The Long Arm of Oppression: How Structural Stigma Against Marginalized Communities Perpetuates Within-Group Health Disparities

Abstract

Understanding and addressing health inequities calls for enhanced theoretical and empirical attention to multiple forms of stigma and its influence on health behaviors and health outcomes within marginalized communities. While recent scholarship highlights the role of structural stigma on between-group health disparities, the extant literature has yet to elucidate the mechanisms through which structural stigma gives rise to within-group health disparities. In this article, we review and use relevant literature to inform the development of a conceptual model outlining how structural stigma contributes to within-group health disparities by creating division and tension within communities marginalized due to their social statuses and identities. We specifically focus on disparities among (1) communities of color due to White supremacy, (2) gender and sexual minority communities due to patriarchy and heterosexism, and (3) the disability community due to ableism. We argue that the nature and extent of the stigma members of stigmatized communities face are intricately tied to how visible the stigmatized characteristic is to others. By visibility, we refer to characteristics that are more easily perceived by others, and reveal a person’s social identity (e.g., race/ethnicity, nativity, relationship status, gender expression, and disability status). This paper advances the literature by discussing the implications of the model for future research, practice, and policy, including the importance of acknowledging the ways in which structural stigma intentionally disrupts the collective identity and solidarity of communities and consequently threatens health equity.

Keywords

health inequities minority communities structural stigma within-group health disparities

Understanding and addressing health inequities calls for enhanced theoretical and empirical attention, particularly, focused on examining the influence of multiple forms of stigma on health behaviors and outcomes within marginalized communities. Structural stigma is defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized” (Hatzenbuehler, 2016, p. 742). Structural stigma—rooted in White supremacy ideologies, patriarchy, heterosexism, and ableism—is tied to social identities based on race and ethnicity, immigration status, gender and sexual identities, and disability status. Such ideologies permeate everyday life—by way of the institutions, policies, and systems that perpetuate and uphold them—and can either be internalized or rejected by the communities subjected to stigma (Campbell & Deacon, 2006). Structural stigma reproduces social hierarchies within stigmatized communities that have been historically and contemporaneously marginalized and excluded from society. The ensuing hierarchies created within these communities result from interpersonal and individual-level manifestations of structural stigma and reflect either an acceptance of the dominant cultural norms and stereotypes of their community, or an active resistance against them and reinforcement of their own norms and means of validation. Conflict and tension within stigmatized communities may arise if the identities of certain subgroups do not align with the collective identity or meet the expectations of the larger community. For instance, within racialized communities, community-level acceptance of colorist stereotypes privileging Eurocentric physical features may lead to conflict with and the marginalization of community members that have traditionally Afrocentric or Afro-Latino characteristics. Consequently, “nonconforming” subgroups of a stigmatized community (e.g., Blacks and Latinos with darker skin tones) may experience worse health than “conforming” subgroups (e.g., Blacks and Latinos with lighter skin tones) because they face within-group marginalization (i.e., social rejection and exclusion for not adhering to the norms of the larger group) or cultural invalidation (i.e., identity threats that invalidate a person’s membership in a group; Major & O’Brien, 2005). To this end, structural stigma, may be more consequential for health disparities.

While recent scholarship highlights the role of structural stigma on between-group health disparities, the extant literature has yet to elucidate the mechanisms through which structural stigma gives rise to within-group health disparities due to the visibility of a stigmatized identity by creating division and tension within stigmatized communities. In this article, we review and use relevant literature to inform a conceptual model outlining how structural stigma contributes to conflict and health disparities within marginalized communities. We specifically focus on disparities based on visible physical attributes that manifest within (1) racialized communities due to White supremacy, (2) gender and sexual minority communities due to patriarchy and heterosexism, and (3) disability communities due to ableism. The article advances the literature by discussing the utility and implications of the model for future research, practice, and policy.

Conceptual Model

Below we outline a conceptual model (Figure 1) describing how structural stigma contributes to within-group health disparities by creating division and tension within communities of color, sexual and gender minority communities, and disability communities. We use these groups illustratively noting that the primary commonality across them is their systematic exclusion from and marginalization by dominant social groups. The central mechanism through which structural stigma perpetuates within-group health disparities in marginalized communities is through the conflict and tension structural stigma creates between a community’s collective identity and the “visibility” of stigmatized characteristics among its community members. By visibility, we refer to characteristics that are more easily perceived by others, and reveal a person’s social identity (e.g., race/ethnicity, relationship status, gender expression, and disability status). We argue that the nature and extent of stigma that subgroups of stigmatized communities face are intricately tied to how visible the stigmatized characteristic is to others. Accordingly, we posit that

Figure 1.

A conceptual model for within-group health disparities among stigmatized communities.

All members of stigmatized groups, regardless of visibility, experience explicit marginalization i.e., (Figure 1, Path A) and discrimination (i.e., Figure 1, Path B) by members of the dominant social group, which leads to between-group health disparities.

Highly visible members of stigmatized communities are more likely to experience marginalization within their community if their community internalizes the structural stigma they face (i.e., Figure 1, Path C), while less visible individuals are more likely to experience acceptance (i.e., Figure 1, Path D).

Less visible individuals are more likely to experience cultural invalidation within their community if their community actively resists structural stigma and, instead, exalts their stigmatized characteristic(s) (i.e., Figure 1, Path E), while highly visible individuals are more likely to experience validation (i.e., Figure 1, Path F).

These pathways will have varying effects on the health behaviors and physical and mental health of community members, depending on the cognitive responses (e.g., internalization, rejection) individuals use to navigate the tension between their personal identity and their community’s collective identity and norms.

