The Experience of Dual Stigma and Self-Stigma Among LGBTQ Individuals With Severe Mental Illness

ABSTRACT

Despite the increase in research pertaining to the stigma and self-stigma experiences of separate groups, research on individuals with multiple marginalized identities remains scant. One little-studied intersection of stigma and self-stigma is that of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals with severe mental illness. Twenty-three individuals identifying as LGBTQ and having a severe mental illness were recruited to participate in a mixed-methods study. All completed self-report measures of self-stigma experiences and participated in one of three focus groups exploring experiences of stigma, self-stigma, and disclosure related to being queer and having a mental illness. Focus group transcripts were then analyzed using a consensual qualitative approach. Along with experiences specific to being LGBTQ and having a severe mental illness, participants reported discrimination and self-stigma specific to the intersection of both marginalized identities ("dual alienation," or feeling excluded from both communities). Participants endorsed more self-stigma related to having a mental illness than to being queer (in both the focus groups and self-report measures) and described experiences of stigma and self-stigma relevant to mental illness as being more pervasive and distressing than those pertaining to being LGBTQ. Findings highlight both the unique challenges LGBTQ individuals experience with severe mental illness, and the need for targeted services to address their needs. Findings may also inform the adaptation of interventions targeting mental health self-stigma for use with LGBTQ individuals.

Research on internalized oppression has grown in the past two decades, focusing on stigmatized groups such as racial minorities, sexual minorities, and individuals with mental illness. However, research on individuals with multiple marginalized identities remains scant ( Livingston & Boyd, 2010). One particular intersection of self-stigma that has received little attention is that of individuals with severe mental illness (SMI) within lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. Roughly 20 years ago, it was estimated that there were up to a half million individuals within this specific population in the United States (Hellman, 1996), so it is likely that it is considerably larger at the time of this writing.

A recent review by Kidd, Howison, Pilling, Ross, and McKenzie (2016) on individuals with SMI who identify as LGBTQ noted that 27 publications had specifically studied this population; most focused on culturally competent treatment, with few directly examining experiences of stigma. One qualitative study that did explore the stigma experiences of LGT individuals with SMI (Kidd et al., 2011) found that people experienced a sense of "dual alienation." Dual alienation has also been discussed by Harris and Licata (2000) and Huygen (2006), who described that those within this population often feel compelled to hide their sexual orientation or gender identity in mainstream mental health settings, while also feeling that mentions of mental illness are often unwelcome in queer communities.

Beyond this sense of dual alienation, initial qualitative research in this area suggests that stigmatization due to sexual identity and mental illness are interrelated (Kidd et al., 2011; Lucksted, 2004; Mizock, Harrison, & Russinova, 2014). Participants report that mental illness influences their ability to resist homophobia, while homophobia negatively impacts their mental health. In support of the second component of this finding, there is now widespread recognition of the mental health implications (e.g., depression and anxiety) of stigma faced by LGBTQ individuals (e.g. Hendricks & Testa, 2012; Meyer, 2003). Additionally, research shows that facing mental health stigma does not reduce the incidence or exclude one from experiencing other forms of marginalization or prejudice (Corrigan et al., 2003). Instead, facing these two forms of stigmatization has been described as having cumulative negative impacts on the ability to cope (Kidd et al., 2011).

These findings suggest the importance of examining the impact of dual stigma, yet efforts to do so remain limited. This article aims to extend early findings and enrich the theoretical understanding of this form of dual stigma. Although Kidd et al. (2011) conducted an important initial exploration of these intersectional experiences, their study used a predominately White Canadian sample and did not directly explore experiences of self-stigma. Additionally, the literature speaks to the "cumulative" negative impact of dual stigma, but this process is not yet fully understood.

This study aims to extend the findings of Kidd and colleagues by exploring experiences of dual societal and self-stigmas with a predominately Black American sample. Further, while interventions targeting self-stigma among individuals with SMI (e.g., Honest, Open, Proud; Corrigan, Kosyluk, & Rüsch, 2013) have been heavily influenced by research on the LGBTQ coming-out process, no study has aimed to understand self-stigma experienced by individuals with both identities. Findings in this regard could provide further information on the similarities and differences of these respective coming-out processes.

