Sexual Orientation and Disclosure in Relation to Psychiatric Symptoms, Diurnal Cortisol, and Allostatic Load

ROBERT-PAUL JUSTER, MSC, NATHAN GRANT SMITH, PHD, EMILIE OUELLET, BSC, SHIREEN SINDI, MSC,
AND

SONIA J. LUPIEN, PHD

Objectives: Lesbian, gay, and bisexual (LGB) individualsVparticularly those who have not disclosed their sexual orientationVare believed to experience increased chronic stress in comparison with heterosexuals. This interdisciplinary study assessed whether psychiatric symptoms (self-rated anxiety, depression, and burnout), stress hormone proles (diurnal cortisol), and physiological dysregulations (allostatic load [AL]) would differ for a) LGBs versus heterosexuals and b) disclosed LGBs versus nondisclosed LGBs. Methods: The study included 87 healthy participants (mean [SD] age = 24.6 [0.6] years; LGB n = 46, 43% women; and heterosexual n = 41, 49% women). Diurnal cortisol sampled at ve time points was averaged for 2 days. AL indices were based on an algorithm incorporating 21 biomarkers representing neuroendocrine, immune/inammatory, metabolic, and cardiovascular functioning. Psychological measures were assessed with well-validated questionnaires. Results: Between-group results revealed no signicant differences in symptoms of anxiety and burnout, nor among diurnal cortisol levels between sexual orientations. By contrast, gay/bisexual men unexpectedly had lower depressive symptoms (p = .003) and AL levels (p = .043) compared with heterosexual men. Within-group results revealed that disclosed LGBs had fewer psychiatric symptoms (p values G 0.01) and lower cortisol levels +30 minutes upon awakening (p = .004) compared with nondisclosed LGBs. Disclosure was not signicantly related to AL levels. Conclusions: LGBs did not manifest more stress-related problems than did heterosexuals. Life transitions like disclosing to ones family and friends may be protective against psychopathologies and hyperactive cortisol awakening responses. Our novel ndings underline the roles disclosure processes have on positive health and well-being for sexual minorities. Key words: sexual minority stress, disclosure, allostatic load, diurnal cortisol, mental health, sexual orientation, stigma. AL = allostatic load; ANCOVA = analysis of covariance; CAR = cortisol awakening response; HPA = hypothalamic-pituitary-adrenal; IOM = Institute of Medicine; LGB = lesbian, gay, bisexual.

INTRODUCTION Despite social progress, lesbian, gay, and bisexual (LGB) populations are persistently stigmatized. According to a report by the Institute of Medicine, LGBs generally experience more mood and anxiety disorders, suicidal ideation and attempts, and cigarette smoking and alcohol/drug use compared with heterosexuals (1). Sexual minority stress models (2Y4) propose that LGBs experience chronic stress from stigma generated by distal processes referring to objective stressors like discrimination and violence (i.e., enacted stigma), as well as by proximal processes referring to subjective distress like internalized homophobia and concealment of ones sexual orientation (i.e., felt stigma) (5). For example, perceived discrimination attributable to ones sexual orientation is reported by 29% to 78% of Canadian LGBs and (6) and 42% of American LGBs (7). Although extant literature has focused on psychosocial questionnaires and population-based surveys, few interdisciplinary studies have assessed biopsychosocial stress among LGBs compared with heterosexuals and LGBs who have fully disclosed their sexual orientation to others compared with those who have not. In addition to social injustices, a major obstacle for LGBs is the self-acceptance of their sexual orientation despite external and internal stressors (8). Stigma inuences the formation, repression, and expression of ones sexual orientation that
From the Departments of Neurology and Neurosurgery (R.-P.J., S.S.) and Educational and Counselling Psychology (N.G.S.), McGill University, Montreal, Quebec, Canada; and Departments of Psychology (E.O.) and Psychiatry (S.J.L.), University of Montreal, Montreal, Quebec, Canada. Address correspondence and reprint requests to Sonia J. Lupien, PhD, Centre for Studies on Human Stress, 7401 Hochelaga, Pavilion Louis Riel, Unit 226, Montreal, Quebec, Canada, H1N 3M5. E-mail: sonia.lupien@umontreal.ca Received for publication February 26, 2012; revision received September 22, 2012. DOI: 10.1097/PSY.0b013e3182826881 Psychosomatic Medicine 75:00Y00 (2013)
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if/when self-accepted is generally disclosed to others (9,10). Coming out of the closet (11) to family, friends, and coworkers can, however, be one of the most signicant stressors in the lives of LGBs (12). Disclosure can eventually have positive health and well-being benets as evidenced by less distress than nondisclosure (13,14) as well as improved physical health (15). Conversely, some evidence suggests that disclosure does not always reduce distress (16,17) and is actually a period whereby the risks of harassment, victimization, (18) and suicide (19) are inadvertently elevated. Life stressors from distal and proximal processes are believed to render LGBs more vulnerable to various psychopathologies that can be demarcated by distinct pathophysiological proles. In particular, situations that are novel, unpredictable, threatening to the self, and/or uncontrollable contribute to biological stress responses (20,21), namely, sympathetic-adrenalmedullary axis release of catecholamines such as adrenalin and hypothalamic-pituitary-adrenal (HPA) axis secretion of glucorticoids such as cortisol (22,23). According to Sterling and Eyer (24), this metabolic allocation of energy potentiating ght-or-ight behaviors exemplies allostasis dened as the biological processes that facilitate dynamic adaptation to environmental demands. The price the brain and body pay for cumulatively activating allostatic responses is called allostatic load (AL) (25), operationally dened as the biological damage of chronic stress that is measurable by using multisystemic algorithms (26). Increased AL levels are consistently associated with various antecedents (e.g., socioeconomic disadvantage, nonwhite race/ ethnicity, poor social networks, workplace stress, maladaptive personality traits, life-style behaviors, and genetic polymorphisms) and numerous stress-related consequences (e.g., premature mortality, cardiovascular disease, psychiatric symptoms, cognitive decline, physical/mobility limitations, and neurological atrophy) in both cross-sectional and longitudinal studies (for reviews, see Refs. (27,28)). With the exception of research focused on the HIV/AIDS pandemic among gay/bisexual men
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R.-P. JUSTER et al.

