Minority stress and emotional intimacy among individuals in lesbian and gay couples: Implications for relationship satisfaction and health

Abstract

Lesbian and gay (LG) couples face a particular stress that is unique from their heterosexual counterparts: minority stress, the increased stress experienced as a result of living in an environment that is stigmatizing of their sexual orientation and identity. Research demonstrates that minority stress has far-reaching health implications for LG individuals. However, the literature examining the effects of minority stress on health at the couple level is limited. This study examined the impact of minority stress on emotional intimacy, relationship satisfaction, and psychological and physical health outcomes, as well as the moderating role of gender and marital status. A total of 181 LG-identified adults in same-sex relationships completed an online self-report survey. Results indicated that internalized homonegativity and sexual orientation concealment were negatively related to emotional intimacy and that emotional intimacy was positively related to relationship satisfaction. Emotional intimacy mediated the link between internalized homonegativity and relationship satisfaction for married—but not unmarried—individuals. Sexual orientation concealment mediated the link between sexual orientation concealment and relationship satisfaction for married men but not for any other group. Findings from the current study highlight the importance of emotional intimacy among individuals in LG couples. Areas for future research are explored, and implications for research, clinical practice, and policy are explicated.

Keywords

Couples emotional intimacy gay lesbian minority stress relationship satisfaction

As has been the case historically, lesbian and gay (LG) individuals in same-sex relationships live in a social context where they are stigmatized as a result of both their sexual minority identity and their romantic involvement with a same-sex partner (Frost & Meyer, 2009; Peplau & Fingerhut, 2007; Rostosky, Riggle, Gray, & Hatton, 2007; Todosijevic, Rothblum, & Solomon, 2005). Same-sex relationships do not receive the same universal support and recognition as different-sex relationships (Herek, 2006) and as such LG couples experience stigmatization, prejudice, and discrimination. Views that committed same-sex relationships are inferior to heterosexual partnerships in various ways persist, including the belief that individuals in LG couples are psychologically maladjusted (Roisman, Clausell, Holland, Fortuna, & Elieff, 2008). While North American attitudes toward LG couples have shifted, many adults in the U.S. still hold negative attitudes toward same-sex behavior, viewing it as wrong and unnatural (Avery et al., 2007). While attitudes toward LG individuals are more positive in Canada (Morrison, Morrison, & Franklin, 2009), these negative attitudes persist. This context of stigmatization, prejudice, and discrimination toward LG couples creates distinct stressors not experienced by heterosexual couples.

Minority stress

Arguably, the most striking difference between individuals in different-sex and individuals in same-sex relationships is the experience of everyday stressors related to their sexual minority status. Stigma, prejudice, and discrimination directed at members of stigmatized minority groups engender a social environment that is stressful, which can result in physical and mental health problems (Friedman, 1999). Meyer (2003) termed this stress minority stress and identified a number of components of minority stress (e.g., experiences of discrimination, internalized homonegativity, sexual orientation concealment). Experiences of minority stress affect the well-being of LG individuals. For example, studies link minority stress to HIV risk behavior, substance use, depressive symptoms (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008), generalized anxiety disorder, and attention deficit hyperactivity disorder (Frisell, Lichtenstein, Rahman, & Langstrom, 2010).

Given the interdependent nature of couples, stress experienced by one partner will likely have a negative impact on the other partner (Kurdek, 2000; Otis, Rostosky, Riggle, & Hamrin, 2006; Rostosky & Riggle, 2002). Moreover, LG couples live in a climate epitomized by prejudice and stigmatization associated with their sexual minority identity and, as a consequence, their relationships. Indeed, evidence has emerged demonstrating that LG couples are negatively affected by minority stress (Balsam & Szymanski, 2005; Frost & Meyer, 2009; Jordan & Deluty, 2000; Mohr & Daly, 2008; Otis et al., 2006; Rostosky et al., 2007). Among same-sex couples, minority stress has been associated with decreases in relationship duration (Frost & Meyer, 2009), self- and partner-respect (Keller & Rosen, 1988), relationship quality/satisfaction (Balsam & Szymanski, 2005), comfort with sexuality (Green & Mitchell, 2002), and ability to cope with general stress (Elizur & Mintzer, 2003), as well as increases in withdrawal (Green & Mitchell, 2002), relationship problems (Frost & Meyer, 2009), cognitive burden, fatigue, and distress (Smart & Wegner, 2000).

Regardless of whether individuals are in same- or different-sex couples, the harmful effects of stress are felt at all levels of functioning—the relational, the psychological, and the physiological. For example, research on heterosexual couples has revealed that couple distress is linked to emotional and behavioral difficulties such as depressed mood, anxiety, and substance use disorders (Whisman, Sheldon, & Goering, 2000), with distressed couples reporting higher rates of the aforementioned than nondistressed couples. It is therefore no surprise that individuals experiencing stress in their primary relationship are overrepresented in mental health services (Lin, Goering, Offord, & Campbell, 1996). Distressed couples are also more likely to report higher rates of domestic violence (Whisman et al., 2000). In the health domain, physiological systems affected by couple distress include the cardiovascular, endocrine, immune, and neurosensory systems, all of which factor into physical health problems (Kiecolt-Glaser & Newton, 2001).

In the case of same-sex couples, the impact of specific components of minority stress on LG couples has received some attention in the literature. While there is a clear link between LG individuals’ experiences of discrimination (i.e., experiences of stigma and prejudice based on one’s LG identity) and negative health outcomes (e.g., Institute of Medicine, 2011; Meyer, 2003), the impact of discrimination experiences on LG couples is somewhat mixed. For example, past studies found that lesbian women reported that sexual orientation discrimination did not affect their intimate relationships (Mays, Cochran, & Rue, 1993); perceived discrimination was not a predictor of relationship quality (i.e., partners felt that their needs were met and they reported high relationship satisfaction; Otis et al., 2006); and that discriminatory experiences were not significantly related to relationship quality in lesbian victims of domestic violence (Balsam & Szymanski, 2005).