To enhance theoretical understanding of this form of dual stigma, this article examines whether this "cumulative" process is additive or intersectional (or some combination of the two) in nature. We attempted to establish a nuanced understanding of this process through a mixed-methods design.

Methods

Participants

Twenty-three participants were recruited from Rainbow Heights Club, an LGBTQ-affirming peer-based psychosocial program that provides support and advocacy for LGBTQ adults with SMI in New York City. Criteria for membership in the program include being over 18, identifying as LGBTQ, and meeting criteria for an SMI. Membership in the program, along with English-language proficiency, was considered to meet study inclusion criteria. Participant age ranged from 28 to 65 (M = 46.74). As seen in Table 1, the sample consisted of transgender, gender-nonconforming (TGNC), and cisgender individuals. Of the cisgender individuals, the majority identified as male. The sample consisted of a fairly even number of gay, lesbian, and bisexual individuals (n = 20), with the remaining three identifying as queer, questioning, and straight (a trans individual). Participants were primarily Black and had completed a minimum of high school. The most common mental health diagnoses (per self-report) were schizoaffective disorder, bipolar disorder, schizophrenia, and major depressive disorder.

Procedure

Institutional Review Board approval was received for the study. Recruitment took place at the support and advocacy program; research staff attended a community meeting, gave a brief description of the

Table 1.

Summary of Demographic Information

study, and answered initial questions. Those interested in participating were then given a full explanation of study procedures. Written informed consent was obtained, and participants were divided into three focus groups completed over three days. Groups were determined based on participants' availability and the order in which participants approached study staff. Guidelines for the optimal number of participants in focus groups range from 4 to 12 (Krueger & Casey, 2014); the sizes of our three focus groups were 10, 11, and 2. This third group was scheduled to consist of eight participants, but only two showed up on the day of the focus group.

Prior to participating in the focus groups, researchers met with participants individually to complete demographic and quantitative measures. All participants completed the Internalized Stigma of Mental Illness Scale (ISMI), while those who self-identified as LGBQ and TGNC completed the Internalized Homophobia Scale (IHP) and Transgender Identity Scale (TGIS), respectively. Each focus group consisted of 50 to 60 minutes of active exploration of the topics of interest and was led by a two-person team: a doctoral-(moderator) and master's-level (assistant moderator) student. The moderator's role included leading discussion and asking questions, while the assistant moderator took notes on discussion content and provided summarizing statements. Focus groups were audio-recorded and recordings were deleted after transcription. All study procedures were completed in a private, enclosed space at the program. In addition to written consent, participants were asked to verbally agree to maintain confidentiality of the topics discussed before the focus groups. Participants were compensated $20 for their participation.

Measures

Participants were administered demographic and clinical questionnaires to provide information on race/ethnicity, gender identity, sexual orientation, age, education, and self-reported diagnosis. In addition, participants completed the following self-report measures (when applicable).

Internalized Stigma of Mental Illness Scale (ISMI; Ritsher, Otilingam, & Grajales, 2003)

The ISMI consists of 29 items divided into five subscales: Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal, and Stigma Resistance. The measure consists of items such as "People with mental illness tend to be violent" that are coded on a 4-point Likert-type scale. The ISMI was found to have good internal consistency in the present study (α = .85).

Internalized Homophobia Scale (IHP; Martin & Dean, 1987)

The IHP is a nine-item measure focused primarily on how an LGBTQ individual feels about their sexuality. This measure consists of items such as "If someone offered me the chance to be completely heterosexual, I would accept the chance" that are coded on a 5-point Likert-type scale. In the current study, internal consistency for the IHP was high (α = .91).

Transgender Identity Scale (TGIS; Bockting, personal communication, March 1, 2016)

The TGIS consist of 26 items divided into four subscales: Alienation, Passing, Pride, and Shame. The measure consists of items such as "I envy people who are not transgender" that are coded on a 7-point Likert-type scale. This scale had high internal consistency within the current study (α = .91).