Because decades of research have already elucidated mechanisms leading to between-group health disparities (i.e., Figure 1, Paths A and B; Hatzenbuehler et al., 2013), we focus on pathways that perpetuate within-group community conflict and tension (i.e., Figure 1, Paths C and E). Additionally, a large body of literature has examined intrapersonal cognitive responses to stigma (Festinger, 1957; Mendoza-Denton et al., 2002; Pachankis, 2007; Richman & Lattanner, 2014); we, therefore, do not focus on these processes in our discussion. Lastly, our examples primarily focus on the United States and Westernized societies because the experiences of marginalized communities outside of this context likely differ.

Community Stigma and Disparities Within Races and Ethnic Groups

Scholars have sought to dismantle the prevailing notion that groups defined by race and ethnicity are monolithic entities with homogeneous lived experiences (Crenshaw, 1991). They have called for greater recognition and examination of the heterogeneity within communities of color, resulting in research on within-group differences in health and health behaviors (Monk, 2015). However, the conceptual and empirical research in this area has only peripherally considered (1) a person’s racial identity in relation to the visible characteristics that denote membership into communities, (2) intragroup conflict due to differences in the norms stipulating how communities of color expect their members to look and/or behave relative to how members actually look and/or behave, and (3) the contribution of this conflict to within-group health disparities. Skin tone is a visible characteristic that has been linked to differences in health within communities of color. Below, we consider its relationship to community-level pathways leading to within-group health disparities.

Research on the relationship between skin tone and health has largely focused on differences within Black and Latino communities, generally finding that individuals with darker skin tones have worse health outcomes and behaviors than those with lighter skin tones (Cobb et al., 2016; Hargrove, 2018a, 2018b; Moore et al., 2020; Slaughter-Acey et al., 2019; Stewart et al., 2020; Uzogara, 2019). However, findings are inconsistent with some studies finding no differences (Uzogara, 2019) and at least one documenting the health advantages of darker skin tones (Moore et al., 2020), suggesting that either extreme may be harmful (Hunter, 2005). These mixed findings highlight the need to assess the community context surrounding the lived experiences of people of color with varying skin tones (Harvey et al., 2016).

Skin tone as a marker of stigma (i.e., colorism or color prejudice) has its roots in colonialism, slavery, and White supremacy. White supremacy generally refers to the belief in the superiority of the White race. Internalizing this belief can foster a “colonial mentality” within communities of color, such that community members seek separation from subgroups considered inferior by White communities as a means of achieving greater acceptance in White communities (David, 2013). Consequently, the valuing of lighter skin tones may be heightened within Black and Latino communities where a colonial mentality is prevalent. That said, Peter Frost (1990) notes that even before colonizing the United States, Europeans considered lighter complexions and Eurocentric physical features more desirable and valuable, particularly among women. The preference for lighter complexions permeated all aspects of the slave trade from the pricing of enslaved bodies to the distribution of labor (e.g., assignment to fieldwork vs. housework). In the same way, the physical and psychological traumas of slavery and other forms of oppression have been passed down intergenerationally (Sotero, 2006; Walters et al., 2011), colorist beliefs and practices have also become embedded within Black and Latino communities to varying degrees (Abrams et al., 2020; Wilder & Cain, 2011). For instance, using semistructured interviews with Black women, Hall (2017) found that darker-skinned women reported never needing to authenticate their blackness within their families but being described as less attractive, less intelligent, and more militant and “ghetto” than lighter-skinned family members; lighter-skinned participants, on the other hand, reported being bullied by darker-skinned Blacks, because their darker-skinned counterparts resented the value and privileges they receive in society and their communities (Hunter, 2002; Uzogara & Jackson, 2016). Relatedly, lighter-skinned Blacks are also less likely to be considered “legitimate” members of the Black community and, as a result, may be subjected to exclusion and isolation (Hunter, 2005, 2008). In line with our conceptual model, these studies suggest that the White supremist belief that “lighter is better” reproduces social hierarchies based on skin tone within communities of color that subsequently expose darker-skinned members to marginalization within their communities (i.e., Figure 1, Path C) and lighter-skinned members to invalidation (i.e., Figure 1, Path E).

Community Stigma and Disparities Within Sexual Minority Communities

The sociocultural justification for structural stigma based on heterosexism and patriarchy involves (1) the false framing of sexual minorities (SMs) as a monolithic group who violate societal gender and relationship norms and (2) the attribution of these norm violations to stereotypes (e.g., sexual promiscuity or predation) that justify systematic efforts to render SMs invisible or nonidentifiable (e.g., continuous exclusion of sexual orientation data; nonrecognition of same-sex marriages), ensure their vulnerability (e.g., lack of protective policies against hate crimes) and limit their access to institutionalized relationships that confer social, economic and legal benefits (e.g., marriage and adoption policies; Hatzenbuehler, 2014, 2016; Herek, 2016). This environment withholds from SMs the legal recognition that protects marginalized groups; ignores the fluidity of their identities across time and space; and erases the rich diversity in how SM populations manifest their identities, attractions, and behaviors in private, community, and public settings. Such structural policing on sexual identity contributes to explicit marginalization and discrimination between groups, as depicted in Figure 1 (i.e., Path A), and has implications for within-group conflict and health disparities. Specifically, local community responses to structural stigma—whether it be internalization or rejection of cultural messaging and structural consequences—can lead to marginalization and invalidation of subgroups of SM within their own community (i.e., Figure 1, Paths C and D). Below, we consider two characteristics that can make SMs more or less visible to others, specifically gender expression and relationship status.