While the impact of discrimination on relationships is unclear, sexual orientation concealment (i.e., hiding one’s sexual minority identity from others), another facet of minority stress, has been linked to decreased relationship satisfaction through a devaluation of the relationship (Berzon, 1988) as well as to anxiety about the relationship (Jordan & Deluty, 2000). Additionally, concealment can deprive LG individuals of social support. For example, when an individual becomes isolated within a same-sex relationship, they may decrease or avoid contact with others and thereby deprive themselves of validation and support for the relationship (Almeida, Woods, Messineo, Font, & Heer, 1994). Decreased support can lessen the couple’s ability to cope with the stresses and strains faced by all couples (Elizur & Mintzer, 2003) and can contribute to relationship dissolution (Kurdek & Schmitt, 1987). Conversely, sexual orientation disclosure can positively affect relationship quality by increasing acknowledgment and validation of the couple from important others (Beals & Peplau, 2001).

A third component of minority stress, internalized homonegativity (i.e., internalized negative beliefs and feelings about being LG), has been linked to several negative relationship outcomes among LG couples, including decreased relationship quality (Balsam & Szymanski, 2005; Elizur & Mintzer, 2003), greater relationship problems (Frost & Meyer, 2009), isolation from the community, negative expectations of relationship quality and longevity (Otis et al., 2006), and decreased relationship attractions and constraints (Mohr & Daly, 2008). Frost and Meyer (2009) reasoned that to alleviate negative feelings stemming from the application of anti-gay beliefs to the self, individuals may either avoid lasting and deep relationships with other LG people or seek out opportunities for sexual expression lacking in intimacy and interpersonal closeness. In long-term LG relationships, one’s partner and shared experiences become constant reminders of one’s own sexual orientation and related negative feelings toward the self as an LG person. Such beliefs reduce both self-respect and respect for one’s partner even amid feelings of genuine affection between partners (Keller & Rosen, 1988) and may negatively affect relationship functioning by increasing levels of depression, interpersonal withdrawal, and inhibited sexuality (Green & Mitchell, 2002).

Emotional intimacy in LG couples

Although less studied in LG couples, the importance of emotional intimacy has been consistently highlighted in the literature on heterosexual couples. Emotional intimacy is best understood as the “perception of closeness to another that allows sharing of personal feelings, accompanied by expectations of understanding, affirmation, and demonstrations of caring” (Sinclair & Dowdy, 2005, p. 193). Emotional intimacy has been highlighted as a major factor contributing to emotional/psychological and physical well-being (Ornish, 1998) and serves as the foundation for close relationships providing a sense of purpose and belonging (Goleman, 1997; Wood, 1984). Conversely, studies of individuals who are isolated (Miller & Lefcourt, 1982) and consequently incapable of communicating their inner thoughts and feelings are at risk for developing psychological symptoms. Emotional intimacy also has been shown to be related to physical health in a variety of longitudinal studies (Graves, Thomas, & Mead, 1991; Russek & Schwartz, 1997). The incidence of various chronic illnesses (e.g., coronary artery disease) has been inversely correlated with emotional intimacy (Orth-Gomer, Rosengren, & Wilhelmsen, 1993; Seeman & Syme, 1987). After reviewing the literature on emotional support, Ornish (1998) suggested that individuals who report they have no confidante or person who cares for them have a 3- to 5-times greater risk of premature death and disease from all causes, including heart attacks, strokes, cancer, and autoimmune and infectious diseases. Compared to no support, the presence of even one intimate relationship that offers emotional support can dramatically improve health outcomes (Ornish, 1998).

In addition to the important role of emotional intimacy in health outcomes, emotional intimacy is also an important predictor of relationship satisfaction. Relationship satisfaction has served “as a cornerstone for our understanding of how relationships and marriages work” (Funk & Rogge, 2007, p. 572) and is an important index of the health of a couple. Indeed, same-sex couples whose partners are highly satisfied with their relationship are more likely to stay in the relationship (Kurdek, 2000; Peplau & Spaulding, 2000). Although studies of emotional intimacy in same-sex couples are limited, a small number of studies have consistently indicated that emotional intimacy is the most important predictor of relationship satisfaction in this population (Deenen, Gijs, & Van Naerssen, 1994; Eldridge & Gilbert, 1990; Koepke, Hare, & Moran, 1992; Schreurs & Buunk, 1996). For example, Deenen et al. (1994) investigated the relationship between verbal, physical, and emotional intimacy and sexual aspects of relationship functioning in a sample of Dutch gay men. Results showed that gay men value emotional aspects of their relationships above sexual satisfaction. Independent of relationship duration and partner’s age, emotional intimacy best predicted relationship satisfaction. Eldridge and Gilbert (1990) also investigated emotional intimacy in a study of lesbian couples. Of all measured constructs, emotional intimacy was the most highly correlated with relationship satisfaction.

Though emotional intimacy is an important predictor of relationship satisfaction in LG couples, research to date has not examined how minority stress impacts emotional intimacy. However, research in heterosexual couples suggests that stress has a negative impact on couple functioning, including emotional intimacy. For example, chronic minor stresses (e.g., work stress, financial stress, and family of origin stress) increase the likelihood of couple tension and conflict (Bodenmann, 2005). Bodenmann, Ledermann, and Bradbury (2007) outlined four ways that chronic external stress affects couple functioning, by (a) decreasing the time partners spend together, resulting in a reduction in shared experiences and weakening feelings of togetherness, decreasing self-disclosure, and jeopardizing dyadic coping; (b) decreasing communication quality by eliciting less positive interaction and more negative interaction and withdrawal; (c) increasing the risk of psychological and physical problems (e.g., sleep disorders, sexual dysfunction, mood disturbances); and (d) increasing the likelihood that problematic personality traits are expressed between partners (e.g., in the form of rigidity, anxiety, hostility). Findings from heterosexual samples demonstrate that stress and lack of intimacy decrease relationship satisfaction (Bodenmann, 2005; Cohan & Bradbury, 1997; Schaefer & Olson, 1981). However, it is unknown how stress—specifically, minority stress—impacts emotional intimacy, and how emotional intimacy may explain the relationship between minority stress and relationship satisfaction.

Marital status and gender

Marital status is an important variable to consider when examining emotional intimacy, relationship satisfaction, and health outcomes. Among heterosexual couples, married couples have been shown to experience higher levels of intimacy and relationship satisfaction than unmarried couples (Moore, McCabe, & Brink, 2001). Furthermore, marital status has been linked to favorable well-being when comparing married and unmarried couples (Wood, Rhodes, & Whelan, 1989). In general, married people are healthier than those who are not married across a wide array of health outcomes (Schoenborn, 2004). Among same-sex couples, research has demonstrated that married LG couples have had lower attachment-related anxiety than nonmarried couples (Macintosh, Reissing, & Andruff, 2010). Thus, relationship status (married versus unmarried) may be an important moderating variable to consider in the relationship between minority stress, emotional intimacy, and health and relationship outcomes.

