Authors: Ohshue S. Gatanaga (1. Department of Sociomedical Sciences, Columbia Mailman School of Public Health; 2. Social Intervention Group, Columbia School of Social Work; 3. Department of Health Systems and Population Health, University of Washington School of Public Health), Daniel Kwak (4. Teachers College, Columbia University), Sahnah Lim (5. Department of Population Health, New York University Grossman School of Medicine), Christian T. Gloria (1. Department of Sociomedical Sciences, Columbia Mailman School of Public Health)
Categories: Article, intersectional discrimination, LGBTQ+ Asians, minority stress, mental health, disparities, depression
Source: Psychology and sexuality
Authors: Ohshue S. Gatanaga, Daniel Kwak, Sahnah Lim, Christian T. Gloria
LGBTQ+ Asians are an under-researched population and face higher risk for mental health problems than heterosexual individuals due to intersectional discrimination and minority stress. This exploratory, mixed-methods study sought to understand associations between minority stress, intersectional discrimination, and mental health outcomes among LGBTQ+ Asians. Between 2022 and 2023, convenience sampling was used to survey 136 LGBTQ+ Asian residents of New York City. Controlling for demographics, logistic regression was used to compare the proportion of individuals with clinically-significant symptoms for major depressive disorder, generalized anxiety disorder, and suicide risk by self-reported measures of discriminatory and microaggressive experiences towards LGBTQ+ people of color. A subsample of 24 individuals participated in semi-structured interviews that were conducted in English. Thematic content analysis was utilized to understand contextual factors and discriminatory experiences influencing LGBTQ+ Asian mental health. Individuals with higher levels of everyday discrimination had higher odds of exhibiting clinically-significant depressive symptoms, anxiety symptoms, and suicide risk. Individuals with higher levels of racialized and LGBTQ-related microaggressions had higher odds of exhibiting clinically-significant depressive and anxiety symptoms. Among interviewed participants, predominant themes include social isolation, anticipated stigma attributed to discriminatory experiences within both LGBTQ+ and Asian communities, and pervasive impacts of racial and LGBTQ+ discrimination on mental health and self-worth. Findings reveal disparities in mental health outcomes among LGBTQ+ Asians, with differences based on levels of self-reported discrimination and targeted microaggressions towards LGBTQ+ racial/ethnic minorities. More research is needed to understand the causal and temporal mechanisms by which intersectional discrimination impacts LGBTQ+ Asians’ mental health.
LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other sexual/gender minorities) Asians remain heavily underrepresented in mental health research in the United States (U.S.). While Asians constitute the fastest-growing racial group in the U.S., there exists limited disaggregation of data that meaningfully captures mental health disparities across Asian subgroups (Budiman and Ruiz 2021, Schweis 2021). In a scoping review of peer-reviewed literature from 1991 to 2018, four studies, of the 76 that included disaggregated health data on Asian subgroups, assessed mental health outcomes (Yom and Lor 2022).
The Model Minority Myth, which purports that Asians universally achieve wellbeing through academic and occupational success, exacerbates this lack of disaggregated data by characterizing Asians as a monolithic group requiring little public health research (Yi and Museus 2015). Combined with national findings reporting historically lower rates of serious mental health problems among Asians compared to other racial groups, the Model Minority Myth perpetuates the false narrative that mental health problems and access to mental health care are non-issues across all Asian communities in the U.S (Substance Abuse and Mental Health Services Administration 2011, Sue et al. 2012). However, in an analysis of the National Surveys on Drug Use and Health, Asians with higher perceived need for mental health treatment were found to access care at lower rates than their White counterparts (Yang et al. 2020). Additionally, an emerging research base highlights variation in mental health outcomes among Asian Lee et al. (2015) found that Southeast Asians reported a higher prevalence of any DSM-IV psychiatric disorders compared to South and East Asians.
Among Asian subgroups, LGBTQ+ Asians may be at heightened risk for mental health problems due to the unique stressors and challenges attributed to their intersecting minority identities (Ching et al. 2018). Intersectionality theory, first introduced by Kimberlé Crenshaw (1989), recognizes how systems of oppression overlap to create distinct, typically-deleterious experiences for people with multiply-marginalized identities. Most commonly, experiences of intersectional discrimination (i.e. discrimination stemming from an individual’s identity as multiply-marginalized) may lead to minority chronic stress experienced by members of marginalized social groups, typically through acts of microaggressions and othering (Meyer 2003). At the interpersonal level, intersectional discrimination among LGBTQ+ Asians may manifest itself as the hyper-emasculation of gay Asian men among LGBTQ+ communities and rejection of LGBTQ+ identity within Asian immigrant communities (Dang and Vianney 2007, Han 2016). At the structural level, limited recognition of LGBTQ+ Asians as underserved and marginalized—a lasting impact of the Model Minority Myth—may pragmatically lead to limited funding for research that better captures subgroup disparities and informs culturally and/or linguistically-sensitive health services for LGBTQ+ Asians (Ching et al. 2018, Russel and McCurdy 2023).