Gender Expression

Societal rejection of SMs has roots in patriarchy and the conflating of sexual identities with gender identity (Pharr, 1997). The conflating of sexual and gender identities partially arises from the assumption that intimate relationships must be heteronormative, that is, a couple with one “masculine-like” and one “feminine-like” partner, including within SM communities. This assumption however specifically villainizes gender nonconforming, sexual minorities (GNC-SMs), whose appearance and behaviors do not ascribe to prevailing norms of gender expression and characterizes them as deviants from the patriarchal norms and power structures that perpetuate toxic masculinity, while also invalidating their SM identity (Clarke et al., 2012). Qualitative research has provided insight into how community internalization and rejection of these structural stigmas result in the marginalization of GNC-SMs (i.e., Figure 1, Path C) and the SMs who are not GNC (i.e., Figure 1, Path E), respectively, based on visible gender-related mannerisms (Blair & Hoskin, 2014; Edmonds & Zieff, 2015; Edwards, 2018; Hoskin, 2020; Taywaditep, 2002). Consequently, diverse subcommunities have emerged to overcome exclusion experienced from broader SM populations (e.g., butch, bear, femme; Levitt, 2019).

Although gender expression is a major topic of interest within SM research, extant research has not distinguished how between-group discrimination, SM community marginalization, and SM community invalidation contribute to within-group health differences by GNC status. Consequently, scholars are unable to differentiate the roles of between-group discrimination versus SM community marginalization on GNC-SM’s particularly poor mental health outcomes (e.g., Baams et al., 2013; Lehavot & Simoni, 2011; Li et al., 2016; Puckett et al., 2016; Skidmore et al., 2006; van Beusekom et al., 2018) and worse health behaviors (Hiestand et al., 2008; Lehavot & Simoni, 2011; Rosario et al., 2008). Relatedly, extant quantitative instruments with items that focus on SM community stressors pertaining to gender expression often do not distinguish between marginalization versus invalidation processes (e.g., Daily Heterosexist Experiences Questionnaire—“Feeling invisible in the LGBT community because of your gender expression”; Balsam et al., 2013).

Relationship Status

A core component of structural heterosexism concerns the rejection of the fluidity of sexual identities. Through this lens, SMs who have intimate partners that challenge heteronormative standards face explicit marginalization, including exotification and discrimination based on their presumed promiscuity and deviant sexual practices. Simultaneously, SMs who have intimate partners that are diverse in their sexual and gender identities face unique forms of discrimination based on cultural attributions that characterize them as promiscuous, predatory, and/or indecisive. Such discrimination is particularly important to consider given the growing diversity in relationship labels that address an increasing diversity in sexual and gender identities among SM including transgender and nonmonosexual groups (i.e., polyamory, asexual; Barsigian et al., 2020; Hammack et al., 2018).

Past qualitative and quantitative research suggests that the identity rigidity imposed on sexual identities has been internalized by SM communities, resulting in the invalidation of bisexual, non-monosexual, and other SM populations with diverse intimate partner relationships (i.e., Figure 1, Path E). Discrimination and exclusion in SM communities has ranged from invalidation of individuals’ preferred identity labels to explicit exclusion from SM spaces, especially if SM individuals are currently in heterosexual relationships (e.g., Arriaga & Parent, 2019; Dyar et al., 2014; Flanders et al., 2017; Morandini et al., 2018; Sarno et al., 2020). While limited, quantitative research has implicated SMs in heterosexual relationships have worse mental health, poor alcohol-related outcomes, and greater SM-related intimate partner violence than SM in exclusively nonheterosexual relationships (Bermea et al., 2018; Dyar et al., 2014; Molina et al., 2015; Vencill et al., 2017). Studies have attributed these within-group health differences to the invalidation of the bisexual and nonmonosexual identities, although this work has not distinguished between societal versus SM community invalidation (Dyar et al., 2014; Molina et al., 2015).

Community Stigma and Disparities Within Disability Communities

Disability communities are diverse, representing a range of disability types, including psychiatric, sensory, intellectual, developmental, emotional, and physical, as well as chronic illnesses and fatigue. In response to the Disability Rights Movement, living with a disability has been increasingly recognized as an identity, culture, and community, instead of a biomedical deficit (Fleischer & Zames, 2001). That said, structural stigma against disabled people still exists in the form of ableism:

“. . . a system that places value on people’s bodies and minds based on societally constructed ideas of normalcy . . . [which] leads to people and society determining who is valuable and worthy based on a person’s appearance and/or their ability to satisfactory [re]produce, excel and “behave” (Lewis, 2020).

The devaluation of disabled people has material consequences, including worse physical health, health behaviors, and emotional well-being among disabled people (Havercamp & Scott, 2015; Krahn et al., 2015), primarily due to the structural stigma they face and not the underlying disability they embody (Krahn, et al., 2015). Importantly, however, ableism and structural stigma against disabled people can create tension and division within the disability community based on the extent to which the disability is visible to others.

The visibility of a disability can vary within a disability type and research suggests that persons with visible and invisible disabilities experience mental distress as a result of ableism. What is considered a “visible” disability is often based on medical diagnoses and self-identification. Visible disabilities are characterized by apparent physical limitations or “body disfigurement” and some developmental and intellectual disabilities with physical manifestations (e.g., Down’s syndrome); invisible disabilities typically entail psychiatric, intellectual, and nonapparent physical and learning disabilities (e.g., fibromyalgia, dyslexia). Research on health disparities based on the visibility of disability has yielded mixed results. Some studies have shown no difference in emotional well-being (Wolman et al., 1994), while others suggest that having a visible disability is associated with worse mental health (van Dalen et al., 2020). For example, van Dalen and colleagues (2020), examined the impact of visible differences on adolescent mental health and found that adolescents with visible differences experienced more anxiety and depressive symptoms compared to adolescents without visible—but still present—differences. Scholars hypothesize the internalization of societal stigma as one reason for this disparity.