Gender also warrants consideration when examining minority stress, emotional intimacy, relationship satisfaction, and health outcomes. There is a lack of research examining gender differences in emotional intimacy specifically. However, Twohey and Ewing (1995) conducted a review of the literature and found that men are as emotionally intimate as women. There is limited literature on gender differences in emotional intimacy in LG relationships. The scant studies that exist focus mainly on emotional intimacy in serodiscordant (i.e., different HIV status) gay male couples (e.g., Remien, Carballo-Dieguez, & Wagner, 1995) but do not compare across men and women. A small number of studies have consistently indicated that emotional intimacy is the most important predictor of relationship satisfaction for both gay men and lesbian women (Deenen et al., 1994; Eldridge & Gilbert, 1990; Koepke et al., 1992; Schreurs & Buunk, 1996). Though research on gender differences in emotional intimacy is lacking, there is some evidence that women and men experience different levels of minority stressors, with sexual minority men experiencing more sexual orientation-based victimization (e.g., Herek, 2009) and internalized homonegativity (e.g., Mohr & Fassinger, 2000) than sexual minority women. Moreover, the relationship between discrimination and mental health outcomes has been shown to be moderated by gender (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Bontempo & D’Augelli, 2002; de Graaf, Sandfort, & ten Have, 2006). Thus, given the lack of research exploring potential gender differences in emotional intimacy—especially among LG individuals in same-sex couples—combined with documented gender differences in minority stressors, as well as a documented role of gender as a moderator of the link between minority stress and health outcomes, examining gender appears warranted.

Current study

The current study was built on the understanding that stress in general, and more specifically minority stress, has well-established psychological and physical health implications. Additionally, research on heterosexual couples has revealed that stress and lack of intimacy decrease relationship satisfaction. However, the impact of minority stress on emotional intimacy, as well as the role that emotional intimacy may play in the relationships between minority stress and health and couple outcomes, has not been explored. The purpose of the present study was to investigate the relationship between minority stress, emotional intimacy, relationship satisfaction, and health outcomes in same-sex couples. The proposed model is presented in Figure 1, in which we posit that emotional intimacy will mediate the relationship between minority stress (i.e., experiences of discrimination and rejection, internalized homonegativity, sexual orientation concealment) and outcomes (i.e., relationship satisfaction, psychological distress, health symptoms). Moreover, the model tests whether gender and marital status will moderate the mediated relationship between minority stress variables, emotional intimacy, and outcomes. Specifically, the extant literature reveals that being married is related to more emotional intimacy among heterosexual couples and heightened well-being among both heterosexual and LG couples; thus, marriage may help to buffer the negative effects of stress on these outcomes (the a and c paths in Figure 1) and may strengthen the relationship between emotional intimacy and outcomes (the b paths). Likewise, the extant literature has demonstrated that gender moderates the relationship between discrimination—one facet of minority stress—and outcomes; thus, gender may similarly moderate the link between minority stressors and both emotional intimacy and outcomes (the a and c paths). It is unknown whether gender may moderate the relationship between emotional intimacy and outcomes (the b paths).

Method

Participants

In order to be included in the study, candidates had to currently be in a same-sex couples. Participants included 181 adults living in Canada (n = 127), the U.S. (n = 49), and countries outside of North America (n = 5) who ranged in age from 18 to 65 (M = 34.56, SD = 12.34). The sample consisted of 107 women (59.1%), 64 men (35.4%), 3 transgender individuals (1.7%), including 2 female-to-male individuals (1.1%), and 1 male-to-female individual (0.6%). Four people (2.2%) did not identify their gender. One hundred and nine participants identified as lesbian (60.2%) and 72 identified as gay (39.8%). The large majority of participants (85.6%, n = 155) identified as White. Three (1.7%) identified as Black, three (1.7%) identified as Latino/Latina, nine (5.0%) identified as Asian/Pacific Islander, one (.6%) identified as Native American/American Indian/Aboriginal, and nine (5.0%) identified as multiracial. Relationship status categories were presented in a non-mutually exclusive manner. Sixty participants (33.1%) identified as being in a relationship, living together; another 60 (33.1%) identified as being in a relationship, living apart; and 65 (35.9%) identified as being married or in a civil union/domestic partnership/equivalent. Length of time in the relationship ranged from 4 months to 40 years (M = 5.76 years, SD = 7.45). The majority of the sample (74.6%, n = 135) reported having no children.

Procedure

Participants were contacted via recruitment e-mails sent to LG-focused email lists, organizations, and academic associations. They were asked to complete an online survey concerning stress, intimacy, relationship satisfaction, and health in their intimate relationship. The study announcement specified that participants would have the option to be entered in a lottery for the chance to win one of three prizes of US$50. It was also specified that only one partner per intimate relationship could complete the survey (in order to avoid statistical issues concerning nonindependence). Data were collected using a secure online survey platform.

Measures

Minority stress variables

Three minority stress variables were measured. Experiences of discrimination and rejection were assessed using the 14-item Heterosexist Harassment, Rejection, and Discrimination Scale (HHRDS; Szymanski, 2006). Participants were asked to rate the frequency with which they had experienced heterosexist harassment, rejection, and discrimination within the past year. Example items include “How many times have you been rejected by family members because you are a lesbian woman/gay man?” and “How many times have you been treated unfairly by your employer, boss, or supervisors because you are a lesbian woman/gay man?” Each item was rated on a 6-point Likert-type scale, from 1 (the event has never happened to you) to 6 (the event happened almost all the time [more than 70% of the time]). Mean scores were used, with higher scores indicating greater experiences of heterosexist harassment, rejection, and discrimination in the past year. Reported α for scores on the HHRDS full scale was .90. Validity of the original HHRDS was supported by exploratory factor analysis; by significant, positive correlations with measures assessing depression, anxiety, interpersonal sensitivity, somatization, obsessive compulsiveness, and overall psychological distress; and by the demonstration that the HHRDS was conceptually distinct from internalized heterosexism (Szymanski, 2006). Cronbach’s α for the current study was .91.