(29Y34), biological stress mechanisms (e.g., HPA axis and AL levels) have not been investigated among healthy LGB populations. As such, there is a strong need to explore these biological mechanisms among LGB individuals, an otherwise healthy population at increased risk for stress-related outcomes. Although peer-reviewed studies do not exist, two thesis dissertations have applied similar approaches as those used in the current study. First, Benibgui (35) found that young LGBs from Montreal with low social support experienced increased psychosocial stress that corresponded to increased depressive symptoms and decreased self-esteem. Although most of the sample (77%Y88%) had disclosed their sexual orientation to family members, LGBs with increased internalized homophobia had atter cortisol proles that corresponded with increased psychopathological vulnerabilities (35). This novel study did not, however, have a heterosexual contrast group. Second, Adams (36) analysis of the American National Health and Nutrition Examination Survey IV cohort found no significant differences in AL levels as a function of sexual orientation; although LGBs were more likely to have higher levels of glycosylated hemoglobin representing glucose metabolism and lower levels of high-density lipoprotein or good cholesterol. This study was not, however, able to ascertain concealment of sexual identity and features concerning disclosure processes. The current study builds from these two studies and addresses some of their key limitations by including a heterosexual contrast group and assessing disclosure processes to further understand biopsychosocial stress among healthy LGBs. Hypotheses The general aims of this study were therefore twofold. First, in between-group analyses, we hypothesized that LGBs would 1a) self-report increased psychiatric symptoms of anxiety, depression, and burnout; 1b) increased diurnal cortisol levels; and 1c) increased AL indices in comparison to heterosexual men and women. Second, in within-group analyses, we hypothesized that disclosed LGBs would experience 2a) decreased psychiatric symptoms of anxiety, depression, and burnout; 2b) decreased diurnal cortisol levels; and 2c) decreased AL indices in contrast to nondisclosed LGBs. METHODS Participants Eighty-seven participants aged 18 to 45 years (mean [M; standard error {SE}] = 24.61 [0.61]) identifying as lesbian or gay (8 women and 20 men), bisexual (12 women and 6 men), and heterosexual (20 women and 21 men) were recruited from the greater Montreal region. Three separate advertisements with identical language were stated as follows to recruit groups: Study of Stress in (A) Gay Men and Lesbians, (B) Bisexual Men and Women, and (C) Heterosexual Men and Women in a study that measured the association between stress, hormones, personality, and memory in healthy adults identifying as A, B, or C, respectively. We used Internet advertisements, posters, liaisons among university community groups, and word of mouth to generate a total pool of 257
2

prospects. Inclusionary criteria were relatively liberal to best represent the communities approached and to avoid selfselection biases. The main exclusionary criteria were medicinal use of synthetic glucocorticoids, major health problems, and severe mental illness. Likewise, we did not solicit transgender individuals because of potential changes in sex hormones that affect the HPA axis; however, we did not have to reject any individuals from inclusion because none contacted us. To equalize groups because of disproportionately fewer lesbians and bisexual men, we combined sexual minorities by sex (20 women and 26 men) and contrasted them to heterosexuals (20 women and 21 men). Although we must acknowledge that there are important distinctions within the LGB community, many studies have likewise combined groups according to sex to preserve power (1). Table 1 straties sample descriptive information according to demographics, socioeconomics, general health, well-being, life-style behaviors, and interpersonal features of our sample as a function of sexual orientation and sex. Protocol This study was approved by the research ethics board of Louis-H. Lafontaine Hospital. Upon a 15-minute study explanation and screening interview via telephone, eligible participants were scheduled for a rst visit at our Centre for Studies on Human Stress. Testing was conducted from July 2010 to November 2010. Visit 1 was scheduled between 8:00 AM and 11:00 AM and lasted approximately 40 minutes. This visit involved written consent; blood draw from a certied nurse; a Continental breakfast to break a 12-hour fast; completion of questionnaires measuring sexual orientation, chronic stress, and depressive symptoms; and, nally, detailed oral and written instructions for take-home urinary and salivary collection protocols. Participants were given take-home materials to collect saliva at ve time points throughout two nonconsecutive days. Participants also completed take-home questionnaires measuring disclosure status, burnout symptoms, and demographics. Finally, participants were instructed to collect all urine produced over a 12-hour period starting the night before returning to the laboratory. Visit 2 was scheduled between 12:00 PM and 7:00 PM and lasted 120 minutes. This visit served for the return of completed saliva samples and the urine container subsequently stored at j20-C and 3-C, respectively. A researcher took measurements of waist, hip, and three seated resting measures of blood pressure for each participant. In addition, participants completed the last packet of questionnaires measuring anxiety symptoms and conscientiousness. Participants were explained their blood results in detail and compensated with 50 Canadian dollars upon debrieng. Sexual Orientation Sexual orientation was ascertained by using three combined methods: a) response to one of three separate advertisements, b) asking participants their identied sexual orientation in an open-ended manner, and c) administration of a modied
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SEXUAL MINORITY STRESS AND DISCLOSURE

TABLE 1. Descriptive Statistics and Group Differences Information Sample Lesbian/Bisexual Women
20 24.10 (1.34) 85.0 40.0 60.0 28.40 (3.63) 4.75 4.25 5.15 5.15 5.05 (0.33) (0.44) (0.25) (0.44) (0.43)

Heterosexual Women
20 25.45 (1.13) 50.0 35.0 65.0 28.5 (4.38) 1.40 1.30 1.65 1.115 1.15 (0.15) (0.11) (0.25) (0.08) (0.08)

Gay/Bisexual Men
26 23.77 (0.98) 84.0 23.1 76.9 29.96 (3.24) 5.96 6.00 5.81 5.54 6.04 (0.30) (0.29) (0.32) (0.33) (0.26)

Heterosexual Men
21 25.33 (1.47) 76.2 42.9 57.1 24.91 (3.54) 1.29 1.114 1.29 1.10 1.19 (0.10) (0.8) (0.12) (0.07) (0.09)

p
V .685 .088 .490 .490 .789 G.001 G.001 G.001 G.001 G.001 .575 .737 .311

n 87 Demographic Age, M (SE) 24.61 (0.61) White, % 71.3 Workers, % 34.5 Students, % 65.5 Working/studying, h/wk, M (SE) 28.02 (1.82) Sexual orientationa Sexual attractions, M (SE) 3.51 (0.26) Sexual behaviors, M (SE) 3.34 (0.26 Sexual fantasies, M (SE) 3.61 (0.26) Life-style preferences, M (SE) 3.37 (0.27) Sexual identity, M (SE) 3.52 (0.27) Socioeconomic Post-secondary education, % 95.3 Personal annual income, $ CAD, M (SE) 16,000 (0.17) Household annual income, $ CAD, M 32,100 (0.32) (SE) Health and well-being Medication use, % 18.4 Oral contraceptive use, % 16.1 Minor physical condition, % 34.5 Psychiatric history None, % 28.7 Past history, % 8.0 Family history, % 35.6 Both past and family history, % 27.6 Subjective dimensionsb Self-rated health, M (SE) 3.72 (0.09) Self-rated physique, M (SE) 3.37 (0.10) Self-rated diet, M (SE) 3.30 (0.11) Behavioral Tobacco smoking: Smokers, % 11.5 Social smokers, % 14.9 Nonsmokers, % 73.6 Alcohol consumption (weekly) 0 or infrequently, % 25.3 1Y5, % 40.2 6Y10, % 26.4 Q11, % 8.0 Elicit drug use None, % 66.7 Occasional (monthly or annually), % 24.1 Regular (daily or weekly), % 9.2 Interpersonal Single, % 72.1 Children, % 4.7 Siblings, % 86.0 Parents alive, % 94.2 Infrequent family gatherings, % 36.1 Nonreligious/spiritual, % 78.8
a