Presently, research investigating LGBTQ+ Asian mental health remains in its nascent stages. In the sole study investigating the impact of discrimination on mental health outcomes among LGBTQ+ Asians, Takeda et al. (2021) found that experiences of racialized, intersectional, and LGBTQ+ discrimination were positively associated with internalizing symptoms related to anxiety and depression. However, less is known about the relationship between intersectional discrimination and suicide among LGBTQ+ Asians—though LGBTQ+ Asians reported higher odds of suicidal ideation and attempts than their non-Hispanic, white peers in a national sample of U.S. college students (Lytle et al. 2014).
This mixed-methods study expands upon the existing literature by quantitatively exploring the relationship between intersectional discrimination and clinically-significant depression, anxiety, and suicide risk among LGBTQ+ Asians. Additionally, the qualitative portion of the study examines the lived experience of intersectional discrimination among LGBTQ+ Asians and examines its relationship to their mental health. Given the prior literature on the relationship between discrimination on mental health outcomes generally, this study hypothesizes that there will be a positive and modest relationship between intersectional discrimination and clinically-significant depression, anxiety, and suicide risk among LGBTQ+ Asians.
Between October 2022 and January 2023, online convenience sampling was utilized to survey 136 individuals who 1) identified as LGBTQ+ Asians; 2) resided or worked in New York City (NYC); and 3) were 18 years or older. Study fliers were distributed through email lists and social media of NYC-based organizations serving LGBTQ+ Asians. Participants who expressed interest in the study were provided with informed consent, a consent form, link to an online survey via Qualtrics (2020), and a 25 gift card as compensation. All participants provided informed consent before study participation. This study received Institutional Review Board approval from the Columbia University Irving Medical Center (AAU2606).
The following demographic variables were measured in the age at time of survey, racial subgroup, and whether the participant was born in the U.S (i.e. U.S. born status). Age was measured as a continuous variable ranging from 19 to 45. Racial subgroup was dichotomized to East Asian vs. non-East Asian. While the survey included questions on specific ethnic subgroups, the final analysis included a dichotomized variable capturing East Asian vs. non-East Asian due to small sample size and prior literature which suggests that East Asians may experience lower rates of mental health diagnoses compared to non-East Asians (Lee et al. 2015). Additionally, East Asian subgroups have historically experienced higher wages and socioeconomic status, and the explicit distinction between East Asian and non-East Asian is important given these disparities and the historical focus on East Asians within Asian American public health literature (Schweis 2021, Banerjee, 2022). Finally, participants were asked whether they were born in the U.S., and responses were dichotomized into “yes” or “no.” While the initial survey asked for other demographic variables (religious affiliation, income level, sexual orientation, gender identity), these variables were removed from the final analyses due to sample size limitations or their demonstrated lack of association with the outcome variables during preliminary analyses.
The outcome variables consist of three dichotomized measures operationalizing clinically-significant major depressive disorder (MDD), generalized anxiety disorder (GAD), and suicide risk. The Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-administered questionnaire that assesses the severity of depressive symptoms via a continuous scale from 0 to 27, with 27 indicating the presence of severe symptoms related to MDD (Kroenke et al. 2006). The PHQ-9 has excellent internal consistency (Cronbach’s α = .89), test-retest reliability (r = 0.84), and strong associations between PHQ-9 scores and convergent scales measuring depression (r = .73) (Kroenke et al. 2006, Martin et al. 2006). Participants were asked to rate various items representing loss of pleasure, feelings of hopelessness, energy levels, and appetite on a scale from 0 to 3, with 0 representing “Not at all,” 1 representing “Several days,” 2 representing “More than half the days,” and 3 representing “Nearly every day.” A few example items from the questionnaire “Over the last two weeks, how often have you been bothered by having little interest or pleasure in doing things?” and “Over the last two weeks, how often have you felt down, depressed, or hopeless?” After adding scores across items, a predetermined cut-off score of ≥ 10, based on prior literature, was used to dichotomize the variable into individuals who did and did not report clinically-significant MDD symptoms (Kroenke et al. 2006).