Internalized homonegativity was assessed using the Internalized Homonegativity subscale from the Lesbian and Gay Identity Scale (LGIS; Mohr & Fassinger, 2000). The subscale consists of 5 items that assess the degree to which participants evaluate their LG sexual orientation negatively (e.g., “I wish I were heterosexual”) or positively (e.g., “I am glad to be an LG person,” reverse-scored). Items are rated on a 7-point Likert-type subscale ranging from 1 (agree strongly) to 7 (disagree strongly). Cronbach’s α for the original subscale was .70. In the current study, Cronbach’s α was .81. Validity evidence for LGIS subscales has been provided through predicted associations with phase of LG identity development, degree of investment in one’s LG social identity, self-esteem, and degree of interaction with heterosexual individuals (Mohr & Fassinger, 2003).

Sexual orientation concealment was assessed using the Sexual Orientation Concealment Scale (Jackson & Mohr, 2016). The 6-item scale measures how often respondents behaved in ways that hid their sexual orientation in the past 2 weeks (e.g., “I concealed my sexual orientation by telling someone that I was straight or denying that I was LGB”). Participants rated items on a 7-point Likert-type scale ranging from 1 (not at all) to 7 (all the time). Psychometric data for the scale are not available; however, it was chosen for the proposed study for its clear focus on concealment. Cronbach’s α for the current study was .85.

General stress

A general stress measure was included in addition to the minority stress measures, given that the latter is an additive stress to that experienced by all people. The 10-item Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983) measures the frequency of stressful events in the past month (e.g., “In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?”). Participants rated items on a 5-point Likert-type scale ranging from 0 (never) to 4 (very often). Coefficient α reliability for the original scale ranged from .84 to .86. Concurrent validity was established by positive associations with the number and perceived impact of life stressors in college samples. Also, the PSS predicted depressive symptomatology, physical symptomatology, and social anxiety. In the current study, Cronbach’s α was .91.

Emotional intimacy

Emotional intimacy was assessed using the Emotional Intimacy Scale (EIS; Sinclair & Dowdy, 2005), which measures self-reported perceptions of being validated (e.g., “My partner completely accepts me as I am”), understood (e.g., “My thoughts and feelings are understood and affirmed by my partner”), and cared for (e.g., “My partner cares deeply for me”). The scale consists of 5 items and is scored on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). The standardized α coefficient for the original scale was .88, indicating strong scale reliability. Cronbach’s α for the current study was .91. Substantial evidence has been provided for construct and criterion-related validity of the EIS (Sinclair & Dowdy, 2005).

Relationship satisfaction

Relationship satisfaction was assessed with the 3-item Kansas Marital Satisfaction Scale (KMSS; Schumm et al., 1986), which asks participants to indicate how true each of the following statements was: “I am satisfied with my relationship; I am satisfied with my partner in his/her role as my partner; I am satisfied with my relationship with my partner.” Consistent with the usage of this scale in previous studies of same-sex couples (e.g., Kurdek, 1991), the wording of the KMSS was changed slightly to reflect the nonmarital status of some same-sex relationships (i.e., “partner” instead of “husband/wife”). Each item on the KMSS has a possible score ranging from 1 to 7 (1 = not at all true, 7 = extremely true). Cronbach’s α for the KMSS has been reported at .84 (Schumm et al., 1986) and .96 (Jeong, Stephan, & Walter, 1992). Kurdek (1991) reported αs of .98 and .97 (for each partner) when adapting the scale for use with LG couples. Cronbach’s α for the current study was .96. Test–retest reliability for the original scale was .71 (Schumm et al., 1986). Regarding validity, couples scoring in the distressed range on the KMSS also scored in the distressed range on the Revised Dyadic Adjustment Scale (Busby, Christensen, Crane, & Larson, 1995) and the Dyadic Adjustment Scale ( Crane, Middleton, & Bean, 2000; Spanier, 1976).

Psychological functioning

Psychological functioning was assessed using the Kessler Psychological Distress Scale (K-10; Kessler et al., 2002), a 10-item instrument that measures nonspecific psychological distress. Participants were asked how frequently they experienced symptoms of psychological distress during the past 30 days using a 5-point Likert-type scale ranging from 1 (none of the time) to 5 (all of the time). Item examples include “Did you feel restless or fidgety” and “Did you feel that everything was an effort?” The K-10 has been reported to have excellent internal consistency reliability (α = .93). Cronbach’s α for the current study was .93. Validation studies have shown that the K-10 has good concordance with masked clinical diagnoses of serious mental illness in general population samples (Kessler et al., 2002).

Health symptoms

Health symptoms were assessed using the Pennebaker Inventory of Limbic Languidness (PILL; Pennebaker, 1982). The 54-item checklist measures physical symptoms such as coughing, insomnia, diarrhea, and nausea. Participants were asked to rate the frequency with which they had experienced these symptoms in the past year using a 5-point scale ranging from 1 (have never or almost never experienced the symptom in the past year) to 5 (more than once every week in the past year). Cronbach’s α for the original measure was .88 (Pennebaker, 1982), demonstrating high internal consistency. In the current study, Cronbach’s α was .94. Validation support for the PILL has been shown through positive correlations with physician visits, aspirin use, and health-related work absenteeism (Pennebaker, 1982).

Demographic questionnaire

An author-generated demographic questionnaire assessed various participant characteristics including age, gender, race/ethnicity, relationship status, occupation, income, education, sexual orientation, place of residence, and religious affiliation. Sexual orientation was assessed by participants’ self-identification as lesbian, gay, or other.

Results

Two hundred and sixty-eight participants began the survey; a total of 181 completed and submitted the questionnaire in its entirety. Mean scores on scales were computed for those participants who had completed at least 80% or more of the items on the scale, as per recommendations by Downey and King (1998). Prior to conducting any analyses, data were tested for univariate outliers, using Box plots for all measures to identify extreme outliers. Twenty such outliers were detected and the respective measure scores were removed from the data set. Additionally, Mahalanobis distance was used to detect multivariate outliers. The data set contained four such outliers, which were removed from the data set prior to analyses. For any outliers, the individual outlier score was removed from the data set, keeping the participant’s other scores. Prior to conducting the conditional process analyses, data distributions were examined for assumptions of normality. Three variables were transformed with a logarithm transformation due to substantial negative skewness. These variables were experiences of discrimination and rejection (HHRDS), internalized homonegativity (LGIS Internalized Homonegativity subscale), and sexual orientation concealment (Sexual Orientation Concealment scale). In order to detect multicollinearity, the data set was examined for values of inflation factors above 10 and tolerance below .2, as per the generally accepted rule. No multicollinearity was detected. Because we ran three models—one predicting each outcome, which included regressing the mediator (emotional intimacy) and the moderators (gender and marital status) on the predictor variables (minority stress variables), and regressing each of our three outcome variables on the mediator—we adjusted the overall error rate to be .0125 (.05 divided by four, for the regressions predicting each of the three outcomes and the regression predicting the mediator). The means, standard deviations, and bivariate correlations between variables are displayed in Table 1.