Contrarily, a growing body of research has documented greater emotional distress and less social acceptance among those with invisible disabilities (Nalavany et al., 2013; Quinn & Chaudoir, 2009; Shpigelman & HaGani, 2018; Stone, 2009). Some attribute the health disadvantages associated with invisible disabilities to feelings of rejection or invalidation from both the disability community and society at large. For instance, Tuersley-Dixon and Frederickson (2016) found that students with invisible disabilities were less accepted by their nondisabled peers compared with their visibly disabled peers. Moreover, those with invisible disabilities attributed their distress to the discrepancy between what society expects of their abilities—given society’s inability to perceive their disability—and their actual abilities as a disabled person (Stone, 2009), the need to engage in impression management and strategic disclosure of their disability (Valeras, 2010), and the stress of both concealing their disability for fear of “being discovered” and not believed when claiming to have a disability and needing accommodations (Kattari et al., 2018; Olkin et al., 2019).

Although the aforementioned studies highlight how societal-level stigma can differentially affect the health of subgroups of disability communities based on the visibility of a disability, other studies have examined the influence of community-level internalized stigma. Mark Deal (2003), for instance, coined the term “impairment hierarchy” to describe within-group conflict based on different aspects of disability including the profoundness of one’s disability (e.g., how much assistance one needs), intellectual versus nonintellectual disabilities, and “prototypical” disabilities versus those that are not (e.g., wheelchair users more readily recognized as disabled than those with subtler physical disability; Deal, 2003; also see Mastro et al., 1996). Tom Shakespeare (1996) found that disabled people rated those with invisible disabilities as more attractive and desirable than those with visible disabilities, which aligns with ableist beliefs and attitudes that marginalize people with more visible disabilities (i.e., Figure 1, Path C). In contrast, within disability communities, wheelchair users are overrepresented in community leadership, creating an atmosphere where disabled people with visible disabilities feel a greater sense of belonging compared to those with invisible disabilities (Paul K. Longmore Institute on Disability, n.d.). The “ownership” and gatekeeping of the disability identity are often observed along visibility lines (Deal, 2003) such that those with invisible disabilities often report not feeling “disabled enough” to belong to disability communities, or deserving of accommodations (Caldwell, 2010; Olkin et al., 2019). Central to this hierarchy is the validation of highly visible disabled people (i.e., Figure 1, Path F) and the invalidation of less-visible disabled people (i.e., Figure 1, Path E).

Intersectionality and Multiply Marginalized and Stigmatized Identities

Although our discussion of the empirical basis of our model focused on social identities in isolation, the communities discussed are heterogeneous and reflect multiple intersecting identities, which may lead to qualitatively different experiences of stigma, marginalization, and discrimination due to intersecting systems of oppression. For instance, manifestations of colorism may differ by gender within Black and Latino communities. A study using national data on Black adults identified a “three-tier system” of economic advantage, where lighter-skinned men (i.e., Tier 1) had higher incomes than medium- and lighter-skinned men and women (i.e., Tier 2), followed by darker-skinned men and women (i.e., Tier 3; Reece, 2021). Additionally, Maroto et al. (2019) found that women of color with disabilities and lower levels of education had the lowest incomes and highest rates of poverty compared to other multiply identified groups.

Although these studies focus on intersectionality and economic outcomes, it is not beyond reason to extend their findings to the relationship between structural and community-level stigma, intersecting social identities, and within-group health disparities. The intersection of multiple marginalized identities may render multiply marginalized individuals uniquely visible or invisible in society or within their specific communities (Crenshaw, 1991). Prior research has shown that individuals with multiply-marginalized—and ultimately stigmatized—identities feel more invisible than individuals experiencing stigma based on a single characteristic (Collins & Bilge, 2016; Remedios & Snyder, 2018). At the same time, individuals with a mix of “desirable” and “undesirable” visible characteristics (e.g., lighter-skinned, disabled, Black male) may simultaneously experience rejection due to one aspect of their identity (e.g., being disabled and Black) and acceptance or validation for another aspect of their identity (e.g., being lighter-skinned and male). Thus, an intersectional lens highlights how subgroups of marginalized communities may differentially experience structural and community-level stigma because of their intersecting identities.

Implications for Public Health Research, Practice, and Policy

In this brief review of the proposed conceptual model, our primary intention was to demonstrate the “long-arm” or reach of structural stigma and how it can disrupt community solidarity and create conflict and hierarchies within stigmatized communities. We posit that this disruption of group solidarity contributes to within- and between-group health disparities. In discussing our model, we were deliberate and discerning about the literature reviewed to more clearly highlight the model’s contribution and innovation, specifically, the conceptualization of within-group conflict as a product of structural stigma and mediator of between- and within-group health disparities. Conflict within communities impinges on the health of its members in multiple ways. Its relationship to the health of individual community members depends on the cognitive and emotional responses they use to cope with the added stress they experience from within-group marginalization or invalidation (Major & O’Brien, 2005; Miller & Kaiser, 2001; Richman & Lattanner, 2014). However, the ways in which this conflict systematically produces within-group health disparities is a diverse and nonlinear process intricately tied to the chosen identity of the community and its members, all of which can vary over time and geographic spaces. Thus, our model is not static or deterministic in nature; instead, it is broadly applicable and elaborates a piece of the relationship between structural stigma and health disparities that has yet to be examined.

Our focused attention on the pathway between structural stigma, within-group conflict, and health disparities has its limitations. For instance, prior research suggests that contextual factors such as geography (e.g., Pachankis et al., 2017) and time-related factors such as age, period, and cohort effects (e.g., van der Star et al., 2020) may influence the manifestation of structural stigma. Relatedly, the collective and personal identities of members of stigmatized communities may shift over time and context (Tovar & Feliciano, 2009). Additionally, our focus on within-group pathways that marginalize and invalidate certain subgroups of a community limited our discussion of pathways that promote acceptance and validation of those same subgroups. This limited discussion of the affirming role communities play in no way reflects a lessening of its importance. Rather, it reflects the opposite; namely, the need for a separate, focused, and comprehensive discussion of the many ways stigmatized communities actively resist systemic oppression and structural stigma to protect the health of their members.