95.0 14,500 (0.34) 37,000 (0.68)

90.0 19,000 (0.53) 25,000 (0.54)

100.0 14,000 (0.19) 27,100 (0.52)

95.0 16,800 (0.33) 39,000 (0.75)

25.0 20.0 50.0 15.0 15.0 35.0 35.0 3.50 (0.21) 3.15 (0.22) 3.25 (0.19)

15.0 50.0 40.0 40.0 5.0 45.0 10.0 3.95 (0.14) 3.70 (0.18) 3.40 (0.25)

15.4 V 23.1 26.9 11.5 30.8 30.8 3.69 (0.17) 3.27 (0.14) 3.34 (0.19)

14.3 V 28.6 33.3 33.3 33.3 33.3 3.75 (0.20) 3.40 (0.28) 3.15 (0.25)

.105 G.001 .238 .522 .522 .522 .522 .419 .284 .832

5.0 10.0 85.0 25.0 45.0 25.0 5.0 60.0 35.0 5.0 60.0 10.0 95.0 95.0 30.0 76.5

10.0 5.0 85.0 50.0 40.0 10.0 0.0 85.0 5.0 10.0 80.0 5.0 85.0 90.0 30.0 84.2

11.5 19.2 69.2 18.1 26.9 38.5 11.5 61.5 30.8 7.7 80.8 0.0 80.8 92.3 57.7 84.0

19.0 23.8 57.1 4.8 52.4 28.6 14.3 61.9 23.8 14.3 65.0 5.0 85.0 100.0 20.0 68.4

.376 .376 .376 .134 .134 .134 .134 .334 .334 .334 .315 .463 .578 .559 .169 .569

Sexual orientation was ascribed by using subscales from the Klein Sexual Orientation Scale ranging from 1 (other sex only), 2 (other sex mostly), 3 (other sex somewhat more), 4 (both sexes equally), 5 (same sex somewhat more), 6 (same sex mostly), and 7 (same sex only). b Self-rated health, physique, and diet ranged from 1 (poor), 2 (fair), 3 (good), 4 (very good), and 5 (excellent). M = mean; SE = standard error.

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R.-P. JUSTER et al.

ve-item Klein Sexual Orientation Scale (37). This latter instrument uses a 7-point Likert scale to assess sexual attractions, sexual behavior, sexual fantasies, life-style preference, and sexual identity. Scores on these items range from 1 (other sex only) to 7 (same sex only). The samples responses were internally consistent (> = .982) and subsequently used for the purposes of verifying overall correspondence among the three methods as follows. Each participants sexual orientation was then coded as sexual minority or heterosexual. Next, responses on the Klein Sexual Orientation Scale were compared as a function of sexual orientation to verify correspondence in preliminary analyses reported in our within-group analyses below. Taken collectively (see Table 1), our method conrmed sexual orientation, and no participant was reassigned to a different group. Disclosure Status We designed a brief four-item questionnaire administered only to sexual minority participants (n = 46) to measure disclosure status. Instructions were as follows: Please try to remember the feelings and circumstances you experienced through the process of identication and acceptance of your sexual orientation. Participants responded to the following four questions: A) How old were you when you rst recognized samesex attractions? B) How old were you when you conclusively identied your sexual orientation? C) At what age, if at all, did you come out to friends? and (D) At what age, if at all, did you come out to family? Disclosure status was coded as disclosed if A, B, C, and D were all answered and was otherwise coded as nondisclosed if one or more were not answered or refuted with statements such as Only my cousins know and not my parents. Accordingly, disclosed (n = 31) and nondisclosed (n = 14) groups were assigned irrespective of ones sex. Chronic Stress Chronic stress is a central outcome in sexual minority stress models (2Y4), but it also reported by one third of Canadians independent of sexual orientation (38). Furthermore, chronic stress is intricately linked to psychiatric symptoms, HPA axis functioning, and AL levels. As such, it is important to account for any confounding effects chronic stress might exert on one of these health outcomes. We therefore control for chronic stress in all our between-group analyses. The 30-item English version of the Trier Inventory for the Assessment of Chronic Stress (39) measured chronic stress on a 5-point Likert scale ranging from 0 (never) to 4 (very often) over the past month. Test-retest reliability (r = 0.60Y0.91), internal consistency (> = .61Y.93), and intercorrelations (r = 0.42Y0.63) were acceptable for the following subscales: work overload, work discontent, overextended at work, performance pressure at work, worry propensity, social overload, social tension, lack of social recognition, performance pressure in social interactions, and social isolation. These subscales were aggregated into an index measure representing chronic stress that showed high internal
4

consistency in our sample (> = .895). Students were instructed to imagine their academics for work-related items. Conscientiousness The personality trait of conscientiousness is consistently associated to positive health outcomes (40). Conscientiousness is linked to impulse control, delayed gratication, and responsibility, task- and goal-related behaviors; and socially prescribed norms and rules (40,41). One study showed that for disclosure processes among seropositive participants, conscientiousness correlated strongly with higher CD4 count denoting stronger immune functioning (42). It has been strongly recommended that personality traits such as conscientiousness be included as covariates in investigations of outness or disclosure of ones sexual orientation (43). We accordingly control for conscientiousness in all our within-group analyses. Conscientiousness was measured in the current study by using a subscale from the 60-item NEO Five Factor Inventory (44) that uses a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) in response to statements that best represent participants opinion of themselves. Psychometric validation demonstrated acceptable internal consistency for this short version with Cronbach > values ranging from .68 to .89. The current study revealed moderate internal consistency for the conscientiousness subscale (> = .657). Psychiatric Symptoms Anxiety Symptoms The 40-item State and Trait Anxiety Inventory Form Y (45) was restrictively used for the 20 trait anxiety items answered by using a 4-point Likert scale ranging from 1 (not at all) to 4 (very much so). Psychometric results (45,46) demonstrated the following for the overall instrument: test-retest reliability for 2 months (r values = 0.65Y0.75), concurrent validity with other anxiety questionnaires (r values = 0.73Y0.85), and internal consistency (> values = .86Y.95). The current sample had high internal consistency for the trait anxiety subscale (> = .866). Depressive Symptoms The 21-item Beck Depression Inventory II (47) was administered to assess depressive symptoms with a 4-point Likert scale ranging from 0 to 3 in accord to statements pertaining to the last two weeks. Psychometrics revealed high test-retest reliability (r = 0.93) and internal consistency (> = .91). Similarly, results from the current sample using a total sum score revealed strong internal consistency (> = .896). Burnout Symptoms The 16-item Maslach Burnout Inventory General Survey (48Y50) was used to assess burnout symptoms on a 7-point Likert scale for symptom frequencies ranging from 0 (never) to 6 (daily) over the course of several years. One-year testretest reliability (r) ranged from 0.60 to 0.67 for the three subscales shown to be internally consistent; namely, emotional exhaustion (> = .88), cynicism (> = .79), and personal accomplishment (> = .79). The reliability analysis for the current sample revealed the following: emotional exhaustion
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SEXUAL MINORITY STRESS AND DISCLOSURE