For GAD, the Generalized Anxiety Disorder-7 (GAD-7), a 7-item self-administered questionnaire ranging from scores of 0 to 21, was utilized to assess the severity of symptoms related to GAD (Spitzer et al. 2006). The GAD-7 has excellent internal consistency (Cronbach’s α = .92), test-retest reliability (r = 0.83), and modest construct validity for measuring anxious symptoms across individuals with diverse demographic characteristics (Spitzer et al. 2006, Löwe et al. 2008). A score of 21 indicates the presence of severe symptoms related to GAD. The individual items in the GAD-7 are scored similarly to the PHQ-9 and instead measure feelings of nervousness, not being able to control worrying, restlessness, irritability, and trouble relaxing. A few example items from the GAD-7 questionnaire “Over the last two weeks, how often have you been bothered by not being able to stop or control worrying?” and “Over the last two weeks, how often have you been bothered by feeling afraid as if something awful might happen?” After adding scores across items, a predetermined cut-off score of ≥ 10, based on prior literature, was used to dichotomize the variable into individuals who did and did not report clinically-significant GAD symptoms (Spitzer et al. 2006).
For suicide risk, the Columbia-Suicide Screener Rating Scale (C-SSRS) screen version was utilized to dichotomize individuals into those who did and did not indicate high suicide risk (Posner et al. 2011, Bjureberg et al. 2022). The C-SSRS has high internal consistency (Cronbach’s α = .88), inter-rater reliability (k > .67), and exhibited moderate convergent validity (r = 0.52) for measuring the most suicidal period during an individual’s lifetime (Posner et al. 2011, Nam et al. 2024). The screen version of the C-SSRS is an adapted version of the C-SSRS that has been utilized by the Centers for Medicare and Medicare Services to identify high suicide risk.^21^ Participants who answered affirmatively to any of the following questions were categorized as having high suicide “Have you had thoughts or killing yourself and had some intention of acting on them?”; “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?”; or “Have you ever done anything, started to do anything, or prepared to do anything to end your life?”
The independent variables consist of four measures of discrimination. Three subscales from the Lesbian, Gay, Bisexual, and Transgender People of Color Microaggression Scale (LGBT-PCMS) measure the unique types of microaggressions experienced by ethnic minority LGBT adults (Balsam et al. 2011). Each subscale of the LGBT-PCMS was operationalized as a continuous scale from 0 to 30, with higher scores indicating greater levels of distress and instances of microaggressions attributed to 1) racism in dating and close relationships; 2) racism in LGBTQ+ communities, and 3) heterosexism in Asian communities. While a newer scale, the LGBTQ-PCMS has a strong correlation between its frequency and appraisal measures for the entire scale (r = .78), the racism in dating and close relationships subscale (r = .80), the racism in LGBTQ+ communities subscale (r = .83), and the heterosexism subscale (r = .83) (Balsam et al. 2011).
Outside of experiences specific to LGBTQ+ racial/ethnic minorities, the Everyday Discrimination Scale (EDS) was utilized to capture recurrent instances of discrimination in individuals’ day-to-day life based on an individuals’ gender, age, height, weight, and other factors (Williams et al. 1997). The EDS has a high internal consistency (Cronbach’s α = .74), high test-retest reliability (r = .70), and excellent construct validity for measuring discrimination (r = .79) (Krieger et al. 2005). The EDS was operationalized as a continuous scale from 0 to 42, with higher scores indicating greater perceived discrimination. Additionally, the EDS includes a follow-up question for individuals who reported experiences of discrimination at least a few times a “What do you think is the main reason for these experiences?” Participants were provided a list of reasons that included their race, age, gender, sexual orientation, ancestry or national origins, and physical appearance.