The conceptual model presented has important implications for research on within-group health disparities and the design of public health interventions and policies. Future research should assess the empirical support for our model. A particularly important area of investigation includes the role of acceptance and validation as community processes that counteract the discrimination, marginalization, and invalidation stemming from structural stigma. Additionally, we consider community processes mediators between structural stigma and intrapersonal responses to stigma; however, the local community context could also function as a moderator of this relationship (e.g., community-level internalization of stigma can exacerbate the effects of structural stigma on intrapersonal cognitive responses). Last, to address additional limitations of our model, future research needs to elucidate how the relationships between structural stigma, community-level stigma and within-group health inequities are shaped by time, space, and multiply intersecting identities.

The effective elimination of health disparities requires that public health programs and policies recognize the impact structural and community-level stigma have on individual well-being and the lived experiences of marginalized individuals in the larger society and within their own communities. Of paramount importance is the explicit recognition of structural stigma and the internalization, or appropriation of such stigma within stigmatized communities, as the primary culprit of within-group health disparities (Tappan, 2006). This sociocultural perspective stands in direct opposition to psychological perspectives that simply center the causal pathways of within-group health disparities within stigmatized communities themselves. A reframing of within-group health disparities as a sociocultural process instead of a psychological one can facilitate the creation of programs and policies that seek to eliminate within-group social hierarchies that perpetuate tension and division among community members. Moreover, it can foster greater within- and between group collective action that moves policy and intervention conversations away from proposals that seek to “fix” presumably “broken” marginalized communities toward upstream initiatives that dismantle the systems of oppression that relentlessly and intentionally plague and disrupt the collective identity and solidarity of these communities.

Footnotes

Authors’ Note

Faith E. Fletcher is now at Baylor College of Medicine, Houston, TX, USA.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Uchechi A. Mitchell

Yamilé Molina

References

Abrams

J. A.

Belgrave

F. Z.

Williams

C. D.

Maxwell

M. L.

(2020). African American adolescent girls’ beliefs about skin tone and colorism. Journal of Black Psychology, 46(2–3), 169–194. https://doi.org/10.1177/0095798420928194

Arriaga

A. S.

Parent

M. C.

(2019). Partners and prejudice: Bisexual partner gender and experiences of binegativity from heterosexual, lesbian, and gay people. Psychology of Sexual Orientation and Gender Diversity, 6(3), 382–391. https://doi.org/10.1037/sgd0000337

Baams

Beek

Hille

Zevenbergen

F. C.

Bos

H. M. W.

(2013). Gender nonconformity, perceived stigmatization, and psychological well-being in Dutch sexual minority youth and young adults: A mediation analysis. Archives of Sexual Behavior, 42(5), 765–773. https://doi.org/10.1007/s10508-012-0055-z

Balsam

K. F.

Beadnell

Molina

(2013). The daily heterosexist experiences questionnaire: Measuring minority stress among lesbian, gay, bisexual, and transgender adults. Measurement and Evaluation in Counseling and Development, 46(1), 3–25. https://doi.org/10.1177/0748175612449743

Barsigian

L. L.

Hammack

P. L.

Morrow

Q. J.

Wilson

B. D. M.

Russell

S. T.

(2020). Narratives of gender, sexuality, and community in three generations of genderqueer sexual minorities. Psychology of Sexual Orientation and Gender Diversity, 7(3), 276–292. https://doi.org/10.1037/sgd0000384

Bermea

A. M.

van Eeden-Moorefield

Khaw

(2018). A systematic review of research on intimate partner violence among bisexual women. Journal of Bisexuality, 18(4), 399–424. https://doi.org/10.1080/15299716.2018.1482485

Blair

K. L.

Hoskin

R. A.

(2014). Experiences of femme identity: Coming out, invisibility and femmephobia. Psychology and Sexuality, 6(3), 229–244. https://doi.org/10.1080/19419899.2014.921860

Caldwell

(2010). We exist: Intersectional in/visibility in bisexuality & disability. Disability Studies Quarterly, 30(3/4). https://dsq-sds.org/article/view/1273/1303

Campbell

Deacon

(2006). Unravelling the contexts of stigma: From internalisation to resistance to change. Journal of Community & Applied Social Psychology, 16(6), 411–417. https://doi.org/10.1002/casp.901

10.

Clarke

Hayfield

Huxley

(2012). Lesbian, gay, bisexual and trans appearance and embodiment: A critical review of the psychological literature. Psychology of Sexualities Section Review, 3(1), 51–70.

11.

Cobb

R. J.

Thomas

C. S.

Laster Pirtle

W. N.

Darity

W. A.

(2016). Self-identified race, socially assigned skin tone, and adult physiological dysregulation: Assessing multiple dimensions of “race” in health disparities research. SSM–Population Health, 2, 595–602. https://doi.org/10.1016/j.ssmph.2016.06.007

12.

Collins

P. H.

Bilge

(2016). Intersectionality. Polity Press.

13.

Crenshaw

(1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43(6), 1241–1299. https://doi.org/10.2307/1229039

14.

David

E. J. R.

(Ed.). (2013). Internalized oppression: The psychology of marginalized groups. Springer.

15.

Deal

(2003). Disabled people’s attitudes toward other impairment groups: A hierarchy of impairments. Disability & Society, 18(7), 897–910. https://doi.org/10.1080/0968759032000127317

16.

Dyar

Feinstein

B. A.

London

(2014). Dimensions of sexual identity and minority stress among bisexual women: The role of partner gender. Psychology of Sexual Orientation and Gender Diversity, 1(4), 441–451. https://doi.org/10.1037/sgd0000063

17.