Table 1.

Correlations between predictors, moderators, mediator, and outcome variables.

Variable	1	2	3	4	5	6	7	8	9	10
1. Discrimination	–
2. Internalized homonegativity	.19*	–
3. Sexual orientation concealment	.29***	.35***	–
4. General stress	.18*	.18*	.16*	–
5. Marital status	−.04	−.22**	−.21**	−.20**
6. Gender	.06	−.23**	−.10	.07	.18*	–
7. Emotional intimacy	−.10	−.29**	−.26**	−.28***	.28***	.10	–
8. Relationship satisfaction	−.21*	−.25**	−.28***	−.22*	.24**	.20*	.70***	–
9. Psychological distress	.19*	.24**	.17*	.77***	−.24**	.06	−.24**	−.27***	–
10. Health symptoms	.20**	.08	.11	.43***	−.06	.19*	−.03	−.12	.52***	–
Mean	1.86	1.72	1.47	18.09	N/A	N/A	4.63	18.37	20.15	109.58
SD	.65	1.01	.60	7.59	N/A	N/A	.50	2.72	7.87	30.11
Range	1–4.5	1–5.8	1–3.67	0–37	N/A	N/A	2.8–5	9–21	10–44	54–221.09

Note. Unmarried and male were coded as 0; married and female were coded as 1.

*p < .05; **p < .01; ***p < .001.

Conditional process model

The SPSS PROCESS macro provided by Hayes (2014) was used to perform multiple regression analyses and to create 10,000 bootstrapped samples. Using the bootstrapped samples, the macro generates a confidence interval for the indirect effect of the mediating variable on the outcome variable. When zero is not included in the 95% confidence interval, there is evidence of mediation. The conditional process model does not allow for multiple dependent variables; therefore, each outcome variable was tested separately (relationship satisfaction, psychological distress, and health symptoms). General stress was entered as a covariate into each model. For each model, marital status and gender were entered as moderators. For all analyses, the confidence interval was set to 95% (α = .05). According to Fritz and MacKinnon (2007), 148 participants are required to detect a significant mediated effect for a and b paths that fall between small and medium. As such, our sample size was adequate to attain power of .80.

Model results

The models predicting emotional intimacy were significant, accounting for between 19% and 22% of the variance in emotional intimacy (R ²), p < .001, depending on the variables in the model. Likewise, the models predicting relationship satisfaction were significant, accounting for 53% of the variance in relationship satisfaction (R ²), p < .001. The models predicting psychological distress also were significant, accounting for between 66% and 69% of the variance in psychological distress (R ²), p < .001, depending on the variables in the model. Finally, the models predicting health symptoms were significant, accounting for 26% of the variance in health symptoms (R ²), p < .001. Each overall model was significant at the adjusted α rate of .0125 (.05 divided by four, for the regressions predicting each of the three outcomes and the regression predicting the mediator). Note that the R ² values fluctuate slightly—as do the regression coefficients (discussed below)—because the interaction terms change in each model (e.g., gender by experiences of discrimination and rejection in the first row of Table 2; gender by internalized homonegativity in the second row). In addition, because the PROCESS macro uses listwise deletion, the a paths and b paths vary slightly depending on the outcome measure, based on missing data among all variables in each model. With this caveat in mind, below we discuss the path coefficients.

Table 2.

Summary of path coefficients and standard errors (in parentheses).

X	M	Y	Effect of X on M (a₁ )	Effect of W on M (a₂ )	Effect of Z on M (a₃ )	Effect of XW on M (a₄ )	Effect of XZ on M (a₅ )	Effect of M on Y (b)	Effect of X on Y (c₁ )	Effect of W on Y (c₂ )	Effect of Z on Y (c₃ )	Effect of XW on Y (c₄ )	Effect of XZ on Y (c₅ )
EDR	EI	RS	−0.69 (0.53)	0.24 (0.17)	−0.22 (0.17)	−0.22 (0.62)	1.22 (0.63)	3.23*** (0.41)	−1.82 (1.85)	−4.46 (3.27)	2.84 (2.64)	1.99 (2.14)	−0.07 (2.22)
IH	EI	RS	−0.42 (0.30)	0.32** (0.10)	−0.04 (0.11)	−0.96* (0.43)	0.62 (0.40)	3.36*** (0.42)	1.53 (1.07)	−1.32 (3.52)	3.64 (2.61)	−2.07 (1.65)	−0.74 (1.44)
SOC	EI	RS	−1.02* (0.41)	0.26* (0.10)	−0.15 (0.11)	−0.64 (0.60)	1.48** (0.51)	3.16*** (0.43)	−1.24 (1.54)	−4.89 (3.29)	2.32 (2.63)	2.64 (2.17)	0.15 (1.91)
EDR	EI	PD	−00.41 (0.49)	0.21 (0.15)	−0.11 (0.15)	−0.17 (0.57)	0.67 (0.58)	−0.87 (1.18)	−10.81* (4.74)	7.41 (8.72)	−14.42 (7.42)	−15.01** (5.64)	19.38** (5.76)
IH	EI	PD	−0.65* (0.23)	0.28** (0.09)	−0.07 (0.10)	−0.79* (0.40)	0.64 (0.37)	0.19 (1.30)	3.10 (3.09)	3.93 (9.88)	−2.09 (7.93)	−4.44 (4.54)	−1.58 (4.02)
SOC	EI	PD	−0.59 (0.39)	0.26** (0.10)	−0.11 (0.10)	−0.72 (0.56)	1.05* (0.48)	0.32 (1.26)	5.45 (4.15)	3.79 (9.03)	−1.40 (7.55)	−9.84 (5.89)	−5.16 (5.14)
EDR	EI	HS	−0.35 (0.51)	0.28 (0.16)	−0.18 (0.16)	−0.41 (0.59)	0.90 (0.60)	6.63 (7.20)	30.85 (29.07)	−14.60 (52.29)	−4.87 (43.55)	−15.00 (34.22)	−35.00 (35.00)
IH	EI	HS	−0.64* (0.29)	0.31** (0.10)	−0.10 (0.10)	−0.87* (0.41)	0.73 (0.38)	4.68 (7.66)	1.09 (18.16)	−31.79 (57.45)	−22.95 (45.12)	14.01 (26.72)	2.04 (23.62)
SOC	EI	HS	−0.58 (0.41)	0.29** (0.10)	−0.14 (0.10)	−0.85 (0.58)	1.14* (0.50)	5.55 (7.47)	0.67 (24.70)	−20.87 (52.86)	−17.80 (43.51)	10.51 (34.97)	−1.28 (30.55)