The quantitative analysis was performed using SAS OnDemand for Academics software (2023). First, univariate analysis was conducted to examine demographic variables (age, racial subgroup, U.S. born status, religious affiliation, income level, sexual orientation, gender identity), measures of discrimination, and mental health outcomes. Comparisons were made using chi-squared tests and t-tests, and the final analysis excluded religious affiliation, income level, sexual orientation, and gender identity due to sample size limitations or their demonstrated lack of association with the outcome variables. Controlling for the remaining demographic variables, several multivariable binary logistic regression models were used to examine the relationships between the independent variables (EDS and LGBT-PCMS subscales) and the outcome variables (clinically-significant symptoms associated with MDD, GAD, and suicide risk). Prior to analysis and binarization of outcome variables, Cronbach’s α were calculated for all scale items to ensure high internal PHQ-9 (α = .90), GAD-7 (α = .91), C-SSRS (α = .83), LGBTQ-PCMS (α = .90), the racism in dating and close relationships subscale (α = .83), the racism in LGBTQ+ communities subscale (α = .83), the heterosexism subscale (α = .79), and the EDS (α = .89). The level of statistical significance was set at a p-value less than 0.05 for all inferential statistics.
In-depth interviews elicited information on participants’ lived experiences of intersectional discrimination and the impact of these events on their mental health. All interviews were conducted in English, audio-recorded, and transcribed verbatim. The interviewing team was composed of two trained qualitative the first author is an Asian, gender non-conforming individual with several years of experience conducting graduate-level qualitative research. The second interviewer (second author) is an Asian, gender non-conforming individual with several years of experience conducting qualitative research at the postgraduate level.
Data were iteratively analyzed using an inductive process integrating narrative, content analysis, and thematic approaches (Pope et al. 2000). An inductive approach allowed for the authors to engage deeply with the interviews and allow themes to organically emerge from the text. A narrative approach facilitated an understanding of how participants constructed their own stories, contextualized their experiences, and derived meaning from them. Finally, content analysis provided a systematic framework to identify significant patterns and trends of recurring words, phrases, or concepts across participants. Through the integration of these three approaches, the transcripts were double coded, and a codebook was developed by a team of two coders that included the two interviewers. The codebook outlined definitions of codes and included examples directly from the transcripts. Reliability of coding was ensured through frequent discussions and consensus between coders to achieve inter-coder reliability (Miles et al. 2018). The codebook was repeatedly revised until a final consensus was reached between both coders. After reading transcripts multiple times, the study team then compiled several themes and subthemes across participants, utilizing each participants’ narratives to ensure that responses were grounded in their specific contexts. The coding and analyses were conducted via Atlas.ti Web, an online software for qualitative data analysis (ATLAS.ti Scientific Software Development, 2023).
Qualitative interviews supplemented the findings from the quantitative data by providing tangible examples of intersectional discrimination aligned with the three subscales of the LGBTQ-PCMS: racism in dating and close relationships, racism in LGBTQ+ communities, and heterosexism in Asian communities. Moreover, while the quantitative analysis identifies associations between measures of discrimination and mental health outcomes, the qualitative portion provides additional context into how discrimination may impact LGBTQ+ Asians’ mental health in their day-to-day lives.
Table 1 provides univariate estimates for participant demographics, discrimination measures, and mental health outcomes. The average age of participants in the study was 27.03 years, with a standard deviation of 5.13 years. Of the participants, 51.47% (n=70) identified as East Asian, whereas 48.53% (n=66) identified as non-East Asian. Additionally, 38.97% (n=53) of participants identified as male, 42.65% (n=58) as female, and 18.38% (n=25) as gender non-binary. A majority of participants identified as cisgender (n=111, 81.62%), and 18.38% (n=25) identified as transgender. A plurality of participants reported their income level as less than 50,000 to 75,000 or more (n=31, 22.79%), and finally income levels of 49,999 (n=20, 14.71%). Most participants identified as gay or lesbian (n=66, 48.53%), whereas 25.74% (n=35) identified as bisexual, and 25.74% (n=35) identified as queer or another sexual orientation. A majority of participants were born in the U.S. (n=85, 62.50%).
On average, participants had an EDS score of 15.86 (SD=9.16). A majority of participants reported race (n=111, 81.62%) and gender (n=72, 52.94%) as reasons for experiencing discrimination. Other reasons for experiencing discrimination include participants’ ancestry or national origins (n=61, 44.85%), sexual orientation (n=58, 42.65%), physical appearance (n=55, 40.44%), and age (n=47, 34.56%). For the LGBT-PCMS subscales, participants had a mean score of 8.99 (SD=7.71) on the Racism in Dating and Close Relationships Subscale, 12.40 (SD=8.05) on the Racism in LGBTQ+ Communities Subscale, and 13.01 (SD=7.33) on the Heterosexism in Asian Communities Subscale. 42.65% (n=58) of participants reported clinically-significant MDD symptoms, 45.59% (n=62) reported clinically-significant GAD symptoms, and 33.09% (n=45) were categorized as having high suicide risk.