Edmonds

S. E.

Zieff

S. G.

(2015). Bearing bodies: Physical activity, obesity stigma, and sexuality in the bear community. Sociology of Sport Journal, 32(4), 415–435. https://doi.org/10.1123/ssj.2014-0166

18.

Edwards

A. M.

(2018). The role of hegemonic masculinity in gay men’s health disparities [University honors thesis, Portland State University] https://doi.org/10.15760/honors.595

19.

Festinger

(1957). A theory of cognitive dissonance (Vol. 2). Stanford University Press.

20.

Flanders

C. E.

Dobinson

Logie

(2017). Young bisexual women’s perspectives on the relationship between bisexual stigma, mental health, and sexual health: A qualitative study. Critical Public Health, 27(1), 75–85. https://doi.org/10.1080/09581596.2016.1158786

21.

Fleischer

D. Z.

Zames

(2001). The disability rights movement: From charity to confrontation. Temple University Press.

22.

Frost

(1990). Fair women, dark men: The forgotten roots of colour prejudice. Null, 12(5), 669–679. https://doi.org/10.1016/0191-6599(90)90178-H

23.

Hall

J. C.

(2017). No longer invisible: Understanding the psychosocial impact of skin color stratification in the lives of African American women. Health & Social Work, 42(2), 71–78. https://doi.org/10.1093/hsw/hlx001

24.

Hammack

P. L.

Frost

D. M.

Hughes

S. D.

(2018). Queer intimacies: A new paradigm for the study of relationship diversity. Journal of Sex Research, 56(4–5), 556–592. https://doi.org/10.1080/00224499.2018.1531281

25.

Hargrove

T. W.

(2018a). BMI trajectories in adulthood: The intersection of skin color, gender, and age among African Americans. Journal of Health and Social Behavior, 59(4), 501–519. https://doi.org/10.1177/0022146518802439

26.

Hargrove

T. W.

(2018b). Light privilege? skin tone stratification in health among African Americans. Sociology of Race and Ethnicity, 5(3), 370–387. https://doi.org/10.1177/2332649218793670

27.

Harvey

R. D.

LaBeach

Pridgen

Gocial

T. M.

(2016). The intragroup stigmatization of skin tone among Black Americans. Journal of Black Psychology, 31(3), 237–253. https://doi.org/10.1177/0095798405278192

28.

Hatzenbuehler

M. L.

(2014). Structural stigma and the health of lesbian, gay, and bisexual populations. Current Directions in Psychological Science, 23(2), 127–132. https://doi.org/10.1177/0963721414523775

29.

Hatzenbuehler

M. L.

(2016). Structural stigma and health inequalities: Research evidence and implications for psychological science. American Psychologist, 71(8), 742–751. https://doi.org/10.1037/amp0000068

30.

Hatzenbuehler

M. L.

Phelan

J. C.

Link

B. G.

(2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103(5), 813–821. https://doi.org/10.2105/ajph.2012.301069

31.

Havercamp

S. M.

Scott

H. M.

(2015). National health surveillance of adults with disabilities, adults with intellectual and developmental disabilities, and adults with no disabilities. Disability and Health Journal, 8(2), 165–172. https://doi.org/10.1016/j.dhjo.2014.11.002

32.

Herek

G. M.

(2016). A nuanced view of stigma for understanding and addressing sexual and gender minority health disparities. LGBT Health, 3(6), 397–399. https://doi.org/10.1089/lgbt.2016.0154

33.

Hiestand

K. R.

Horne

S. G.

Levitt

H. M.

(2008). Effects of gender identity on experiences of healthcare for sexual minority women. Journal of LGBT Health Research, 3(4), 15–27. https://doi.org/10.1080/15574090802263405

34.

Hoskin

R. A.

(2020). “Femininity? it’s the aesthetic of subordination”: Examining femmephobia, the gender binary, and experiences of oppression among sexual and gender minorities. Archives of Sexual Behavior, 49(7), 2319–2339. https://doi.org/10.1007/s10508-020-01641-x

35.

Hunter

M. L.

(2008). The cost of color: What we pay for being black and brown. In Hall

R. E.

(Ed.), Racism in the 21st century: An empirical analysis of skin color (pp. 63–76). Springer.

36.

Hunter

M. L.

(2002). “If you’re light you’re alright”: Light skin color as social capital for women of color. Gender & Society, 16(2), 175–193. https://doi.org/10.1177/08912430222104895

37.

Hunter

M. L.

(2005). Race, gender, and the politics of skin tone. Routledge.

38.

Kattari

S. K.

Olzman

Hanna

M. D.

(2018). You look fine!”: Ableism experiences by people with invisible disabilities. Affilia: Journal of Women and Social Work, 33(4), 477–492.

39.

Krahn

G. L.

Walker

D. K.

Correa-De-Araujo

(2015). Persons with disabilities as an unrecognized health disparity population. American Journal of Public Health, 105, S198–S206. https://doi.org/10.2105/ajph.2014.302182

40.

Lehavot

Simoni

J. M.

(2011). The impact of minority stress on mental health and substance use among sexual minority women. Journal of Consulting and Clinical Psychology, 79(2), 159–170. https://doi.org/10.1037/a0022839

41.

Levitt

H. M.

(2019). A psychosocial genealogy of LGBTQ+ gender: An empirically based theory of gender and gender identity cultures. Psychology of Women Quarterly, 43(3), 275–297. https://doi.org/10.1177/0361684319834641

42.

Lewis

T. A.

(2020). Ableism 2020: An updated definition [TL’s Blog]. https://www.talilalewis.com/blog/ableism-2020-an-updated-definition

43.