(> = .852), cynicism (> = .522), and personal accomplishment (> = .535). An aggregate total burnout symptoms index was calculated by adding respondents scores for the emotional exhaustion and cynicism subscales and dividing this sum by the personal efcacy subscale. Students were instructed to imagine their schooling for work-related items. Diurnal Cortisol There are four postulated physiological proles that represent allostatic states (51): a) repeatedly activated responses, b) nonhabituating responses, c) prolonged responses, and d) inadequate responses. Detecting allostatic states is possible by investigating cortisol dynamics such as the cortisol awakening response (CAR; for a review, see Ref. (52). We therefore analyzed repeated measures of diurnal cortisol that were later incorporated into our calculation of AL indices. Participants were provided with Salivette kits and detailed oral and written instructions for proper saliva collection to measure diurnal cortisol. Over two nonconsecutive days, samples were collected a) upon awakening, b) 30 minutes after awakening, c) 2:00 PM, d) 4:00 PM, and e) before going to bed. These time points have been previously used to assess circadian variation in cortisol patterns (53Y56). Participants were instructed to avoid eating a major meal, drinking beverages other than water, smoking, chewing gum, or engaging in strenuous physical activity thirty minutes before saliva collection as well as to not brush their teeth or oss 2 hours before. Women were asked to coordinate sampling during the nonluteal phase of their menstrual cycles to avoid confounding effects of sex hormones. Upon completion of a sampling day, participants stored samples in their freezer until returning them along with completed logbooks listing the precise sampling times. Samples were stored in freezers at j20-C before assaying. Saliva samples were analyzed at the Centre for Studies on Human Stress (www.humanstress.ca) with a high-sensitivity enzyme immune assay kit (Salimetrics, State College, PA; Catalogue No. 1-3102). Frozen samples were brought to room temperature to be centrifuged at 15,000g (3000 rpm) for 15 minutes. The range of detection for this assay is between 0.012 and 3 Kg/dl. Upon receiving duplicate assay values, we averaged time points for 2 days. Time of awakening was entered as a covariate in all diurnal cortisol analyses because this designates the start of the CAR characteristic of natural circadian variations. Allostatic Load Twenty-one biomarkers representing the following systems were incorporated into an AL index: neuroendocrine (salivary cortisol was transformed into both AM cortisol and PM cortisol slopes to capture dynamic diurnal HPA axis uctuations; serum dehydroepiandrosterone sulfate; 12-hour overnight urinary adrenalin, noradrenalin, and dopamine), immune/inammatory (plasma interleukin-6 and tumor necrosis factor >, serum Creactive protein, and serum brinogen preserved with sodium citrate), metabolic (serum albumin, creatinine, insulin, glycosylated hemoglobin [in percent], total cholesterol, high-density
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lipoprotein, and triglycerides; waist-to-hip ratio measured with graduated tape and calculated by dividing respective inches; body mass index calculated as mass [in kilograms] divided by height [in meters squared]), and cardiovascular (mean of three seated systolic and diastolic blood pressure recordings measured with an electronic sphygmomanometer; A&D Medical: Model UA-631 V). As shown in Table 2, participants values were coded with respect to clinical reference ranges and aggregated into an AL index, as previously done (53). This norm AL index formulation (27,67) is derived from population-based cutoffs for biomarker distributions rather than sample-based cutoffs as originally used in validation of the AL model (68). Percentiles were calculated based on clinical reference ranges whereby values passing the highest 75th percentile were scored as 1, whereas those falling normally below the 75th percentile were scored as 0. Two exceptions to this formulation were applied respecting alternative methods (53,69): a) the lowest 25th percentile denotes high risk for dehydroepiandrosterone sulfate, albumin, and high-density lipoprotein cholesterol, and b) because hypocortisolism and hypercortisolism are both deleterious (70), two-tailed formulations set at 12.5 and 87.5 percentiles based on the samples distribution were used for diurnal cortisol measures. In sum, the AL index was operationally dened as the total number of dysregulated biomarkers that could theoretically range from 0 to 21. Aging is one of the strongest known predictors of increased AL levels because of the physiological price chronic stress exerts on the brain and body over time (27,71). In accordance, age was controlled for in all AL analyses. Statistical Analysis Bivariate correlations were used preliminarily to validate correspondence of our outcome variables in the complete sample. Preliminary between-group analyses next used univariate analysis of variance (ANOVA) or W2 tests to determine any group differences among demographics, sexual orientation, socioeconomics, health and well-being, life-style behaviors, and interpersonal domains. Main analyses as a function of sexual orientation (sexual minority or heterosexual) and sex (male or female) were as follows: 1a) three separate analysis of covariance (ANCOVA) were used to compare group differences in psychiatric symptoms of anxiety, depression, and burnout while covarying for chronic stress; 1b) a repeated-measures ANCOVA was used to compare diurnal cortisol concentrations at awakening, 30 minutes afterward, 2:00 PM, 4:00 PM, and bedtime with chronic stress and awakening time entered as covariates; and 1c) an ANCOVA was used to compare AL indices while controlling for chronic stress and age. Preliminary within-group analyses applied W2 tests to assess the probability of ones disclosure status in relation to selfidentication as lesbian/gay or bisexual as well as function of ones sex. For LGB participants only, main analyses using disclosure status (disclosed or nondisclosed) as the grouping variable and the personality trait of conscientiousness as a covariate were used to reanalyze the same outcomes as above: 2a)
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6 TABLE 2. Biomarker Information Used for Constructing Allostatic Load Indices Cutoff j0.03292 or 0.19069 20 18 21 23 22 21 23 22 20 20 21 26 23 26 21 22 23 22 22 22 22 69.93 (0.87) 0.83 (0.12) 22.95 (0.46) 113.05 (1.22) 1.44 (0.05) 4.27 (0.09) 0.85 (0.06) 44.22 (0.60) 68.28 (1.19) 62.00 (2.25) 41.84 (0.76) 0.88 (0.18) 4.22 (0.19) 1.63 (0.10) 111.42 (1.95) 71.58 (1.69) 0.824 (0.015) 23.53 (1.08) 0.515 (0.00022) 0.052 (0.00043) 48.02 (2.81) 50.98 (6.42) 2.98 (0.08) 3.23 (1.85) 2.74 (0.93) 3.13 (1.85) 0.93 (0.16) 0.63 (0.10) 1.09 (0.45) 2.16 (1.07) 3.14 (0.08) 44.80 (5.08) 0.052 (0.00037) 62.10 (2.84) 42.20 (0.78) 0.68 (0.06) 4.63 (0.18) 1.68 (0.13) 107.65 (2.20) 68.53 (1.67) 0.081 (0.010) 21.43 (1.09) 3.45 (0.91) 2.20 (0.34) 2.14 (0.49) 1681.53 (76.58) 1647.05 (114.94) 1685.30 (150.15) 168.14 (10.57) 181.37 (35.19) 171.10 (17.69) 37.18 (6.17) 55.89 (26.71) 29.40 (3.84) 0.06161 (0.01599) 0.04172 (0.02739) 0.07145 (0.02727) 0.07445 (0.03772) Frequency Sample, M (SE) Lesbian/Bisexual Women, M (SE) Heterosexual Women, M (SE) Gay/Bisexual Men, M (SE) Heterosexual Men, M (SE) 0.05396 (0.03018) j0.03202 (0.00431) j0.03481 (0.00959) j0.02995 (0.00635) j0.02843 (0.00964) j0.03613 (0.00808) 8.49 (0.40) 7.34 (0.64) 5.58 (0.37) 10.19 (0.73) 10.20 (0.83) 33.77 (3.95) 161.77 (14.36) 1826.62 (162.18) 2.02 (0.14) 0.86 (0.29) 1.41 (0.83) 2.74 (0.14) 44.61 (4.61) 0.051 (0.00044) 72.81 (1.54) 46.77 (1.56) 0.76 (0.07) 4.05 (0.14) 1.23 (0.05) 116.67 (2.42) 69.53 (1.48) 0.843 (0.009) 22.41 (0.51) 31.60 (2.97) 160.90 (17.41) 1521.90 (167 7.68 (3.65) 1.16 (0.38) 4.48 (3.15) 2.99 (0.17) 52.64 (6.68) 0.051 (0.00042) 74.24 (1.69) 45.14 (0.74) 1.08 (0.14) 4.24 (0.19) 1.22 (0.07) 115.37 (2.63) 70.22 (2.21) 0.822 (0.043) 24.52 (1.00) 982.5 9373.75 92055.0 96.0 91.875 93.75 94.62 9120.25 90.057 996.0 G38.75 91.4 94.4 G1.175 9127.5 982.5 90.95 923.375

