Multifactorial discrimination as a fundamental cause of mental health inequities

To address the challenges of health inequities and the pervasive consequences of the social determinants of health, continued attention must be paid to the health impacts of social marginalization [1]. Health disparities based on sexual orientation, gender, race, socioeconomic status (SES), and other identity markers may be viewed through the minority stress framework [2], which suggests that unique stressors arising from minority experiences can impact epigenetic processes [3], influence health behaviors [4], and modulate the use of health services [5]. While minority stress may, in part, account for disparities due to the stressful experiences of discrimination [6, 7], the persisting and pervasive nature of these disparities can best be explained by the theory of fundamental causes [8]. According to the fundamental cause theory, despite radical changes in disease mechanisms and risk factors over time, health inequalities persist and replicate, such that health status and outcomes consistently differ across population groups. These disparities are reproduced via the ability of advantaged groups to access more resources-including knowledge, political clout, finances, and social support-than disadvantaged groups.

We expand on recent research showing that racism may be a fundamental cause of health inequalities [9] by examining the associations between intersecting minority identities, the stress experienced by non-White sexual minorities, and mental health outcomes. Given their dual minority status, non-White sexual minorities may experience stressors that differ from those experienced by non-White heterosexuals or White lesbian, gay, bisexual, and queer individuals (LGBQs). Within LGBQ communities, non-White sexual minorities often experience racism that causes them to feel excluded from LGBQ community spaces and events [10]. For example, certain gay bars have been known to provide poor services to African American gay men and in some cases, refuse their entry altogether [11]. Within their own cultural communities, non-White sexual minorities may experience heterosexism causing members to conceal their sexual orientation [12]. Such forms of discrimination can have major implications for health, leading to poor mental and physical health outcomes among non-White sexual minorities [13, 14].

To investigate the effects of multifactorial discrimination on mental health outcomes among multiple minority populations, we incorporated an intersectional framework into our understanding of discrimination as a potential fundamental cause of mental health inequalities. Intersectionality is a framework used to conceptualize how multiple social identities dynamically intersect and concurrently interact with each other in relation to interlocking structures of oppression [15]. Intersectionality allows for a nuanced understanding of how intersecting identities confer unique privileges and oppressions. As a consequence of an individual’s intersecting identities, the oppressions they experience are intrinsically linked and cannot be isolated from another. Within an intersectional framework, it is difficult to examine different types of discrimination independently, because they constitutively overlap and interact. An intersectional approach to discrimination recognizes that discrimination is multifactorial, arising from diverse sources and for numerous reasons, impacting multiple minority identities. Multifactorial discrimination refers to the total discrimination experienced by such individuals, accounting for their sexual orientation, gender, race/ethnicity, and/or other identity markers.

Due to the importance of discrimination in understanding the health of multiple minority identities, we sought to test whether experiences of multifactorial discrimination can be identified as a fundamental cause of mental health inequalities. In order to test this theory, we compared multifactorial discrimination to Link and Phelan’s four necessary criteria to establish a fundamental cause: 1) the cause influences multiple health outcomes; 2) the cause affects health outcomes through multiple risk factors; 3) the cause involves access to resources that can be used to reduce health risks or the progression of disease; and 4) the association between the cause and poor health should be reproduced over time through varied mechanisms [8]. As a result of the limitations of our data, we chose to focus this study specifically on evaluating multifactorial discrimination as a fundamental cause of mental health inequalities among lesbian, gay, and bisexual (LGB) populations.

Table 1 presents the demographics and health characteristics of LGB individuals with low and high depression scores. Lower education levels were associated with an increased probability of depression (\( \chi \) ² = 13.79, p < 0.05). Among individuals with high levels of depression, 42.17% had completed a bachelor’s degree or more advanced education, yet over 72.92% belonged to the lowest two income quintiles (\( \chi \) ² = 10.62, p < 0.05). Nearly half of Latino/Hispanic participants (49.62%) reported high depression symptoms, higher than the risk of depression among White (32.09%) or Black/African-American (30.00%) participants (\( \chi \) ² = 13.03, p < 0.01). People who were unemployed (\( \chi \) ² = 6.14, p < 0.05) or diagnosed with an emotional disorder (\( \chi \) ² = 14.32, p < 0.01) were more likely to report high depression symptoms.

These results lend support to multifactorial discrimination as a fundamental cause of mental health inequities (Tables 2, 3, 4 and 5), given that discrimination meets all four criteria proposed by Link and Phelan [8]. To our knowledge, this is the first study to consider multifactorial discrimination as a fundamental cause of mental health inequities. Our results offer a possible explanation as to why multiple minority identities experience 1) multiple adverse psychological health outcomes, 2) higher exposure to risk factors, 3) less access to protective factors, and 4) poor mental health trajectories [14, 15, 34‐36].