A guide was used for each focus group that included general prompts and topics for discussion. Moderators prompted participants to discuss experiences of discrimination, stigma, self-stigma, and self-disclosure. Participants were asked to share examples and elaborate on how these experiences have impacted them.

Questions were developed based on prior literature and consultation with lead psychologists at the recruitment site. Prompts included items such as:

• • Think about a time when you may have been either blatantly or subtly discriminated against because of your mental illness;

• • Think about a time when you may have felt uncomfortable, hurt, or devalued because you were both LGBTQ and had a mental health diagnosis;

• • Describe a time when an LGBT individual without a mental illness has made you feel uncomfortable because of your mental illness;

• • What impact do these experiences of stereotypes and discrimination have on your mental health and emotional well-being?

• • How do you feel your sexual and/or gender identity affect your life? How does it affect the way you perceive yourself?

• • When meeting new people, do you find it more difficult to disclose your LGBTQ identity or your mental illness diagnosis and why?

For each question pertaining to mental illness, there was a parallel question pertaining to sexual orientation and/or gender identity (and vice versa).

Analyses

Survey data were analyzed using descriptive and correlational statistical analyses using SPSS Statistics Version 23. Analyses were conducted of the following variables: internalized stigma of mental illness (ISMI), internalized homophobia (IHP), and internalized transphobia (TGIS). As the number of TGNC participants was low, the TGIS was excluded from correlational analyses.

Focus group transcripts were analyzed using a consensual qualitative approach (Hill, Thompson, & Williams, 1997). First, general categories of response topics were derived from reading each transcript (e.g., mental illness self-stigma). Groups of text from each respective transcript were then placed into these general categories and brief summaries were derived. These brief summaries were then compiled by category to derive subcategories (e.g., alienation). For each step of the analysis, two researchers independently examined the data. They then met to present and discuss ideas to establish a consensus version, which was then reviewed by an auditor before moving on to the following step of analysis. Qualitative analyses were conducted with the intention of enriching early theory on dual stigma and self-stigma.

After analyzing transcripts for the first two focus groups, we found evidence for data saturation, defined by participants reporting similar themes across groups. The third focus group then acted as a stability check, which confirmed that saturation had in fact been reached. Despite the small size of this group, the same themes were found to emerge. This method is consistent with guidelines for reaching data saturation in qualitative analyses (Morse, 1995). What would appear to be the most likely explanation for reaching saturation so early on (despite the diversity of the sample), was the specific, guided focus on experiences of stigma and self-stigma.

Results: Quantitative

All 23 participants completed the ISMI, 22 completed the IHP (one TGNC participant identified as straight), and 6 completed the TGIS. Participants reported moderate levels of mental illness self-stigma and low levels of internalized homophobia and transphobia. A "moderate" level of mental illness self-stigma was defined as an item mean score between 1 and 1.5, not including the Stigma Resistance subscale (1.5 represents the midpoint of the scale's 0–3 range). Similarly, "low" levels of internalized homophobia and transphobia were defined as item mean scores of 2.5 or below for the IHP and 3.5 or below for the TGIS. The midpoints of these scales were 3 and 4 (ranges = 1–5 and 1–7), respectively, which represent a response of "neither agree nor disagree." Total ISMI scores did not significantly correlate with the IHP; however, the ISMI subscales most closely capturing experiences of self-stigma (Alienation, Social Withdrawal, and Stereotype Endorsement) were moderately and significantly positively correlated with the IHP (Table 2).

Table 2.

ISMI and IHP Scores: Intercorrelations, Means, and Standard Deviations

Results: Qualitative

Although our primary aim was to examine experiences of self-stigma, in doing so, we also uncovered major themes pertaining to societal stigma and coming out. The following section provides overall categories and subcategories of these themes derived from combined focus group transcripts. Of the 23 participants enrolled, 21 participated in the focus group discussions. Tables 3 and 4 summarize the frequency of endorsements on each subcategory.

Participant descriptions of stigma and self-stigma pertaining to either mental illness or being LGBTQ were largely consistent with the literature. Thus, many of the findings within these domains (1 and 2) will simply be summarized, leaving room for thorough descriptions of the distinctive results present within Domains 3 (dual alienation) and 4 (coming out).