Biomarker, Unit

Referencea

Cortisol AM, slope

NA

Cortisol PM, slope Dehydroepiandrosterone sulfate, Kmol/l

NA j0.06902 or 0.00294 1.2Y10.4 G3.5

Adrenalin, nmol/l

0Y110

Noradrenalin, nmol/l

70Y475

Dopamine, nmol/l

420Y2600

Tumor-necrosis factor >, pg/ml

98

Interleukin-6, pg/ml

92.5

C-reactive protein, mg/l

0Y5

Fibrinogen, g/l

2.28Y5.4

Insulin, pmol/l

19Y154

0.042Y0.062

Glycosylated hemoglobin, % Creatinine, Kmol/l

54Y110

Albumin, g/l

35Y50

Triglycerides, mmol/l

0.5Y1.7

Total cholesterol, mmol/l

2Y5.2

1.05Y1.55

High-density lipoprotein cholesterol, mmol/l Systolic blood pressure, mm Hg

90Y140

Diastolic blood pressure, mm Hg

60Y90

Waist-to-hip ratio

0.8Y1

Body mass index, kg/m2

18.5Y25

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R.-P. JUSTER et al.

Psychosomatic Medicine 75:00Y00 (2013)

Clinical reference ranges accompanying blood results were used to determine high-risk cutoffs. Laboratory protocol manuals and government documents that report most of these clinical ranges are based on a compendium of sources (57Y66). Because normative data on cortisol are lacking in the literature, two-tailed (12.5th and 87.5th percentiles) cutoffs based on the samples distribution were used instead. M = mean; SE = standard error.

SEXUAL MINORITY STRESS AND DISCLOSURE

ANCOVA was used to assess differences in psychiatric symptoms while controlling for conscientiousness, 2b) repeated-measures ANCOVA was used to assess diurnal cortisol concentrations while controlling for conscientiousness and awaking time; and 2c) ANCOVA was used to assess AL levels while controlling for conscientiousness and age. In all statistical analyses, Greenhouse-Geisser corrections are reported whenever Mauchly tests denoted violations in sphericity. Signicant effects at > = .05 were decomposed by splitting analyses, executing separate ANOVAs, or conducting Tukeys post hoc test. RESULTS Between-Groups Analyses: Sexual Minorities Versus Heterosexual Preliminary analysis of outcomes based on the whole sample revealed that anxiety symptoms were associated with symptoms of depression (r = 0.628, p G .001) and burnout (r = 0.509, p G .001), as were symptoms of depression to those of burnout (r = 0.504, p G .001). Burnout symptoms were correlated with cortisol levels at 2:00 PM (r = 0.246, p = .025) and before bedtime (r = 0.252, p = .022). Finally, the AL index was correlated with depressive symptoms (r = 0.403, p G .001) and burnout symptoms (r = 0.217, p = .049). Preliminary analyses using univariate ANOVAs and W2 tests revealed that heterosexual women were signicantly more likely to be using oral contraceptives than other groups (Table 1). In addition, sexual minorities and heterosexuals were signicantly different for all ve items of the Klein Sexual Orientation Scale. Tukey post hoc analyses revealed that this was largely caused by consistent differences between sexual minorities and heterosexuals ( p values G .001) as expected. In addition, note that lesbian/bisexual women signicantly differed from gay/bisexual men vis-a-vis sexual attraction ` ( p = .004), sexual behaviors ( p G .001), and sexual identity ( p = .034). Stated otherwise, gay/bisexual men tended to have higher scores, indicating a stronger inclination toward same sex only responses compared with lesbian/bisexual women. No other signicant differences were detected. Missing data occurred for three participants: therefore, degrees of freedom change accordingly for some of the following main analyses. Psychiatric symptoms were investigated by using ANCOVAs with sex and sexual orientation as factors while controlling for chronic stress (Fig. 1AYC). No signicant ndings were detected for sex, sexual orientation, or interaction effects in relation to psychiatric symptoms of anxiety ( p values 9 .15) or burnout ( p values 9 .43). For depressive symptoms, a signicant sex by sexual orientation interaction was found (F(1,80) = 11.870, p G .001, G2P = 0.128). Splitting analyses by sex post hoc revealed that gay/bisexual men had signicantly lower depressive symptoms than did heterosexual men (F(1,44) = 9.66, p = .003, G2P = 0.18), whereas lesbian/bisexual women showed a reversed trend toward higher levels than did heterosexual women (F(1,36) = 3.74, p = .061, G2P = 0.094). Chronic stress was a signicant covariate for symptoms of anxiety (F(1,80) = 58.08, p G .0001, G2P = 0.42), depression (F(1,81) = 71.912, p = .001, G2P = 0.47), and burnout (F(1,78) = 19.65, p G .0001, G2P = 0.20). Diurnal cortisol was assessed by using repeated-measures ANCOVA with sex and sexual orientation entered as factors while covarying for awakening time and chronic stress (Fig. 2A). With the exception of a time effect (F(2.18,171.92) = 2.99,

