_suppl2),
57-61.
Jeong, Y. M., Veldhuis, C. B., Aranda, F., & Hughes, T. L. (2016). Racial/ethnic differences in
unmet needs for mental health and substance use treatment in a community-based sample of
sexual minority women. Journal of Clinical Nursing, 25(23–24), 3557–3569.
https://doi.org/10.1111/jocn.13477
Joiner, T. E. Why people die by suicide. Cambridge, MA: Harvard University Press; 2005.
Jones, L., & Wells, K. (2007). Strategies for academic and clinician engagement in community-
participatory partnered research. JAMA, 297(4), 407–410.
Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., ... & Lim, C.
(2018). Youth risk behavior surveillance—United States, 2017. Morbidity and Mortality
Weekly Report: Surveillance Summaries, 67(8), 1-114.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., Rush, A. J.,
Walters, E. E., & Wang, P. S. (2003). The epidemiology of major depressive disorder.
JAMA, 289(23), 3095. https://doi.org/10.1001/jama.289.23.3095
King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008).
A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and
bisexual people. BMC Psychiatry, 8(1), 70. https://doi.org/10.1186/1471-244X-8-70
Kline, W. (2001). Building a better race: Gender, sexuality, and eugenics from the turn of the century
to the baby boom. University of California Press.

105
Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H.
(2009). The PHQ-8 as a measure of current depression in the general population. Journal of
Affective Disorders, 114(1–3), 163–173. https://doi.org/10.1016/j.jad.2008.06.026
Kwon, S., & Han, D. (2019). Discrimination, mental disorders, and suicidal ideation in Latino
adults: Decomposing the effects of discrimination. Journal of Immigrant and Minority
Health, 21(1), 143-150.
Lamis, D. A., & Lester, D. (2013). Gender differences in risk and protective factors for suicidal
ideation among college students. Journal of College Student Psychotherapy, 27(1), 62-77.
Layman, E. J. (2009). Human experimentation: Historical perspective of breaches of ethics in US
health care. The Health Care Manager, 28(4), 354–374.
Leong, F. T., & Leach, M. M. (Eds.). (2010). Suicide among racial and ethnic minority groups:
Theory, research, and practice. Taylor & Francis.
Lewis, T. T., Cogburn, C. D., & Williams, D. R. (2015). Self-reported experiences of discrimination
and health: scientific advances, ongoing controversies, and emerging issues. Annual Review of
Clinical Psychology, 11, 407-440.
Lick, D. J., Durso, L. E., & Johnson, K. L. (2013). Minority stress and physical health among sexual
minorities. Perspectives on Psychological Science, 8(5), 521–548.
Linehan, M. M., & Nielsen, S. L. (1981). Suicidal behaviors questionnaire (SBQ). University of
Washington.
Little, R. J. A. (1988). Missing-data adjustments in large surveys. Journal of Business and
Economic Statistics, 6(3), 287–296. https://doi.org/10.1080/07350015.1988.10509663
Matheson, K., & Anisman, H. (2009). Anger and shame elicited by discrimination: Moderating

106
role of coping on action endorsements and salivary cortisol. European Journal of Social
Psychology, 39(2), 163-185.
Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief Patient Health
Questionnaire Mood Scale (PHQ-9) in the general population. General Hospital Psychiatry,
28(1), 71–77. https://doi.org/10.1016/j.genhosppsych.2005.07.003
McDonald, R. P. (1999). Test theory: A unified treatment. Mahwah, NJ: Lawrence Erlbaum
Associates.
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–
697. https://doi.org/10.1037/0033-2909.129.5.674
Meyer, I. H., Dietrich, J., & Schwartz, S. (2008). Lifetime prevalence of mental disorders and
suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of
Public Health, 98(6), 1004–1006. https://doi.org/10.2105/AJPH.2006.096826
Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does
disadvantaged social statuses confer more stress and fewer coping resources? Social Science
& Medicine, 67(3), 368–379. https://doi.org/10.1016/j.socscimed.2008.03.012
Miranda, J., McGuire, T. G., Williams, D. R., & Wang, P. (2008). Mental health in the context of
health disparities. American Journal of Psychiatry, 165(9), 1102–1108.
https://doi.org/10.1176/appi.ajp.2008.08030333
Miranda, J., Ong, M. K., Jones, L., Chung, B., Dixon, E. L., Tang, L., Gilmore, J., Sherbourne,
C., Ngo, V. K., Stockdale, S., Ramos, E., Belin, T. R., & Wells, K. B. (2013). Community-
partnered evaluation of depression services for clients of community-based agencies in
under-resourced communities in Los Angeles. Journal of General Internal Medicine,