Pollitt

A. M.

Russell

S. T.

(2016). Depression and sexual orientation during young adulthood: Diversity among sexual minority subgroups and the role of gender nonconformity. Archives of Sexual Behavior, 45(3), 697–711. https://doi.org/10.1007/s10508-015-0515-3

44.

Major

O’Brien

L. T.

(2005). The social psychology of stigma. Annual Review of Psychology, 56(1), 393-421. https://doi.org/10.1146/annurev.psych.56.091103.070137

45.

Maroto

Pettinicchio

Patterson

A. C.

(2019). Hierarchies of categorical disadvantage: Economic insecurity at the intersection of disability, gender, and race. Gender & Society, 33(1), 64–93. https://doi.org/10.1177/0891243218794648

46.

Mastro

J. V.

Burtin

A. W.

Rosendahl

Sherrill

(1996). Attitudes of elite athletes with impairments toward one another: A hierarchy of preference. Adopted Physical Activity Quarterly, 13, 197–210. https://doi.org/10.1123/apaq.13.2.197

47.

Mendoza-Denton

Downey

Purdie

V. J.

Davis

Pietrzak

(2002). Sensitivity to status-based rejection: Implications for African American students’ college experience. Journal of Personality and Social Psychology, 83(4), 896–918. https://doi.org/10.1037/0022-3514.83.4.896

48.

Miller

C. T.

Kaiser

C. R.

(2001). A theoretical perspective on coping with stigma. Journal of Social Issues, 57(1), 73–92. https://doi.org/10.1111/0022-4537.00202

49.

Molina

Marquez

J. H.

Logan

D. E.

Leeson

C. J.

Balsam

K. F.

Kaysen

D. L.

(2015). Current intimate relationship status, depression, and alcohol use among bisexual women: The mediating roles of bisexual-specific minority stressors. Sex Roles, 73(1–2), 43–57. https://doi.org/10.1007/s11199-015-0483-z

50.

Monk

E. P.

(2015). The cost of color: Skin color, discrimination, and health among African-Americans. American Journal of Sociology, 121(2), 396–444. https://doi.org/10.1086/682162

51.

Moore

K. R.

Williams

D. R.

Baird

D. D.

(2020). Disparities by skin color among young African-American women. Journal of Racial and Ethnic Health Disparities. Advance online publication. https://doi.org/10.1007/s40615-020-00856-x

52.

Morandini

J. S.

Pinkus

R. T.

Dar-Nimrod

(2018). Does partner gender influence relationship quality among non-monosexual women? Sexual and Relationship Therapy, 33(1–2), 146–165. https://doi.org/10.1080/14681994.2017.1419568

53.

Nalavany

B. A.

Carawan

L. W.

Sauber

(2013). Adults with dyslexia, an invisible disability: The mediational role of concealment on perceived family support and self-esteem. British Journal of Social Work, 45(2), 568–586. https://doi.org/10.1093/bjsw/bct152

54.

Olkin

Hayward

Abbene

M. S.

VanHeel

(2019). The experiences of microaggressions against women with visible and invisible disabilities. Journal of Social Issues, 75(3), 757–785. https://doi.org/10.1111/josi.12342

55.

Pachankis

J. E.

(2007). The psychological implications of concealing a stigma: A cognitive-affective-behavioral model. Psychological Bulletin, 133(2), 328–345. https://doi.org/10.1037/0033-2909.133.2.328

56.

Pachankis

J. E.

Hatzenbuehler

M. L.

Mirandola

Weatherburn

Berg

R. C.

Marcus

Schmidt

A. J.

(2017). The geography of sexual orientation: Structural stigma and sexual attraction, behavior, and identity among men who have sex with men across 38 European countries. Archives of Sexual Behavior, 46(5), 1491–1502. https://doi.org/10.1007/s10508-016-0819-y

57.

Paul K. Longmore Institute on Disability. (n.d.). The untold stories of the 504 protest [video]. https://longmoreinstitute.sfsu.edu/patient-no-more/untold-stories-504-protests

58.

Pharr

(1997). Homophobia: A weapon of sexism. Chardon Press.

59.

Puckett

J. A.

Maroney

M. R.

Levitt

H. M.

Horne

S. G.

(2016). Relations between gender expression, minority stress, and mental health in cisgender sexual minority women and men. Psychology of Sexual Orientation and Gender Diversity, 3(4), 489–498. https://doi.org/10.1037/sgd0000201

60.

Quinn

D. M.

Chaudoir

S. R.

(2009). Living with a concealable stigmatized identity: The impact of anticipated stigma, centrality, salience, and cultural stigma on psychological distress and health. Journal of Personality and Social Psychology, 97(4), 634–651. https://doi.org/10.1037/a0015815

61.

Reece

R. L.

(2021). The gender of colorism: Understanding the intersection of skin tone and gender inequality. Journal of Economics, Race, and Policy, 4, 47–55. https://doi.org/10.1007/s41996-020-00054-1

62.

Remedios

J. D.

Snyder

S. H.

(2018). Intersectional oppression: Multiple stigmatized identities and perceptions of invisibility, discrimination, and stereotyping. Journal of Social Issues, 74(2), 265–281. https://doi.org/10.1111/josi.12268

63.

Richman

L. S.

Lattanner

M. R.

(2014). Self-regulatory processes underlying structural stigma and health. Social Science & Medicine, 103(February), 94–100. https://doi.org/10.1016/j.socscimed.2013.12.029

64.

Rosario

Schrimshaw

E. W.

Hunter

(2008). Butch/femme differences in substance use and abuse among young lesbian and bisexual women: Examination and potential explanations. Substance Use & Misuse, 43(8–9), 1002–1015. https://doi.org/10.1080/10826080801914402

65.