Domain 1: Societal Stigma

Mental Health Societal Stigma

Three subthemes were identified: overt discrimination, microaggressions related to mental illness, and the role of media.

Table 3.

Summary of Societal Stigma and Self-Stigma Categories and Subcategories

Table 4.

Summary of Dual Alienation and Coming-Out Categories

Overt Discrimination

Six participants reported experiences of overt discrimination pertaining to their mental health diagnosis. Such experiences took place in multiple settings, (e.g., the workplace and social settings) and were reported as perpetrated predominately by strangers and acquaintances. Reports of discrimination largely took the form of verbal rejection following disclosure of a mental health diagnosis. Participants described that people often immediately assumed "the worst" and threatened to have them removed from work or social settings.

Microaggressions

More common than reports of overt discrimination, 16 participants reported experiencing microaggressions due to their mental illness. These subtle forms of discrimination communicated messages of invalidation, inferiority, and fear (Gonzales, Davidoff, Nadal, & Yanos, 2015). Compared to overt acts of discrimination, microaggressions were reported as perpetrated predominately by friends and family members.

Several participants described being "treated like a child," feeling patronized by family members or friends, or being treated as if they are intellectually disabled or inferior. Participants communicated frustration with these varying forms of subtle discrimination and described these experiences as grossly impacting how they subsequently navigate the world (e.g., often concealing their mental health diagnosis).

Role of Media

Although participants were not prompted to discuss the potential role of media in the perpetuation or amelioration of mental health stigma, three participants reported media as a significant factor in global perceptions of mental illness. One White gay cisman described the limited representation of mental illness in the media: "But mental illness is so—a lot is unknown and what you do know of mental illness and what people see in public are the extremes and you hear the extremes of the shootings, of mass shootings." Participants felt that the media's focus on "the extremes" acted as a maintaining factor of society's lack of understanding (or misunderstanding) of mental illness.

Homophobia and Transphobia

Four subthemes were identified: overt discrimination, microaggressions, the role of media and politics, and the role of additional reference groups.

Overt Discrimination

Ten participants described experiences of overt discrimination due to their LGBTQ identity. Such experiences ranged from verbal rejection to hate crimes and most were perpetrated by strangers and acquaintances. Several participants described experiencing violent hate crimes resulting in fear of being identified as LGBTQ when in certain neighborhoods and a need to remain "guarded" in everyday interpersonal encounters.

Microaggressions

In addition to these overt forms of discrimination, 10 participants noted experiences of more subtle forms of discrimination. Such experiences included assumptions of universal LGBTQ experience, assumptions of sexual pathology, discomfort or disapproval of LGBTQ experience, and pressure to adhere to gender norms (Nadal, Whitman, Davis, Erazo, & Davidoff, 2016). Perpetrators of these microaggressions were typically strangers and acquaintances (similar to reported experiences of overt discrimination). Additionally, a more generalized tendency to pathologize LGBTQ individuals was described; as one participant stated, "In many respects people still think being gay is a mental illness."

Role of Media and Politics

In contrast to participant descriptions of the negative role of media in mental health stigma, media and politics were described as playing an instrumental role in the amelioration of homophobia. In total, four participants described that the relatively routine representation of "gay issues . . . in the media and law" helps to make LGBTQ-related discussions easier to broach.

Role of Additional Reference Groups

Although participants were not prompted to discuss the role of additional intersecting identities, six participants noted the intersectional significance of their race, social class, or religion when discussing experiences of LGBTQ-related stigma and discrimination. For example, one Black lesbian ciswoman largely attributed her experiences of homophobia to her race/ethnicity:

My family has a problem with the gay part, and I'm Guyanese . . . and that's why I say it's cultural, because it's not just Caribbean people who have a problem with it, it's African Americans as well. So it's more of a cultural nature than anything else.

Domain 2: Self-Stigma

Mental Health Self-Stigma

Four subthemes were identified: alienation, stereotype endorsement, social withdrawal, and stigma resistance (Ritsher et al., 2003).