The in-depth interviews offer explicit examples of how intersectional discrimination manifests in participants’ day-to-day lives. One participant—a Chinese, cisgender gay male—discusses how he experiences racism on Grindr, an online dating and social networking platform for LGBTQ+ “I feel like the biggest thing is just like, literally just weird comments from guys on Grindr. Like, like being fetishized in weird ways, like, I love your like smooth body, or like, um, a lot of things like mentioning the fact that I’m like Chinese...But like, at the start of COVID, I went home. I was on Grindr and some guy messaged me like, hope you go back to your country, China man or something like that.” (Participant 12) The participant experiences racism in the dating scene through the fetishization of his body and identity as Chinese, while simultaneously facing anti-Asian sentiment related to the coronavirus disease 2019 (COVID-19) pandemic. This discrimination has a tangible impact on this participant’s views of himself, as he reflects how instances of racism make “me think sometimes, in what ways am I, like, less attractive as a gay Asian man in particular” (Participant 12).
Another participant, a Filipino, cisgender queer female, describes how her identity as both Filipino and queer lead to heightened feelings of over-sexualization: “I think for queer women like myself, there’s, you know, this kind of ... intersection of our queerness. And our womanhood, there’s like this doubly impacting over-sexualization that’s put on us, because queer women are over-sexualized and seen as very attractive to straight men and only existing for straight men’s pleasure. And then kind of on the same way, like Asian women are sexualized and fetishized and seen as obedient, seen as innocent, kind of the ideal wife or partner because of that history of colonialism.” (Participant 13) In explicitly acknowledging her multiply-marginalized identities, this participant highlights how intersectional discrimination influences her ability to participate in dating and close relationships. Later, she recognizes that holding additional marginalized identities may lead to compounding experiences unique to LGBTQ+ Asians: “And I think, and then for queer [Asian] men, you know, it’s being emasculated, you know, it’s being seen as submissive...But then also being sexualized as like a gay man and also, I don’t know between those, it’s like, where does that leave queer Asian non-binary people? You know? And it kind of leaves them, you know, dealing with both, both that like emasculation and sexualization, you know, because that’s how oppressive systems work. You know, they make it so that no matter what you do, like you can’t win.” (Participant 13) Another participant, a transgender Korean individual, echoes experiences of intersectional discrimination owing to their transgender identity and stereotypes around Asian “I think for trans folks, trans masc people... you usually face the problem of like, not being taken seriously for their gender, like being like, seen as like, that’s the word, not masculine enough to be a man, kind of way. And I think, like Asian men are already emasculized. And I feel like I would say like, Asian trans-masc people have double that, I guess, because I know being Asian and being a trans-masc person.” (Participant 22) Outside of dating, participants also underscored experiences of isolation and intersectional discrimination within their queer communities. A South Asian, cisgender bisexual female participant discusses her frustration when initially trying to find LGBTQ+ community in NYC: “I think definitely when I first started seeking queer spaces, I found a lot of them to be mainly centered towards white male queer people. And I didn’t really feel very understood by certain people who would identify like that...Yeah, I think for a long time, it almost made me question my queerness, if that makes any sense, that I felt like I wasn’t really, I didn’t feel like the community was relatable to me, or I didn’t feel like I belonged.” (Participant 9) A sense of isolation and othering was underscored by numerous participants, who felt driven away by the existing LGBTQ+ community because of a lack of representation and respect for Asians. One participant, a Filipino, cisgender gay male, explicitly highlights how his experience of racism within the LGBTQ+ community was informed by misguided notions of Asians as a homogenous racial “There’s a lack of respect for our culture and for who we are as people. Like we are just seen as jokes and tropes...But the thing is that like, if you didn’t fucking know me, like I know how to kickbox and I’m also really loud...Like all the stereotypes that you have about Asian people kind of go out the fucking window. And that’s not just with me, but with everyone obviously. Cause we’re not one big monolith. We are our own individual people with our own experiences. So I do feel like we, as Asian people and Asian people in general, we’re just like blocked into a