Figure 1. Estimated M (SE) scores for psychiatric symptoms as a function of sexual orientation and sex and disclosure status. First, anxiety symptoms (A), depressive symptoms (B), and burnout symptoms (C) among male and female sexual minorities and heterosexuals are depicted while controlling for chronic stress. Second, anxiety symptoms (D), depressive symptoms (E), and burnout symptoms (F) among disclosed and nondisclosed sexual minorities are depicted while controlling for conscientiousness. M = mean; SE = standard error. Psychosomatic Medicine 75:00Y00 (2013) 7

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R.-P. JUSTER et al.

Figure 2. Estimated M (SE) diurnal cortisol levels for two averaged days as a function of sexual orientation and sex while controlling for chronic stress and awakening time (A) and for disclosed and nondisclosed sexual minorities while controlling for conscientiousness and awakening time (B). M = mean; SE = standard error.

p = .048, G2P = 0.036), no other signicant within-subject ( p 9 .30) nor between-subject ( p values 9 0.30) main or interaction effects were detected. Results rerun among women while controlling for oral contraceptive users (n = 13) did not contribute to statistical signicance ( p 9 .10). AL indices were investigated by using ANCOVA, with sex and sexual orientation entered as factors and age entered as a covariate (Fig. 3A). Signicant covariation effects were found for age (F(1,79) = 7.98, p = .006, G2P = 0.092) and chronic stress (F(1,79) = 5.69, p = .019, G2P = 0.067) as well as a signicant interaction effect between sex and sexual orientation (F(1,79) = 6.54, p = .012, G2P = 0.076). Splitting analyses by sex post hoc revealed that gay/bisexual men had signicantly lower AL indices than did heterosexual men (F(1,42) = 4.34, p = .043, G2P = 0.094) while controlling for age (F(1,42) = 10.04, p = .003, G2P = 0.19). No other effects were detected ( p values 9 .12).

Within-Group Analyses: Disclosed Versus Nondisclosed Sexual Minorities Disclosure status among sexual minority participants was distributed as follows: disclosed (n = 31) and nondisclosed (n = 14). The disclosed group tended to be predominantly composed of lesbian/gay individuals (n = 22) rather than bisexuals (n = 9), whereas the nondisclosed group was composed more equally

of lesbian/gay individuals (n = 6) and bisexuals (n = 8). Notwithstanding, preliminary W2 test and ANOVA revealed no statistically signicant relation between disclosure status and self-identication as lesbian/gay or bisexual ( p 9 .10) nor sex differences ( p 9 .25). Psychiatric symptoms were investigated by using ANCOVAs as a function of disclosure status while covarying for conscientiousness (Fig. 1D-F). Signicant group differences revealed that disclosed LGBs experienced fewer symptoms of anxiety (F(1,42) = 7.344, p = .010, G2P = 0.149), depression (F(1,42) = 14.18, p = .010, G2P = 0.146), and burnout (F(1,41) = 12.14, p G .001, G2P = 0.228) compared with nondisclosed LGBs. Consistently, conscientiousness was covaried with symptoms of anxiety (F(1,42) = 5.93, p = .019, G2P = 0.124), depression (F(1,42) = 14.18, p G .0001, G2P = 0.464), and burnout (F(1,41) = 10.03, p = .003, G2P = 0.196). Diurnal cortisol was assessed by using repeated-measures ANCOVAs as a function of disclosure status while covarying for awakening time and conscientiousness (Fig. 2B). A signicant between-group effect (F(1,41) = 9.27, p = .004, G2P = 0.184) was detected, but no within-group effects ( p values 9.13) were found. Post hoc exploration applying univariate ANCOVAs with disclosure status as the between-group factor and the ve time points as the within-group factor revealed that disclosed LGBs had signicantly lower cortisol levels

Figure 3. Estimated M (SE) allostatic load indices based on 21 biomarkers as a function of sexual orientation and sex while controlling for chronic stress and age (A) and for disclosed and nondisclosed sexual minorities while controlling for conscientiousness and age (B). M = mean; SE = standard error. 8 Psychosomatic Medicine 75:00Y00 (2013)

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SEXUAL MINORITY STRESS AND DISCLOSURE