Sarno

E. L.

Newcomb

M. E.

Feinstein

B. A.

Mustanski

(2020). Bisexual men’s experiences with discrimination, internalized binegativity, and identity affirmation: Differences by partner gender. Archives of Sexual Behavior, 49(5), 1783–1798. https://doi.org/10.1007/s10508-020-01712-z

66.

Shakespeare

(1996). Disability, identity and difference. In Barnes

Mercer

(Eds.), Exploring the divide (pp. 94–113). Disability Press.

67.

Shpigelman

HaGani

(2019). The impact of disability type and visibility on self-concept and body image: Implications for mental health nursing. Journal of Psychiatric and Mental Health Nursing, 26(3–4), 77–86. https://doi.org/10.1111/jpm.12513

68.

Skidmore

W. C.

Linsenmeier

J. A. W.

Bailey

J. M.

(2006). Gender nonconformity and psychological distress in lesbians and gay men. Archives of Sexual Behavior, 35(6), 685–697. https://doi.org/10.1007/s10508-006-9108-5

69.

Slaughter-Acey

Sneed

Parker

Keith

V. M.

Lee

N. L.

Misra

D. P.

(2019). Skin tone matters: Racial microaggressions and delayed prenatal care. American Journal of Preventive Medicine, 57(3), 321–329. https://doi.org/10.1016/j.amepre.2019.04.014

70.

Sotero

(2006). A conceptual model of historical trauma: Implications for public health practice and research. Journal of Health Disparities Research and Practice, 1(1), 93–108.

71.

Stewart

Q. T.

Cobb

R. J.

Keith

V. M.

(2020). The color of death: Race, observed skin tone, and all-cause mortality in the united states. Ethnicity & Health, 25(7), 1018–1040. https://doi.org/10.1080/13557858.2018.1469735

72.

Stone

S. D.

(2009). Reactions to invisible disability: The experiences of young women survivors of hemorrhagic stroke. Disability and Rehabilitation, 27(6), 293–304. https://doi.org/10.1080/09638280400008990

73.

Tappan

(2006). Reframing internalized oppression and internalized domination: From the psychological to the sociocultural. Teachers College Record, 108(10). http://web.colby.edu/ed215s/files/2010/12/Tappan_TCR_2006.pdf

74.

Taywaditep

K. J.

(2002). Marginalization among the marginalized: Gay men’s anti-effeminacy attitudes. Journal of Homosexuality, 42(1), 1–28. https://doi.org/10.1300/J082v42n01_01

75.

Tovar

Feliciano

(2009). “Not Mexican-American, but Mexican”: Shifting ethnic self-identifications among children of Mexican immigrants. Latino Studies, 7(2), 197–221. https://doi.org/10.1057/lst.2009.18

76.

Tuersley-Dixon

Frederickson

(2016). Social inclusion of children with complex needs in mainstream: Does visibility and severity of disability matter? International Journal of Developmental Disabilities, 62(2), 89–97. https://doi.org/10.1179/2047387715Y.0000000011

77.

Uzogara

E. E.

(2019). Dark and sick, light and healthy: Black women’s complexion-based health disparities. Ethnicity & Health, 24(2), 125–146. https://doi.org/10.1080/13557858.2017.1315376

78.

Uzogara

E. E.

Jackson

J. S.

(2016). Perceived skin tone discrimination across contexts: African American women’s reports. Race and Social Problems, 8(2), 147–159. https://doi.org/10.1007/s12552-016-9172-y

79.

Valeras

A. B.

(2010). ‘We don’t have a box’: Understanding hidden disability identity utilizing narrative research methodology. Disability Studies Quarterly, 30(3–4). https://doi.org/10.18061/dsq.v30i3/4.1267

80.

van Beusekom

Bos

H. M. W.

Kuyper

Overbeek

Sandfort

T. G. M

. (2018). Gender nonconformity and mental health among lesbian, gay, and bisexual adults: Homophobic stigmatization and internalized homophobia as mediators. Journal of Health Psychology, 23(9), 1211–1222. https://10.1177/1359105316643378

81.

van Dalen

Dierckx

Pasmans

S. G. M. A.

Aendekerk

E. W. C.

Mathijssen

I. M. J.

Koudstaal

M. J.

Timman

Williamson

Hillegers

M. H. J.

Utens

E. M. W. J.

Okkerse

J. M. E

. (2020). Anxiety and depression in adolescents with a visible difference: A systematic review and meta-analysis. Body Image, 33(June), 38–46. https://doi.org/10.1016/j.bodyim.2020.02.006

82.

van der Star

Bränström

Pachankis

. (2020). Lifecourse-varying exposure to structural stigma, minority stress reactions, and mental health among sexual minority male migrants. European Journal of Public Health, 30(Suppl. 5), Article ckaa165.282. https://doi.org/10.1093/eurpub/ckaa165.282

83.

Vencill

J. A.

Carlson

Iantaffi

Miner

(2017). Mental health, relationships, and sex: Exploring patterns among bisexual individuals in mixed orientation relationships. Sexual and Relationship Therapy, 33(1–2), 14–33. https://doi.org/10.1080/14681994.2017.1419570

84.

Walters

K. L.

Mohammed

S. A.

Evans-Campbell

Beltrán

R. E.

Chae

D. H.

Duran

(2011). Bodies don’t just tell stories, they tell histories. Du Bois Review, 8(1), 179–189. https://doi.org/10.1017/s1742058x1100018x

85.

Wilder

Cain

(2011). Teaching and learning color consciousness in black families: Exploring family processes and women’s experiences with colorism. Journal of Family Issues, 32(5), 577–604. https://doi.org/10.1177/0192513X10390858

86.

Wolman

Resnick

M. D.

Harris

L. J.

Blum

R. W.

(1994). Emotional well-being among adolescents with and without chronic conditions. Journal of Adolescent Health, 15(3), 199–204. https://doi.org/10.1016/1054-139x(94)90504-5