UC Berkeley

It is well established that socially marginalized groups experience worse health than dominant groups. However, many questions remain about the health of members of multiple marginalized groups, such as Black sexual minority women (SMW). In addition, research on the relationship between structural stigma and the health of members of multiple marginalized groups is scarce. This dissertation addressed important gaps in knowledge in three studies. Studies one and two investigated how sexual orientation, race, and the intersection of sexual orientation and race are associated with health-related quality of life (HRQOL; study one) and heavy episodic drinking (study two) among a general population sample of Black and White women. Study three investigated the relationship between state-level structural stigma and sexual orientation inequities in self-rated health among women, and how this relationship varies by race.

This dissertation used cross-sectional 2014 and 2015 Behavioral Risk Factor Surveillance System data from approximately 150,000 women residing in 20 states in the United States. G-computation with bootstrapping was used to estimate adjusted prevalence differences and assess for interaction between sexual orientation and race (studies one and two) and modification by race (study three). Nine measures of HRQOL were analyzed. Heavy episodic drinking was investigated among all women and among current drinkers only. Structural stigma was operationalized using an index that includes concentration of same-sex couples, state policies, proportion of secondary schools with a Gender and Sexuality Alliance, and public opinions. For studies one and two, lesbian and bisexual women were analyzed both separately and together. Due to power considerations, lesbian and bisexual women were analyzed together in study three.

Age-adjusted prevalence differences suggested that Black SMW experience worse HRQOL and higher prevalence of heavy episodic drinking than both Black heterosexual women and White heterosexual women. HRQOL among Black bisexual women was often similar to or worse than White bisexual women. Prevalence of heavy episodic drinking among Black SMW was similar to or slightly higher than that of White SMW. Most prevalence differences comparing Black SWM to White heterosexual women suggested additive interaction such that Black SMW had worse HRQOL and higher prevalence of heavy episodic drinking than expected based on considering race and sexual orientation separately. However, HRQOL interaction results were mixed for bisexual women. Inequities in heavy episodic drinking were more pronounced when analyses were restricted to current drinkers only. Although many point estimates suggested meaningful differences in HRQOL, many 95% confidence intervals were wide and included the null. In examining structural stigma, SMW had worse self-rated health than heterosexual women in high stigma states (5.1% difference in prevalence), but not in low stigma states. The relationship between structural stigma and sexual orientation health inequities was similar for Black and White women.

Results support the hypothesis that being a member of multiple marginalized groups, compared to one marginalized group, is associated with worse HRQOL. Black SMW, especially current drinkers, appear to be at particularly high risk of heavy episodic drinking. In addition, sexual orientation and race may interact in their relationship to HRQOL and heavy episodic drinking. Findings suggest that information about the health of Black SMW, and by extension, prevention and intervention efforts, cannot be fully inferred from research on the health of other groups of women. This suggests that additional research about health behaviors, outcomes, and mechanisms among Black SMW is necessary to develop nuanced, intersectionality-informed prevention and intervention approaches. Higher structural stigma is associated with greater sexual orientation health inequities, and reducing structural stigma may reduce health inequities. Longitudinal and multi-level studies would improve understanding of the relationship between structural stigma and health, thereby informing expectations of the results of social change.