Alienation

Six participants described feelings of alienation due to their mental health diagnosis. These participants described feelings of inferiority and inadequacy, mostly discussed in the context of seeking romantic partners. One Black gender-nonconforming queer individual described such feelings in the context of collecting disability: "Me collecting money from my mental illness, I feel like I'm not adequate to somebody who works and gets their money. I feel like if I get in a relationship . . . I don't add up to that person."

Stereotype Endorsement

Two participants expressed agreement with common stereotypes about individuals with mental illness: that they cannot contribute to society, and that they cannot be competent and intelligent.

Social Withdrawal

Two participants reported socially withdrawing due to their mental health diagnosis. These participants described avoiding social situations or not pursuing romantic relationships as a result of feeling inadequate or out of place around those without mental illness. A White gay cisman described such avoidance:

I feel I have internalized some of that, I'm not that comfortable seeking out relationships because you know, why would someone want someone who was mentally ill? Or who's also not working because of his mental illness? So yeah, I feel intimidated about pursuing any kind of intimate relationship.

Stigma Resistance

Although several participants reported selfstigmatizing cognitions, seven participants also endorsed stigma-resistant beliefs. Participants described that having a mental illness "does not define them," impact their intellectual functioning or general competence, or limit their ability to "contribute to society."

Internalized Homophobia and Transphobia

Two subthemes were identified: struggle with public identification as LGBTQ, and stigma resistance.

Struggle With Public Identification

Four participants reported avoidance or difficulty surrounding public identification as LGBTQ. Some participants reported never disclosing their LGBTQ identities, whereas others described disclosing only when absolutely necessary and otherwise avoiding community involvement that could potentially lead to public identification. A Black bisexual cisman described such limitations and avoidance:

I say it if I have to, but to certain people. I mean I'm not trying to be the leader of the parade or nothing like that, I'm not trying to be out there . . . there's no need to know unless you're close.

Stigma Resistance

Six participants described being unaffected by homophobia and/or transphobia. Some participants stated that they are "comfortable with their sexuality" and largely unaffected by stigma, while a Black bisexual ciswoman stated, "The things they project on you has nothing to do with you."

Domain 3: Dual Alienation

In addition to descriptions of these separate experiences of stigma and self-stigma, eight participants described a sense of dual alienation as a result of these intersecting forms of oppression. A Black, queer, gender-nonconforming individual described their hesitancy in disclosing their sexual orientation to those in a general mental health setting: "They give you like the one man up kind of notion of I've got a mental illness, but you've got a mental illness and you're gay." Another participant (a multiracial gay cisman) described his experience of disclosing his mental health status in general LGBTQ communities:

It's a certain type of mentality in the gay world . . . you can't tell them that [you have a mental illness]. If you tell them that—they don't want to be bothered with you . . . it's all about image.

This emphasis on "image" within LGBTQ communities was echoed by several participants and was described as resulting in heightened levels of discrimination toward those with mental illness. Another participant (a Black lesbian ciswoman) described being surprised by this level of discrimination within queer communities:

I used to think that being gay, there would be no discrimination and you would be more liberal and free from that type of stuff. But I have found out that within the gay community there's a lot more discrimination than the world outside.

As a result of such experiences, participants described feeling out of place in both settings. A White gay cisman concisely described this experience: "In a gay context sometimes I don't feel comfortable sharing my mental health status, and in a mental health setting I'm not comfortable sharing that I'm gay." A Black bisexual ciswoman described how this sense of dual alienation has affected the way she navigates the world: "I am never really able to bring my full self in any place, you know, I have to adjust myself depending on where I'm going."

Domain 4: Coming Out

Participants did not feel that experiences of coming out as LGBTQ had any influence on their experience of "coming out" with a mental illness (or vice versa). When discussing these respective processes, eight participants reported that coming out with mental illness was more difficult. This increased difficulty was attributed to three separate factors: (a) LGBTQ identities are often assumed (and thus does not require direct disclosure), (b) greater public misconceptions and perceived discrimination toward those with SMI versus LGBTQ individuals, and (c) participants' own negative perceptions of what it means to have a mental illness.