30 minutes after awakening than nondisclosed LGBs (F(1,41) = 9.14, p = .004, G2P = 0.182) while controlling for awakening time and conscientiousness. In our nal analysis, an ANCOVA was used with disclosure status entered as the between-group factor and age and conscientiousness entered as covariates of AL indices (Fig. 3B). Although the disclosed group had lower AL indices than did the nondisclosed groups, this did not reach signicance (p 9 .20). A signicant covariation effect was nevertheless detected for age (p = .036) and as a trend for conscientiousness (p = .058). DISCUSSION Because of stigma that has been associated with sexual minority stress, we hypothesized that LGBs would experience higher levels of psychiatric symptoms, diurnal cortisol, and AL levels compared with heterosexuals. By contrast, completely disclosing ones sexual orientation to others was expected to correspond to lower levels on these outcomes than nondisclosed LGBs. Hypothesis 1 was not conrmed for: 1a) psychiatric symptoms of anxiety and burnout, 1b) diurnal cortisol, and 1c) reversed for depressive symptoms and AL levels whereby gay/bisexual men had lower levels than did heterosexual men. By contrast, Hypothesis 2 was partially supported as disclosure was associated with 2a) decreased symptoms of anxiety, depression, and burnout; 2b) lower cortisol levels 30 minutes upon awakening; and 2c) nonsignicantly lower AL levels in comparison with nondisclosed LGBs. Collectively, our ndings with a Montreal sample suggest that life transitions such as completely disclosing ones sexual orientation may be protective against stress-related psychopathologies and overactivation of diurnal HPA axis functioning. LGBs are believed to experience increased psychosocial distress because of the stigma of being sexual minorities (2Y4,72,73). Recent meta-analyses (74) and systematic reviews (75,76) suggest that adolescent and adult LGBs are anywhere from 1.5 to 4 times more likely to self-report depression, anxiety, suicidal ideation/attempts, substance abuse, eating disorders, risky sexual behaviors, homelessness, and victimization when compared with heterosexuals. By contrast, largescale probability samples reveal that most LGB adolescents (77,78) and adults (79,80) do not experience more mental health problems and are well adjusted (1). Moreover, LGBs are no different in terms of happiness, perceived health, and job satisfaction (81,82). Likewise in the current study, between-group analyses detected no signicant differences for symptoms of anxiety and burnout when comparing LGBs and heterosexuals of both sexes. Our results similar to others before us (83) do not therefore support sexual minority stress models, postulating increased susceptibilities toward mental illness among LGBs. For biological indices, our LGB participants again did not differ from heterosexuals in diurnal cortisol proles. Interestingly and contrary to our hypothesis, gay/bisexual men had signicantly lower depressive symptoms and AL levels compared with heterosexual men.
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That gay/bisexual men had lower depressive symptoms than heterosexual men is unprecedented. Surprised by the analogous reversal for AL levels, we conducted exploratory post-hoc analyses with one-way ANOVAs to identify precisely which biomarkers were implicated: gay/bisexual men had signicantly lower levels of triglycerides ( p = .031) and body mass indices ( p = .050) than heterosexual men and a trend toward lower levels of tumor necrosis factor-> ( p = .092). A behavioral explanation consistent with the literature may be that gay/bisexual men are more likely than heterosexual men to focus on thinness and muscularity by means of diet and exercise that strongly inuence lipid proles, anthropometry, and perhaps also inammation (84). In parallel to our AL ndings are the higher depressive symptoms among heterosexual men compared with gay/bisexual. Although psychiatric history was nonsignicantly higher among heterosexual men in descriptive statistics (see Table 1), it is possible that they differed from gay/ bisexual men in some constitutional manner that eluded us. Alternatively, it has been proposed that certain kinds of stigma-related stress can produce adaptive behavioral responses that make individuals more resilient and effective at managing future stressors, especially if these hardy individuals are well supported and are able to develop adaptive coping strategies (85). Could this have been the case for our sexual minority participants? Given that two thirds of LGB participants had completely disclosed their sexual orientation, we ascertained whether these surprising reversals were caused, in part, by coping processes inherently related to disclosing ones sexual orientation to family and friends. Disclosure is a complex phenomenon that has been purported to involuntarily incite harassment and discrimination among work colleagues (86) and in the community more broadly (87). To date, one study showed that disclosure at work was unexpectedly associated with higher cortisol levels and negative affect in comparison with nondisclosed workers (88). Shedding light on this unintuitive nding are those from another study showing that gay men who disclosed their sexual orientation to supervisors reported signicantly higher hostility in their work environment, signicantly lower perceived promotion opportunities, and signicantly higher turnover intentions (89). Notwithstanding, the ndings from the current study are inconsistent with the notion that disclosure is detrimental. Instead, our results support earlier work showing that disclosure of ones sexual orientation is related to physical health (15). In taking a positive perspective of disclosure, we view disclosure here as a dialectic process by which an individual progresses from a third-person view of homosexuality/ bisexuality to an integrated rst-person awareness and selfacceptance (43,90). Central to this integrated self-identity is stigma management that occurs by developing strategies to help cope with the stressful realities of a marginalized identity (91Y93). Our within-group analyses suggest that full disclosure, at least among our Montreal-based sample, is a form of coping strategy that fosters mental health and physiological integrity of the HPA axis.
9

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R.-P. JUSTER et al.

Disclosure was associated with decreased symptoms of anxiety, depression, and burnout. Our results among workers and students are consistent with those from a study demonstrating that gay men and lesbians who disclosed among workplaces perceived to be more supportive experienced increased job satisfaction and decreased anxiety (94). Although we did not measure disclosure at work or school specically, our ndings based on disclosure to family and friends strongly suggest that passing though this life stage promotes positive psychological health. Complimenting our psychometric ndings were those showing that disclosure was associated with lower salivary cortisol levels 30 minutes after awakening in comparison with nondisclosure. Disclosure processes may protect against hyperactivity of the HPA axis. The CAR represents a natural surge in cortisol levels reaching maximal concentrations approximately 30 minutes upon awakening (95). Excessive and blunted CAR proles are linked to distinct psychiatric symptoms of anxiety, depression, and fatigue/burnout (96). Increased HPA axis functioning during the afternoon and evening has likewise been associated with depressive symptoms (97,98). Our preliminary analyses of outcome intercorrelations revealed that burnout symptoms were correlated with higher levels at 2:00 PM and before bed for the complete sample. Because this is the rst published report of diurnal cortisol levels among healthy LGBs, we must be cautious before making any conclusions about the functional signicance of these ndings, given debate in this eld. There is much controversy concerning how hypercortisolism and hypocortisolism might be differentially associated to diverse psychopathologies (99). We previously found that workers (N = 30; mean age = 45 years) with higher AL levels had lower cortisol levels upon awakening and 30 minutes thereafter compared with those with lower AL levels. Interestingly, increased AL was also correlated with increased self-reported chronic stress and burnout symptoms (53). These previous ndings inform the following question for the current study: are lower levels of cortisol in the disclosed LGB participants an adaptive biological prole? Because disclosure was benecial against psychiatric symptoms across the board, it does not seem likely that these lower cortisol levels are maladaptive, especially because higher afternoon and evening levels corresponded to burnout symptoms. Moreover, low morning cortisol was not accompanied by multisystemic physiological dysregulations among disclosed LGBs, as measured with the norm AL index. Although our AL results were not signicant, disclosed LGBs manifested lower AL levels than the nondisclosed LGBs. This result allows some insights into why gay/bisexual men had signicantly lower AL levels than did heterosexual men in our rst analyses: this is because many gay/bisexual men had fully disclosed. One possibility why we did not attain signicant differences as a function of disclosure may be because AL levels were already comparatively low for LGBs who were disclosed (M [SE] = 1.935 [0.30]) and nondisclosed (M [SE] = 2.143 [0.376]) relative to heterosexual men (M [SE] = 3.350 [0.199]) and similar to heterosexual women (M [SE] = 2.0
10