monolith.” (Participant 17) Within their own Asian communities, participants commonly expressed an inability to openly identify as LGBTQ+ to family and friends. When asked about what may be contributing to experiences of heterosexism within Asian communities, one participant—a Korean, cisgender gay male—explains: “For me specifically it’s really hard to this day for me to come out to another Korean person, a straight Korean person...You know, I was told that in Korea, it [HIV] is thought of as a Western disease from the US...they don’t understand because the culture is like Confucian, which kind of puts everyone in specific categories. Oh, you’re a man, you’re a woman. Therefore you must form a family unit and have a kid. Like, you know, if you fall outside of that, then you’re disrupting society as a whole, you don’t belong in it.” (Participant 7) This participant connects Confucian ideals, alongside historical impacts of the HIV/AIDS pandemic, as reasons why identifying as LGBTQ+ within their Korean community is not acceptable. In a similar vein, another participant explicitly labels the othering she faces in her Filipino community as “I was discriminated against because of how I strongly advocate for...LGBT communities. I just felt like their [Filipino community’s] views were a little bit more conservative. So I think I was discriminated against by my own culture, by my own cultural people for having multiple identities.” (Participant 21)
The results of the binary logistic regression model (see Table 2) suggest an association between various types of intersectional discrimination and LGBTQ+ Asians’ mental health. Higher scores on the EDS, which measures perceived discrimination in individuals’ everyday lives, were associated with higher odds of reporting clinically-significant MDD symptoms (p<0.001), clinically-significant GAD symptoms (p<0.001), and high suicide risk (p<0.010). Adjusting for the covariates, for every increase of one point on the EDS scale, the odds of reporting clinically-significant MDD symptoms was on average 1.15 (95% CI: 1.09, 1.22) times higher, 1.14 (95% CI: 1.08, 1.21) times higher for clinically-significant GAD symptoms, and 1.07 (95% CI: 1.02, 1.12) times higher for high suicide risk.
Higher scores on the Racism in Dating and Close Relationships Subscale were associated with higher odds of reporting clinically-significant MDD symptoms (p<0.001) and GAD symptoms (p<0.001). Adjusting for the covariates, for every increase of one point on the Racism in Dating and Close Relationships Subscale, the odds of reporting clinically-significant MDD symptoms was on average 1.10 (95% CI: 1.03, 1.17) times higher, and 1.11 (95% CI: 1.05, 1.17) times higher for clinically-significant GAD. For the Racism in LGBTQ+ Communities Subscale, higher scores were associated with higher odds of reporting clinically-significant MDD symptoms (p<0.010) and GAD symptoms (p<0.001). Adjusting for the covariates, for every increase of one point on the LGBTQ+ Communities Subscale, the odds of reporting clinically-significant MDD symptoms was on average 1.07 (95% CI: 1.02, 1.12) times higher, and 1.10 (95% CI: 1.04, 1.15) times higher for clinically-significant GAD. Lastly, higher scores on the Heterosexism in Asian Communities Subscale were associated with higher odds of reporting clinically-significant MDD symptoms (p<0.001) and GAD symptoms (p<0.010). Adjusting for the covariates, for every increase of one point on the Heterosexism in Asian Communities Subscale, the odds of reporting clinically-significant MDD symptoms was on average 1.09 (95% CI: 1.03, 1.15) times higher, and 1.09 (95% CI: 1.03, 1.15) times higher for clinically-significant GAD.
In the interviews, participants provided further context on the tangible impact of intersectional discrimination on their mental health. A Korean, cisgender gay male participant explains how his dual identity as gay and Korean contributed to worsened mental health while growing up in NYC: “So it was hard to just understand both [LGBTQ+ and Korean identity] because you saw the benefits of both and you couldn’t really bring it over to either side and you kind of formed like a dual identity...I mean school was tough, you know, and then once I realized I could be gay at the time, like right around middle school, high school, I was like struggling with that. And I did have like deep depression at that point. I remember not like fully suicidal, I remember, but it was more like, you know, if like if I got something bad happened to me, like I wouldn’t complain.” (Participant 7) The same participant, when asked about his general views of mental health within the LGBTQ+ Asian community in NYC, suggests that “I think from the gay Asians that I’ve interacted with here in the city, I think when I talk to them, many of them have these like episodes in their past lives when, you know, where they were depressed or they still are depressed or they feel like they’re not worthy or like no one’s willing to love them or what not” (Participant 7).