Note. X = predictor variable; M = mediator variable; Y = outcome variable; W = marital status (moderator variable 1); Z = gender (moderator variable 2); EDR = experiences of discrimination and rejection; IH = internalized homonegativity; SOC = sexual orientation concealment; EI = emotional intimacy; RS = relationship satisfaction; PD = psychological distress; HS = health symptoms.

*p < .05; **p < .01; ***p < .001.

The model results are presented in Table 2. Note that all models included general stress as a covariate. The first set of path coefficients (the first three rows in Table 2) focused on the outcome of relationship satisfaction. In this set, of the a₁ paths (the effect of each predictor on emotional intimacy), only sexual orientation concealment was significantly (negatively) related to emotional intimacy. For the a₂ paths (the effect of marital status on emotional intimacy), married individuals (coded 1) reported more emotional intimacy than unmarried individuals (coded 0), with the exception of the model in which the predictor variable was experiences of discrimination and rejection. Gender was unrelated to emotional intimacy (the a₃ paths). There was a significant marital status by internalized homonegativity interaction predicting emotional intimacy (the a₄ path); the negative effect of internalized homonegativity on emotional intimacy was greater among married individuals than unmarried individuals. Likewise, there was a significant gender by sexual orientation concealment interaction predicting emotional intimacy (the a₅ path); the effect of sexual orientation concealment on emotional intimacy was negative and significant among men but nonsignificant among women. The b paths (the effect of emotional intimacy on relationship satisfaction) were significant, suggesting that greater emotional intimacy was related to greater relationship satisfaction. There were no significant c₁–c₅ paths (the effects of each predictor, the two moderators, and the interactions on relationship satisfaction).

The second set of path coefficients (the second set of three rows in Table 2) focused on the outcome of psychological distress. In this set, of the a₁ paths (the effect of each predictor on emotional intimacy), only internalized homonegativity was significantly (negatively) related to emotional intimacy. Consistent with the first set of path coefficients, married individuals reported more emotional intimacy than unmarried individuals, with the exception of the model in which the predictor variable was experiences of discrimination and rejection (the a₂ paths). Again consistent with the first set, gender was unrelated to emotional intimacy (the a₃ paths). In addition, there was a significant marital status by internalized homonegativity interaction predicting emotional intimacy (the a₄ path), whereby the negative effect of internalized homonegativity on emotional intimacy was greater among married individuals than unmarried individuals. Likewise, there was a significant gender by sexual orientation concealment interaction predicting emotional intimacy (the a₅ path), whereby the effect of sexual orientation concealment on emotional intimacy was negative and significant among men but nonsignificant among women. The b paths (the effect of emotional intimacy on psychological distress) were nonsignificant. Among the c₁ paths (the effect of each minority stress predictor on psychological distress), experiences of discrimination and harassment were negatively related to psychological distress, though this effect was moderated by both marital status (path c₄) and gender (path c₅). Because both marital status and gender were significant moderators of the relationship between experiences of discrimination and rejection and psychological distress, these interactions were explored via their conditional direct effects, which are detailed below. Finally, neither marital status (path c₂) nor gender (path c₃) was significantly related to psychological distress.

The final set of path coefficients (the third set of three rows in Table 2) focused on the outcome of health symptoms. In this set, of the a₁ paths (the effect of each predictor on emotional intimacy), only internalized homonegativity was significantly (negatively) related to emotional intimacy. Consistent with the first two sets of path coefficients, married individuals reported more emotional intimacy than unmarried individuals, with the exception of the model in which the predictor variable was experiences of discrimination and rejection (the a₂ paths). Again consistent with the first two sets, gender was unrelated to emotional intimacy (the a₃ paths). In addition, there was a significant marital status by internalized homonegativity interaction predicting emotional intimacy (the a₄ path), whereby the negative effect of internalized homonegativity on emotional intimacy was greater among married individuals than unmarried individuals. Likewise, there was a significant gender by sexual orientation concealment interaction predicting emotional intimacy (the a₅ path), whereby the effect of sexual orientation concealment on emotional intimacy was negative and significant among men but nonsignificant among women. Consistent with the second set of path coefficients, the b paths (the effect of emotional intimacy on health symptoms) were nonsignificant. Finally, there were no significant c₁–c₅ paths (the effects of each predictor, the two moderators, and the interactions on health symptoms).

Conditional direct effects

The conditional direct effect of each predictor (i.e., experiences of discrimination and rejection, internalized homonegativity, and sexual orientation concealment) on each outcome—ignoring the mediator—was examined at specific levels of the two moderator variables (i.e., marital status and gender), controlling for general stress. As noted above, both moderators impacted the relationship between experiences of discrimination and rejection and psychological distress. For men, there was a negative relationship between experiences of discrimination and rejection and psychological distress when they were unmarried (B = −10.81, p < .05) or married (B = −25.82, p < .001). However, for unmarried women, there was a positive relationship between experiences of discrimination and rejection and psychological distress (B = 8.57, p < .05). For married women, the direct effect of experiences of discrimination and rejection on psychological distress was not significant (B = −6.44, ns). Thus, it appears that for women, but not men, being married reduced the impact of discrimination and rejection on psychological distress. No other conditional direct effects were significant.