107
28(10), 1279–1287. https://doi.org/10.1007/s11606-013-2480-7
Miranda, J., Nakamura, R., Bernal, G. (2003). Including ethnic minorities in mental health
intervention research: A practical approach to a long-standing problem. Culture, Medicine, and
Psychiatry, 27(4), 467-486.
Miranda, J., Chung, J. Y., Green, B. L., Krupnick, J., Siddique, J., Revicki, D. A., & Belin, T.
(2003). Treating depression in predominantly low-income young minority women: A
randomized controlled trial. JAMA: Journal of the American Medical Association, 290(1),
57–65. https://doi.org/10.1001/jama.290.1.57 U6 -
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=psyc4
&AN=2003-05836-001 M4 - Citavi
Muthén, L. K., & Muthén, B. O. (2011). Mplus User’s Guide. 1998–2011. Los Angeles,
California: Muthén and Muthén.
Myers, H. F. (2009). Ethnicity- and socio-economic status-related stresses in context: An integrative
review and conceptual model. Journal of Behavioral Medicine, 32.
National Institutes of Health. Institutional Clinical and Translational Science Award (U54). 2013;
http://grants.nih.gov/grants/guide/rfa-files/RFA-TR-12-006.html.
Novak, N., Lira, N., O’Connor, K., Harlow, S., Kardia, S., & Stern, A. (2018). Disproportionate
sterilization of Latinos under California’s eugenic sterilization program, 1920-1945. American
Journal of Public Health, 108(5), 611-613.
Oh, S. S., Galanter, J., Thakur, N., Pino-Yanes, M., Barcelo, N. E., White, M. J., ... & Borrell, L. N.
(2015). Diversity in clinical and biomedical research: a promise yet to be fulfilled. PLoS
Medicine, 12(12), e1001918.
O’Malley, A. S., Forrest, C. B., & Miranda, J. (2003). Primary care attributes and care for

108
depression among low-income African American women. American Journal of Public
Health, 93(8), 1328–1334. https://doi.org/10.2105/AJPH.93.8.1328
Pandya, A. (2014). Mental health as an advocacy priority in the lesbian, gay, bisexual, and
transgender communities. Journal of Psychiatric Practice, 20(3), 225–227.
Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-
analytic review. Psychological Bulletin, 135(4), 531.
Parra, L. A, & Hastings, P. D. (2018). Integrating the Neurobiology of Minority Stress with an
Intersectionality Framework for LGBTQ‐Latinx Populations. New Directions for Child and
Adolescent Development, 2018(161), 91–108.
Pérez, D. J., Fortuna, L., & Alegria, M. (2008). Prevalence and correlates of everyday
discrimination among US Latinos. Journal of Community Psychology, 36(4), 421-433.
Pérez-Rodriguez, M. M., Baca-Garcia, E., Oquendo, M. A., Wang, S., Wall, M. M., Liu, S. M.,
& Blanco, C. (2014). Relationship between acculturation, discrimination, and suicidal
ideation and attempts among US Hispanics in the National Epidemiologic Survey of
Alcohol and Related Conditions. The Journal of Clinical Psychiatry.
Plöderl, M., & Tremblay, P. (2015). Mental health of sexual minorities. A systematic review.
International Review of Psychiatry, 27(5), 367–385.
https://doi.org/10.3109/09540261.2015.1083949
Rabkin, J. G. (2008). HIV and depression: 2008 review and update. Current HIV/AIDS Reports,
5(4), 163–171. https://doi.org/10.1007/s11904-008-0025-1
Reynolds, W. M. (2002). RADS-2: Reynolds adolescent depression scale. Psychological
Assessment Resources.

109
Richter, K. P., et al. (2012). Using “warm handoffs” to link hospitalized smokers with tobacco
treatment after discharge: Study protocol of a randomized controlled trial. Trials, 13(1), 127.
Rodríguez, M. F., Granda, M. M., & González, V. (2018). Gender Incongruence is No Longer a
Mental Disorder. Journal of Mental Health and Clinical Psychology, 2(5), 6-8.
Rodríguez-Madera, S. L., Díaz, N. V., Pibernus, A. R., Padilla, M., Guzzi, A. V., Rodríguez, G. R., &
Bockting, W. (2017). Exploring the feasibility and acceptability of biomarker collection for HIV
infection and chronic stress among transwomen in Puerto Rico. Revista Puertorriqueña de
Psicología, 28(2), 268–281.
Russell, E., Koren, G., Rieder, M., & Van Uum, S. (2012). Hair cortisol as a biological marker of
chronic stress: Current status, future directions and unanswered questions.
Psychoneuroendocrinology, 37(5), 589–601.
Satcher, D. (2001). Mental health: culture, race, and ethnicity – A supplement to Mental Health: A
Report of the Surgeon General. US Department of Health and Human Services, NIH.
Schmitt, M. T., Branscombe, N. R., Postmes, T., & Garcia, A. (2014). The consequences of
perceived discrimination for psychological well-being: A meta-analytic review.
Psychological Bulletin, 140(4), 921.
Ross, L. E., Salway, T., Tarasoff, L. A., MacKay, J. M., Hawkins, B. W., & Fehr, C. P. (2018).
Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and
heterosexual individuals: A systematic review and meta-analysis. The Journal of Sex
Research, 55(4–5), 435–456. https://doi.org/10.1080/00224499.2017.1387755
Rubin, D. (1987). Multiple imputation for nonresponse in surveys. John Wiley & Sons.
Schafer, J. (1997). Analysis of Incomplete Multivariate Data. Vol 72: Chapman & Hall/CRC.
Taylor & Francis.