Our finding that multifactorial discrimination influences multiple psychological outcomes (Table 2) is consistent with other studies. Among Black/African-American LGBQ adolescents, racist and antigay discrimination was found to be associated with suicidal ideation and depressive symptoms [37]. Discrimination, including experiences of homophobia and racism, significantly predicted symptoms of psychological distress in a population of gay, Latino men [14]. Compared to White sexual minorities, more Black/African-American and Latino/Hispanic LGBQ subjects reported a history of serious suicide attempts [38]. Meanwhile, compared to heterosexual women of color and white sexual minority women, sexual minority women of color had greater risk of self-reported lifetime substance use [39].

Similarly, the results indicating that multifactorial discrimination affects multiple stress measures (Table 3) are substantiated by recent studies on multiple minority populations. One study showed that young Black/African-American men who have sex with men experience more distal stressors due to racism and homophobia [40]. Furthermore, in relation to advantaged groups, Black sexual minority women experience greater stress due to multifactorial discrimination on the basis of their triply disadvantaged social status in terms of sex, race, and sexual orientation [41, 42]. Research suggests that stress is a mediator of the relationship between discrimination and health in multiple minorities [14, 43, 44].

Moreover, the finding that multifactorial discrimination influences access to protective psychosocial resources is supported by studies that show lower levels of mastery and social support among diverse racial/ethnic LGBQs [45, 46], and studies that show these psychosocial resources buffer experiences of minority stress [6, 47, 48]. Interestingly, our results show that discrimination specifically affects access to individual-level protective factors such as mastery and self-esteem as opposed to interpersonal-level factors such as social support and collective esteem (Table 4).

Finally, our results highlight multifactorial discrimination as a continuous contributor to psychiatric morbidity even after accounting for stress-related risk factors (Table 5). These findings coincide with research examining the different pathways through which discrimination is capable of perpetuating health inequalities more broadly. While the alternative mechanisms through which discrimination affects mental health over time are unidentifiable in our analysis, research shows that multifactorial discrimination encountered by multiple minorities is associated with increased health-risk behaviors, which may be linked to various poor health outcomes [49‐51]. Additionally, multifactorial discrimination may be responsible for widening health disparities by decreasing access to quality health care among marginalized communities. A nationwide survey found that non-White sexual minorities experienced higher rates of discrimination in health care settings relative to their White counterparts [52]. When compared to White sexual minorities, non-White sexual minorities were more likely to report fears and concerns about obtaining necessary health services due to past experiences of discrimination and substandard care [53]. In another study, African American sexual minority women who attributed their negative experiences in a healthcare setting to multifactorial discrimination decreased their health care utilization following the negative experience [54]. Among minority populations, discrimination during health care is significantly associated with delayed care and stopped treatment [55, 56]. Disengagement with the health care system due to negative patient-provider interactions, resulting from discrimination, may partially explain poor health outcomes across marginalized communities [57‐59]. Given that discrimination can affect disease outcomes, through its effect on health care access, the relationship between discrimination and poor health is thought to be partly mediated by non-stress-related risk factors. Even if stress caused by multifactorial discrimination could be eliminated, research indicates that discrimination would continue to maintain and reproduce health inequalities through other intervening mechanisms.

Although multifactorial discrimination has not previously been identified as a fundamental cause of mental health inequities, recent research proposes stigma as a fundamental cause of health inequalities [33]. Hatzenbuehler, Link, and Phelan argue that stigma is an all-encompassing concept that includes various stigmatized statuses, including, but not limited to HIV status, obesity, sexual orientation, disability, and race/ethnicity. They also state that discrimination is a “constitutive feature of stigma” because “the overall stigma process incorporates several other elements, such as labeling and stereotyping”, making the concept broader than discrimination [33]. The Project STRIDE dataset did incorporate a stigma measure, which was moderately correlated with discrimination. However, we used the discrimination measure in our analysis not only for its validity and reliability [60], but also to address a specific theoretical framework that centers on discrimination as it relates to intersecting minority identities, considering individual, intersectional experiences and behavior. While stigma typically refers to beliefs and attitudes that lead people to fear, avoid, or reject those they perceive as different, discrimination is the behavioral manifestation of stigma [61]. Arguably, this quality makes discrimination easier to measure than stigma. Therefore, just as both racism and residential segregation have been established as fundamental causes despite being linked [9, 62], we believe our analysis provides strong evidence to include multifactorial discrimination as a fundamental cause in its own right.

In light of our findings, public health interventions would likely benefit from incorporating intersectional perspectives to adequately serve diverse populations. Currently, few epidemiological studies reflect intersectionality in their theoretical frameworks [77], and therefore, the evidence base informing intersectionality of intervention design and policy is sparse. Moreover, public health practitioners must continue to address the upstream, fundamental causes of inequalities as opposed to focusing on downstream risk factors alone.

While the fundamental cause theory is acknowledged in the public health field, much work remains to be done to implement effective interventions and policies to reduce the impact of fundamental causes on health disparities. Addressing multifactorial discrimination as a fundamental cause will likely involve collaborating across many disciplines, institutions, and fields to organize efforts aimed at eliminating disparities through community mobilization, advocacy, education, and policy change. As a fundamental cause of mental health inequities, multifactorial discrimination will continue to perpetuate health disparities until it is addressed at an upstream level.