Conditional indirect effects

The conditional indirect effect of each predictor on each outcome through emotional intimacy was examined at specific levels of the two moderator variables (i.e., marital status and gender), controlling for general stress. Table 3 displays the conditional indirect effects. Marital status moderated the indirect effect of internalized homonegativity on relationship satisfaction through emotional intimacy. Specifically, emotional intimacy mediated the effect of internalized homonegativity on relationship satisfaction for married women and men but not for unmarried women and men. As indicated in Table 2, the relationship between internalized homonegativity and emotional intimacy is negative, whereas the relationship between emotional intimacy and relationship satisfaction is positive. Thus, the significant conditional indirect effects (which is negative) suggest that, in the case of married individuals, greater internalized homonegativity is related to less emotional intimacy; less emotional intimacy, in turn, is related to less relationship satisfaction. Next, marital status and gender moderated the indirect effect of sexual orientation concealment on relationship satisfaction through emotional intimacy. Specifically, for married men—but no other gender by marital status groups—emotional intimacy mediated the effect of sexual orientation concealment on relationship satisfaction. Again looking at Table 2, the relationship between sexual orientation and emotional intimacy is negative, whereas the relationship between emotional intimacy and relationship satisfaction is positive. Thus, the significant conditional indirect effect (which is negative) suggests that, in the case of married men, greater sexual orientation concealment is related to less emotional intimacy; less emotional intimacy, in turn, is related to less relationship satisfaction. Finally, there were no significant conditional indirect effects for either psychological distress or health symptoms.

Table 3.

Conditional indirect effects of minority stress on relationship satisfaction, psychological distress, and health symptoms via emotional intimacy by marital status and gender.

	DV: Relationship satisfaction Mediator: Emotional intimacy		DV: Psychological distress Mediator: Emotional intimacy		DV: Health symptoms Mediator: Emotional intimacy
	Point estimate	CI	Point estimate	CI	Point estimate	CI
Predictor: Experiences of discrimination and rejection
Unmarried male	−2.21	[−6.33, 1.03]	0.36	[−1.03, 4.81]	−2.34	[−22.72, 3.07]
Unmarried female	1.44	[−1.88, 4.95]	0.34	[−0.74, 3.98]	6.39	[−4.31, 44.17]
Married male	−3.70	[−10.48, 1.05]	1.11	[−1.41, 8.48]	−8.10	[−60.19, 5.99]
Married female	1.10	[−1.28, 4.50]	0.03	[−1.06, 1.51]	2.24	[−7.87, 20.24]
Predictor: Internalized homonegativity
Unmarried male	−1.41	[−4.79, 1.55]	−0.12	[−3.63, 2.87]	−2.99	[−19.62, 4.38]
Unmarried female	0.53	[−1.25, 2.48]	−0.01	[−1.02, 0.79]	1.03	[−5.80, 14.22]
Married male	−5.11*	[−11.07, −1.47]	1.02	[−6.48, 7.98]	−16.86	[−64.25, 15.65]
Married female	−2.30*	[−5.65, −0.13]	0.07	[−2.99, 3.15]	−14.29	[−47.15, 2.04]
Predictor: Sexual orientation concealment
Unmarried male	−3.23	[−7.34, 0.15]	−0.19	[−4.17, 2.34]	−3.19	[−21.90, 3.94]
Unmarried female	1.26	[−0.59, 3.26]	0.39	[−0.40, 2.36]	6.62	[−0.69, 27.12]
Married male	−6.87*	[−14.32, −2.44]	0.61	[−5.53, 7.35]	−14.21	[−70.75, 13.65]
Married female	−0.67	[−5.24, 2.33]	−0.02	[−1.93, 1.75]	−4.65	[−31.93, 6.53]

Note. * p < .05.

Discussion

The current study examined the relationships between minority stress, emotional intimacy, relationship satisfaction, and psychological and physical health. Previous research has shown that stress negatively affects heterosexual couple functioning (Bodenmann et al., 2007), and minority stress negatively affects LG individuals’ functioning (Meyer, 1995). Additionally, emotional intimacy has been shown to positively affect health among heterosexual couples (Ornish, 1998) and both stress and lack of intimacy have been shown to decrease relationship satisfaction (Bodenmann, 2005; Schaefer & Olson, 1981). Among LG couples, emotional intimacy has been shown to be the most important predictor of relationship satisfaction (Deenen et al., 1994; Eldridge & Gilbert, 1990). However, the relationships among these variables (i.e., minority stress, emotional intimacy, and health and couple outcomes) have not been explored among LG individuals in same-sex couples.

We tested a model that hypothesized that emotional intimacy would mediate the relationships between minority stress and relationship satisfaction, psychological distress, and health symptoms. The model also hypothesized that marital status and gender would moderate these relationships. Our results revealed that, controlling for general stress, the only minority stressor that was related to the health or relationship outcomes was experiences of discrimination and rejection, which was negatively related to psychological distress. However, this relationship was moderated by both gender and marital status. For men, regardless of marital status, the relationship between discrimination and psychological distress was negative. However, for unmarried women, more experiences of discrimination were related to more psychological distress; on the other hand, for married women, there was not a significant relationship between discrimination and distress. Thus, it appears that for women, being married may offer protection against the harmful effects of discrimination on well-being, consistent with research on the health benefits of marriage (Schoenborn, 2004). The finding that more discrimination was related to less distress in men was unexpected and contrary to minority stress theory (Meyer, 2003) and most research findings. However, Juster, Smith, Ouellet, Sindi, and Lupien (2003) also found that sexual minority men appear to be doing unexpectedly well, with gay and bisexual men—but not women—reporting lower depression and demonstrating lower allostatic load (an index of physiological wear and tear on the body as a result of stress) than their heterosexual counterparts. It may be that the gay men in our sample had developed resilience that allowed them to thrive in the face of experiencing discrimination (such as stress-related growth; Park, Cohen, & Murch, 1996). Future work in this area should explore the additional factors that contribute to resilience against minority stress among both sexual minority men and women.

Our results also revealed that, after controlling for general stress, both internalized homonegativity and sexual orientation concealment were negatively related to emotional intimacy. The relationship between minority stress and emotional intimacy has not been investigated among LG couples. However, studies of heterosexual couples have found that stress negatively impacted factors closely related to emotional intimacy (e.g., communication, conflict, sexual relations, Bodenmann, 2005; Bodenmann et al., 2007), suggesting that stress impacts emotional intimacy among this group. As such, the findings from the current study (that internalized homonegativity and sexual orientation concealment negatively predicted emotional intimacy) are consistent with the literature on different-sex couples. The nonsignificant finding for the relationship between experiences of discrimination and rejection and emotional intimacy may speak to low levels of experienced discrimination and rejection (M = 1.86 out of a total score of 6.00) and the high levels of emotional intimacy in this sample (M = 4.63 out of a total score of 5.00). Discrimination and rejection may only negatively affect emotional intimacy at higher levels or among individuals who experience low levels of emotional intimacy in their relationship. The current findings on the relationship between the minority stress variables and emotional intimacy in the LG population are novel; as such future research is warranted to replicate findings.