In another instance, a Filipino, cisgender gay male explains that he felt that experiences of racial discrimination lowered his confidence and worsened his perception of self when applying to new “At first, it really killed my confidence and it really raised my anxiety...So I will not apply to jobs that I think I would be gate-kept out of should the hiring manager realize that I’m not like a white person...So yeah, that killed my confidence. I was very anxious about applying for jobs. At some point, like I had thought of leaving the US for somewhere else because I just couldn’t stomach not being like, not being able to well, get a job, and like support myself here. (Participant 18) Additionally, notions of heterosexism in broader societal contexts, such as social media, affected the mental health of some participants. One participant, a Vietnamese, transgender gay individual, reflected on how political discourse on LGBTQ+ issues has worsened their mental “I feel like all the anti-trans legislation that has happened, that has come up really prominently in the past year has been really bad for my mental health. And I saw that one of my medications that I’m on was just banned in Texas. So I’m like, okay, I can never live in Texas, which is where everyone in my family is.” (Participant 23) To this extent, individuals explicitly identified the use of substances as a coping tool to manage their mental health. Another participant, a Chinese, non-binary individual, outlines how they believe discrimination leads to substance use as a coping “But I feel like being Asian and queer, you just kind of put yourself into this very specific corner where you get discriminated against on so many fronts so you can’t help but be defensive all the time... to camouflage yourself so that you look like something that won’t be bullied...but then that damages your mental health and your self-identity too. And then you have to end up dealing with it as an adult. So like... it’s almost understandable for a person to just completely shut down and just resort to drugs to help numb the pain.” (Participant 5) This participant underscores the additive impacts of intersectional discrimination on an individuals’ mental health and identity over the life course, suggesting the long-term impacts of discrimination on LGBTQ+ Asians’ mental well-being.
This exploratory, mixed-methods study presents findings that underscore the relationship between intersectional discrimination and mental health outcomes among a community-based sample of LGBTQ+ Asians in NYC. Specifically, the quantitative portion of the study found disparities in mental health outcomes by self-reported levels of perceived discrimination and experiences of microaggressions directed towards LGBTQ+ Asians. These findings fall in line with broader research underscoring the experiences of intersectional discrimination among LGBTQ+ individuals and are aligned with existing theoretical notions that attribute minority stress to individuals’ intersectional identities (Crenshaw 1989, Meyer 2003, Parmenter et al. 2021, Takeda et al. 2021).
While LGBTQ+ Asians with higher scores on the EDS had higher odds of clinically-significant depression, anxiety, and suicide risk, individuals with higher scores on each of the three subscales measuring microaggressions against LGBTQ+ Asians had higher odds of clinically-significant depression and anxiety, but not for suicide risk. This may be attributed to differences in the measures of while the EDS captures more overt forms of perceived discrimination, the LGBTQ-PCMS aims to measure more subtle forms of intersectional discrimination (i.e. microaggressions) experienced by LGBTQ+ Asians. Extant literature highlights the direct impact of overt discrimination on suicide risk for ethnic minorities and LGBTQ+ individuals (Sutter et al. 2016, Wang et al. 2021). However, the direct link between microaggressions and suicide risk remains less concrete, as the impact of more subtle forms of discrimination may be partially or fully mediated through other factors such as depression symptoms or perceived burdensomeness (O’Keefe et al. 2015, Hollingsworth et al. 2017). Of the existing research examining direct associations between microaggressions and suicide among LGBTQ+ ethnic minorities, microaggressions have been found to increase suicidal ideation and thoughts—though the presence of suicidal ideation alone is not sufficient to identify an individual as having high suicide risk (Parr and Howe 2019).
The qualitative data further underscore the importance of recognizing the various forms of intersectional discrimination faced by LGBTQ+ Asians. That is, participants offered explicit examples of intersectional discrimination that aligned with the subdomains of intersectional racism in dating and close relationships, racism in the LGBTQ+ community, and heterosexism in the Asian community. Within the subdomain capturing racism in dating and close relationships, participants acknowledged interpersonal factors including fetishization and emasculation—with cisgender females discussing feeling fetishized, and cisgender males naming their emasculation and feelings of undesirability within the LGBT+ community. Indeed, the differential experiences of intersectional discrimination align with existing literature underscoring worsened mental health outcomes due to exoticization or fetishization among Asian women, whereas worsened mental health among Asian men are more-so attributed to stereotypes of hypo-masculinity and undesirability from the greater LGBTQ+ community (Lu et al. 2019, Forbes et al. 2023).