110
Shih, J. H., Eberhart, N. K., Hammen, C. L., & Brennan, P. A. (2006). Differential exposure and
reactivity to interpersonal stress predict sex differences in adolescent depression. Journal
of Clinical Child and Adolescent Psychology, 35(1), 103-115.
Smith, T. B., & Silva, L. (2011). Ethnic identity and personal well-being of people of color: A
meta-analysis. Journal of Counseling Psychology, 58(1), 42–60.
https://doi.org/10.1037/a0021528
Sun, R., Ren, Y., Li, X., Jiang, Y., Liu, S., & You, J. (2020). Self-compassion and family
cohesion moderate the association between suicide ideation and suicide attempts in
Chinese adolescents. Journal of Adolescence, 79, 103-111.
Thomas, J. L., Jones, G. N., Scarinci, I. C., Mehan, D. J., & Brantley, P. J. (2001). The utility of
the Ces-D as a depression screening measure among low-income women attending primary
care clinics. The International Journal of Psychiatry in Medicine, 31(1), 25–40.
https://doi.org/10.2190/FUFR-PK9F-6U10-JXRK
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr,
T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575.
Vargas, Sylvanna M., Huey, S. J., & Miranda, J. (2020). A critical review of current evidence on
multiple types of discrimination and mental health. American Journal of Orthopsychiatry,
90(3), 374–390. https://doi.org/10.1037/ort0000441
Vargas, Sylvanna Maria, Wennerstrom, A., Alfaro, N., Belin, T., Griffith, K., Haywood, C.,
Jones, F., Lunn, M. R., Meyers, D., Miranda, J., Obedin-Maliver, J., Pollock, M.,
Sherbourne, C. D., Springgate, B. F., Sugarman, O. K., Rey, E., Williams, C., Williams, P.,
& Chung, B. (2019). Resilience Against Depression Disparities (RADD): A protocol for a
randomised comparative effectiveness trial for depression among predominantly low-

111
income, racial/ethnic, sexual and gender minorities. BMJ Open, 9(10), e031099.
https://doi.org/10.1136/bmjopen-2019-031099
Wang, K. T., Wong, Y. J., & Fu, C. C. (2013). Moderation effects of perfectionism and
discrimination on interpersonal factors and suicide ideation. Journal of Counseling
Psychology, 60(3), 367.
Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical
and mental health: Socio-economic status, stress and discrimination. Journal of Health
Psychology, 2(3), 335-351.
Yancey, A., Ortega, A., & Kumanyika, S. (2006). Effective recruitment and retention of minority
research participants. Annual Review of Public Health, 27(1), 1-28.

Abstract (if available)

Abstract Minority stress theory (MST) suggests that mental health disparities occur partly due to excess the social stress (e.g., discrimination, victimization) associated with belonging to a stigmatized minority group. While empirical support exists for MST, less is known about how MST applies to multiple minority groups, such as sexual minority people of color, or women of color. While some scholars suggest that multiple minority groups might experience incremental risk related to minority stress, intersectionality scholars indicate that risks may vary by specific subgroups. The current three studies use an intersectionality framework to assess the relationship between depression/suicidality and three concepts implicated in MST: minority identity, discrimination, and biological stress. In particular, the manuscripts examine: 1) how intersectional identities are associated with depression; 2) how intersectional characteristics (e.g., gender and ethnicity) contribute to the relationship between minority stressors and suicide risk; and 3) how to engage understudied, intersectional groups in biological stress research. Results from the studies indicate that minority stress may confer different mental health risks across intersectional groups. In combination, these studies support intersectionality frameworks, by suggesting that subgroups, and their mental health risk, should be examined separately. More research is needed to continue extending components of the MST examining diverse intersectional groups.

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Asset Metadata

Creator Vargas, Sylvanna Maria (author)

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

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Psychology

Degree Conferral Date 2021-08

Publication Date 08/04/2021

Defense Date 12/15/2020

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

Tag Adolescent,Depression,ethnic minority,intersectionality,minority stress,OAI-PMH Harvest,sexual minority,Suicide

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Huey, Stanley J., Jr. (committee chair), Miranda, Jeanne M (committee chair), Goldbach, Jeremy (committee member), John, Richard S. (committee member), Saxbe, Darby (committee member)

Creator Email sylvanna.vargas@gmail.com,sylvannv@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15709327

Unique identifier UC15709327

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Rights Vargas, Sylvanna Maria

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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