Finally, there was evidence that, after controlling for general stress, emotional intimacy mediated the relationship between internalized homonegativity and relationship satisfaction—depending on marital status. Likewise, after controlling for general stress, emotional intimacy mediated the relationship between sexual orientation concealment and relationship satisfaction—depending on gender and marital status. Specifically, for married individuals, internalized homonegativity was related to lower levels of emotional intimacy; lower emotional intimacy, in turn, was related to less relationship satisfaction. In addition, for married men, a similar pattern was found, with sexual orientation concealment being related to less emotional intimacy and less emotional intimacy relating to less relationship satisfaction. One of the many negative effects of internalized homonegativity is the erosion of emotional intimacy, which is especially detrimental as emotional intimacy has been shown to be the most important predictor of relationship satisfaction, including among LG couples (Deenen et al., 1994; Eldridge & Gilbert, 1990; Koepke et al., 1992; Schreurs & Buunk, 1996). In addition, concealment has been found to be particularly harmful to LG couple functioning (e.g., decreased relationship satisfaction, anxiety about the relationship, lack of social support due to hiding the relationship, and decreased coping; Almeida et al., 1994; Berzon, 1988; Elizur & Mintzer, 2003; Jordan & Deluty, 2000; ) and these results shed light on the mechanism through which concealment impacts relationship satisfaction (i.e., decreased emotional intimacy). Moreover, that the mediating effect of emotional intimacy on the relationship between minority stressors and relationship satisfaction was only observed in married women and men (in the case of internalized homonegativity) or married men only (in the case of sexual orientation concealment) suggests that minority stress may be particularly harmful for married couples. Research on heterosexual couples has revealed that those who are married report more intimacy and more relationship satisfaction than those who are cohabitating (Moore et al., 2001). It appears that the impact of these stressors is greater among people who are married and who therefore are expected to have greater emotional intimacy. Perhaps minority stressors are more pernicious when a solid base of emotional intimacy and relationship satisfaction has been established through marriage.

Limitations

While a strength of the current study is that it was the first to explore the relationships between emotional intimacy, minority stress, and relationship and health outcomes, several limitations should be taken into consideration. Data from the current study are cross-sectional survey data, which do not allow for the assumptions of causal relationships between variables. Moreover, these cross-sectional data do not allow inferences about the directionality of the relationships—for example, it may be that emotional intimacy leads to more relationship satisfaction, but it is also possible that those who are more satisfied with their relationships are more likely to be emotionally intimate. In addition, only one partner in the couple was permitted to participate in the current study. Allowing both to participate would have allowed for comparisons between partners. Likewise, analyses could have been conducted at the dyadic level rather than the individual level, which would have allowed us to understand LG couples as opposed to individuals in LG couples. Also, the generalizability of these findings is limited by the racially homogenous, well-educated, and largely unmarried sample. These characteristics may not be representative of the larger, more diverse LG population. Taking the sample demographics into consideration, the results should be viewed with caution. There is also the possibility of order effects, as we did not counterbalance the order of the measure presented to participants.

Lastly, the sampling procedure used in the present study also limits the generalizability of findings. Participants were recruited online mainly though LG-focused LISTSERVs. Individuals who did not have access to the Internet or who were not registered with the LISTSERVs were not likely to have seen the study advertisement. Related to the sampling procedure, a statistical limitation in the current study was the strong positive skew in internalized homonegativity and sexual orientation concealment scores (i.e., low scores). This result may be due to self-selection bias, wherein only the individuals who were motivated to participate in a study on LG couples chose to fill out the survey. Such participants may be less likely to apply society’s anti-LG beliefs to the self and less likely to conceal their sexual orientation and same-sex relationship than individuals who are not motivated to share their experiences.

Clinical and training implications

In addition to the implications for research as described above, there are numerous implications for practice. One such implication is that of social justice, which has become a major thrust among programs training individuals to become helping professionals (e.g., Steele, 2008). The sexual minority stress literature highlights the need for social change in order to mitigate the stress LG couples face due to societal discrimination. At the macro level, the dissemination of knowledge gained from research on the effects of minority stress on same-sex couples can inform discriminatory policies affecting sexual minority individuals and couples. Social science research can be used to better the lives of stigmatized individuals through policy changes and improved educational practices. Part of working within a social justice framework has to do with practice at the micro level; therapists can help to facilitate agency in clients by educating same-sex couples about the social context of their problems as well as helping them to create and implement coping strategies that will empower them (Rostosky et al., 2007). Johnson (2012) offers an excellent overview of social justice issues applicable to counseling LG clients. The new knowledge garnered by the present study can help psychologists to better understand the social contexts of discrimination in which their LG clients might be situated and to facilitate in their clients new ways of coping, such as increasing emotional intimacy.

Summary and conclusions

The purpose of the present study was to examine the relationship between minority stress, emotional intimacy, relationship satisfaction, and health. The results suggested that emotional intimacy mediates the relationship between internalized homonegativity and relationship satisfaction for married individuals, as well as the effect of sexual orientation concealment on relationship satisfaction for married men. These findings add support to research suggesting that internalized homonegativity and sexual orientation concealment negatively affect relationship satisfaction. The results are also consistent with literature highlighting the importance of emotional intimacy in same-sex couples. Future research should continue to explore minority stress among individuals in LG couples, with particular attention paid to emotional intimacy. Research on emotional intimacy in this population is relatively new and is a valuable focus, given that it may serve as a protective factor against societal oppression. Continued examination of minority stress in same-sex couples will increase our understanding of both the challenges and sources of strength within a couple. On a broader level, considering that universal rights are not yet a reality for sexual minority people, findings may be used as incentive in the fight for equality. By demonstrating that sexual minority stress affects same-sex couples in terms of relationship and health outcomes, it can be argued that a more egalitarian society would ameliorate the well-being of partners in same-sex couples.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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