Additionally, findings from transgender participants underscore experiences of intersectional discrimination stemming not only from societal expectations around masculinity and femininity but also from the pressure to conform to cisgender norms and presentations (Colliver 2022). Specific to gender-nonbinary participants, our qualitative data found that most individuals did not discuss experiences specific to their non-binary identity. Rather, they generalized their experiences and noted how these were closely aligned with the broader discrimination faced by the LGBTQ+ or queer Asian community. Finally, narratives around the impact of discrimination may point to a temporal and causal relationship between intersectional discrimination and mental health outcomes, though this cannot be concluded due to the cross-sectional nature of the study. This falls in line with emerging research on LGBTQ+ ethnic English et al.’s (2018) longitudinal study on Black, Latino, and multiracial gay and bisexual men found that individuals who experienced racial discrimination and anticipated LGBTQ+ stigma had higher levels of depressive and anxiety symptoms six months later.
Clinically, segmenting the various dimensions of intersectional discrimination in such a way may lead to a more explicit recognition of the unique experiences faced by LGBTQ+ Asians, as well as further consideration for the development of culturally-sensitive behavioral health interventions. While intersectionality-driven approaches in clinical settings remain heavily understudied, exploratory studies in the field of HIV research provide insights into the efficacy of introducing flexible and contextual coping strategies specific to different forms of discrimination (Bogart et al. 2018). In particular, multilevel interventions that simultaneously address multiple forms of discrimination (e.g. racism, sexism, and homophobia) may have greater utility in providing person-centered care that affirms all held identities of LGBTQ+ Asians, rather than just one (Earnshaw et al. 2018). Moreover, peer-driven interventions that focus on increasing social connection among LGBTQ+ Asians may address the isolation and worsened mental health outcomes stemming from rejection within LGBTQ+ communities, Asian communities, and intimate relationships (Willging et al. 2018).
Several limitations exist for the present study. Study data are based on self-reported measures and are therefore subject to recall and reporting bias. Outreach, surveys, and interviews for the study were also conducted in English, leaving out many Asian Americans, who have the highest rates of limited English proficiency at 35 percent (Center for American Progress, 2014). Additionally, some demographic variables were excluded from analyses due to sample size, whereas other variable categories were combined to compensate for this limitation. The quantitative portion of the study utilizes a cross-sectional design and does not capture any temporal or causal relationships between discrimination measures and mental health outcomes. The small sample size of the study, alongside the use of online convenience sampling, may impact the validity of the results and the generalizability to the broader LGBTQ+ Asian community. Lastly, the high prevalence of mental health disorders among the sample may also be partially owed to data collection during the COVID-19 pandemic, which almost universally worsened population mental health and particularly impacted the Asian American community due to the rise of anti-Asian sentiment and discrimination (Rajkumar 2020, Wu et al. 2021).
In spite of these limitations, the study findings reveal that a significant proportion of individuals had clinically-significant symptoms related to major depressive disorder, generalized anxiety disorder, and suicide risk. These findings directly counter the narrative of the Model Minority Myth, which wrongfully asserts the universal wellbeing of all Asians in the U.S (Yi and Museus 2015). Moreover, the explicitly intersectional approach of the study also rejects the notion of the Model Minority Myth by acknowledging how systems of oppressions overlap to create unique experiences for LGBTQ+ Asians (Crenshaw 1989).
In the future, a larger dataset that over-samples for underrepresented LGBTQ+ Asian subgroups, such as non-East Asians and transgender individuals, may allow for analyses of additional intersecting identities that influence mental health outcomes. Transgender individuals face additional risk factors, such as transphobia and anti-transgender legislation at the policy level, that increase their risk of suicide, depression, and anxiety (Su et al. 2016, Wolford-Clevenger et al. 2017). Additionally, a longitudinal study may allow for a better understanding of the temporal relationships between intersectional discrimination and mental health outcomes among LGBTQ+ Asians. To this extent, the causal mechanisms by which intersectional discrimination leads to depression and anxiety, such as social isolation and perceived stress, may be explicitly examined.
Overall, LGBTQ+ Asians face unique, discriminatory experiences stemming from their identity as both Asian and LGBTQ+. Asians with higher levels of perceived discrimination in their everyday lives had higher odds of reporting clinically-significant depression, anxiety, and suicide risk. However, Asians with higher levels of racialized and LGBTQ-related microaggressions had higher odds of reporting clinically-significant depression and anxiety, but not suicide risk. The small sample size of this study, as well as the diversity of the LGBTQ+ Asian community, necessitates further research on LGBTQ+ Asian subgroups to be conducted. Ultimately, this exploratory study is a starting point for a historically-underserved community within the mental health field and may help inform future clinical and public health research on LGBTQ+ Asians.