[0.324]). Akin to the debate concerning the CAR and psychopathology, there is no conclusive indication as to what threshold needs to be attained before the consequences of AL can be detected. In addition, AL levels are low in early adulthood and increase as we age (27,70), which may render its ability to identify proximate processes more difcult. In summary, our within-group ndings underline the role disclosure can have on positive health and well-being for sexual minorities. Also noteworthy were the robust covariation effects of chronic stress in our between-group analyses and conscientiousness in our within-group analyses. Taken together, our individual-level ndings have implications for society-level perspectives: for an individual to successfully disclose and garner benets from doing so, there must be established social policies that facilitate the disclosure process (71). It has been proposed that societal intolerance during the disclosure process impairs the ability to develop ones identity in relation to the society as a whole, which consequently increases susceptibilities toward psychopathologies (100). Compelling research shows that American LGBs living in states without policies that protect them from hate crimes and employment discrimination experience signicantly higher rates of psychopathologies than LGBs living in states with protective policies (101). Likewise, LGBs living in states with constitutional amendments banning same-sex marriages experience increased rates of generalized anxiety disorder, depressive disorders, and alcohol abuse for 3 years, but those living in states that recognize same-sex marriages show no development of psychiatric symptoms (102). A recent study showed that following the Massachusetts legalization of same-sex marriage, there were signicant decreases in medical and mental health care visits and costs 12 months afterward among gay men (103). Collectively, this body of work demonstrates how changes in distal policies can progressively eliminate institutionalized stigma to promote public health benets. Consequently, this likely also facilitates proximal processes for LGBs such as disclosure without prejudice and with pride. Limitations Our main limitations are a small sample size and an unequal proportion of lesbian and bisexual men relative to gay men and bisexual women. Furthermore, sexual orientation is a construct that incorporates elements of attraction, behavior, and identity (104) that we did not investigate continuously because our analyses focused on categorizations. Likewise, collapsing the sexes for our disclosure analyses did not allow us to ascertain differential rates of psychopathologies known to exist among LGB groups (1). Indeed, differences among specic LGB groups intersect according to age cohorts, race/ethnicity (105), socioeconomic status, culture, and geographic location (1). For instance, younger generations of LGBs are 16 times more likely to have disclosed than older generations (106), and African American gay/bisexual men experience higher levels of internalized homophobia and are therefore less likely to disclose than other ethnic groups (107). This study did collect some of these factors but did not analyze nuances with more
Psychosomatic Medicine 75:00Y00 (2013)

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SEXUAL MINORITY STRESS AND DISCLOSURE

sophisticated approaches such as moderation analyses because of restricted power. Individual differences in the experience of sexual minority stress and the propensity to disclose to others could not be addressed in the current analysis. Furthermore, to generalize that disclosure is a positive experience for all sexual minorities is to ignore the complexities of identity development and discount numerous factors associated with distal and proximate processes (108,109). A similar concern is the possibility of selection biases with respect to participants motivations to partake amidst the demands of this study (e.g., approximately 215 minutes to participate, 22 saliva samples, 40 ml of blood, 0.5Y1.0 l of urine, multiple questionnaires, small monetary compensation). Although speculative, it is possible that healthier and hardier LGBs are more likely to partake in such studies than LGBs struggling with psychosocial distress and difculties self-identifying as sexual minorities. Recruiting self-identied and nondisclosed LGBs struggling with their sexual identity is undoubtedly difcult. As such, we cannot assume that our results can generalize to all LGB communities. Specically, Montreal is a liberal city, and Canadian social policies are progressive vis-a-vis sexual mi` nority rights. As such, our ndings might not generalize to more conservative locations in particular. This assertion highlights the importance of place-based factors that inuence stress levels and coping mechanisms adapted by LGB communities (74). Cross-cultural studies comparing psychiatric symptoms and biological markers of stress in different countries could provide very interesting data on this matter. Some discussion of our biological measures is warranted. This study is a cross-sectional snapshot that assumes no temporality with regards to the disclosure process in addition to the time course of our biological indices. Longitudinal studies that can capture changes in cortisol levels and/or AL levels as sexual minorities pass through life transitions would be illuminating in this regard. Another limitation is our inability to monitor compliance of diurnal cortisol sampling. Although participants completed logbooks of collection times, the use of electronic monitoring technologies reveals that participants do not adhere as well as hoped (110). There is no consensus on the most appropriate AL formulation to use (53,69). For instance, studies published in Psychosomatic Medicine have used the traditional high-risk quartile system (111Y114), two-tailed 10th/90th percentiles (115), standard deviation cutoffs (116), z statistic weights generated from bootstrapping (117), and the more recent scaling of multisystemic dysregulations (118). The use of a norm AL index in the current study anchors cutoffs according to subclinical thresholds derived from normative reference ranges and therefore safeguards against articial variation embedded within a samples biomarker distributions. This is an important consideration, given that our sample comprised young and healthy adults. Moreover, it is our conviction that the AL index is something that could be expanded beyond the laboratory as a clinic tool; consequently, using clinical ranges accessible to scientist-practitioners may be helpful for future investigation.
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CONCLUSIONS In summary, our ndings show that sexual minorities did not manifest more stress-related problems than heterosexuals. Quite the contrary, gay/bisexual men had lower depressive symptoms and AL levels than did heterosexual men. To the best of our knowledge, this is the rst published study addressing psychiatric symptoms, diurnal cortisol, and AL levels as functions of sexual orientation and disclosure processes. Pending replication and possible longitudinal studies that can ascertain changes throughout the lifespan, our disclosure analyses suggest that coming out of the closet to family and friends is an important life transition that may promote protection against stress-related symptoms and pathophysiologies. Indeed, disclosure was associated with decreased psychiatric symptoms and lower awakening cortisol levels compared with nondisclosure, although no signicant differences were detected with an AL index. Our novel ndings underlining the role self-acceptance and disclosure have on positive health and well-being of sexual minorities have important implications. Internationally, societies must endeavor to facilitate self-acceptance among LGBs by promoting tolerance, progressing policy, and dispelling stigma. This may no longer be a matter of popular debate but of public health.
We thank our participants for their wholehearted contributions to this demanding study. Many thanks go to our nurses Louise Normandeau, Soaud Lahla, and Carole Feltrin for blood extraction, as well as Helen Findlay and Edouard Kouassi for biochemical assays. Special thanks to Sylvain-Jacques Desjardins for support throughout the testing phase and to Philip Jai Johnson for his encouragement. Lastly, we would like to thank the three anonymous reviewers of our manuscript and Gillian Einstein for their helpful comments. Source of Funding and Conicts of Interest: This study was funded by a grant (222055) from the Canadian Institutes of Health Research to S.J.L. who holds a Senior Investigator Chair on Gender and Mental Health from the Canadian Institute of Gender and Health (GSC 91039). R.P holds a Doctoral scholarship from the Institute of Aging of the .J. Canadian Institutes of Health Research (SIA 95402). The authors report no conicts of interest.

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