LGBTQ Identities Assumed

Participants described that since their LGBTQ identities are frequently assumed based on their physical presentation or behaviors (e.g., hanging out in queer-centric areas), they often do not have to explicitly disclose this facet of their identity. For these participants, this assumption was considered to be beneficial and freeing, as they could often avoid explicitly disclosing. Compared to LGBTQ-related experiences, participants reported that their mental illness is rarely assumed, and thus must often be formally disclosed. One Latina lesbian ciswoman described how her sexual orientation is often assumed based on her physical presentation: "Maybe some people notice that I like women by the way I dress or carry myself, but you can't see my mental illness."

Perceived Discrimination

Participants also described coming out with a mental illness diagnosis as more challenging due to differences in perceived quantity and quality of discrimination targeting these groups. Although participants also reported facing discrimination for being LGBTQ, the lack of societal understanding and microaggressions pertaining to mental illness were described as more pervasive and difficult to grapple with. One Black straight transwoman described two common microaggressions (assumed dangerousness and fragility) she received when disclosing her mental illness diagnosis:

Mental illness is definitely harder than the LGBT part . . . because they kind of look at me as . . . some of them try to coddle me, I didn't want to be coddled—"It's okay, are you alright?"—and some of them was like "oh shit, I better watch out for you."

A White gay cisman described how a lack of general conversation and public knowledge of mental illness makes it more difficult to disclose and discuss with those in the general public:

Gay issues are talked about, it's in the media, it's in the law and everything . . . but mental illness is, you know, it's hard to sit and talk with people about, because they really don't know what to ask.

Heightened Levels of Self-Stigma

Although no participant explicitly described being LGBTQ as "bad" or something "requiring fixing," mental illness was often framed in these terms. One Black lesbian ciswoman described how she compares these two identities and their respective disclosure processes:

I mean to me it's like both ways possible, you're coming out, and I still look at it as mental illness is something wrong. I mean it is what it is, there's something wrong, mental illness, illness is something bad, that's how I look at it. But, your [LGBTQ] lifestyle, there is nothing wrong with that at all.

A White gay cisman voiced a powerful comparison of these two experiences: "You know, growing up—next to being gay, which is the second worst thing growing up to be, was being crazy."

Discussion

The majority of research on stigma and self-stigma for those with severe mental illness has either failed to account for other forms of marginalization or has been focused on predominately white, straight, cisgender individuals. Likewise, the majority of research on stigma and self-stigma pertaining to LGBTQ individuals has not accounted for queer individuals with SMI. This study aimed to explore these experiences of dual stigma and self-stigma and extend the findings from Kidd et al. (2011) to a predominately Black American sample.

When discussing these two forms of stigma or self-stigma in isolation, participants' descriptions were consistent with research focused on these respective populations (e.g., Herek et al., 1998; Ritsher et al., 2003). Although many of these individuals' experiences of stigma or self-stigma may be consistent with their straight, cisgender, or psychologically healthy counterparts, our study provides additional support for both a cumulative and intersectional impact of these two forms of marginalization.

Participants largely described experiences of internalized homophobia and transphobia and mental health self-stigma as additive, as opposed to intersectional processes, and reports of these varying forms of stigmatization were typically compartmentalized. However, an exception to this additive conceptualization surfaced in reports of dual alienation. Consistent with initial explorations of this concept (Harris & Licata, 2000; Huygen, 2006; Kidd et al., 2011), participants described feeling out of place in both queer communities and general mental health settings. Kidd et al. (2011) reported that participants attributed their difficulties participating in queer-positive spaces to the reality that access to many of these spaces requires money that they do not necessarily have, due to financial dependence on disability benefits. Although participants in our study mentioned money as something they perceived as highly valued by queer communities, they predominately attributed this sense of alienation to an emphasis on "image" within LGBTQ communities. Due to this emphasis, participants described resistance to disclosing their mental health status for fear of rejection. Similarly, within general mental health settings and communities, participants reported often concealing their LGBTQ identity for fear of marginalization.

This sense of dual alienation was described as affecting how participants navigate the world, rarely feeling as if they can bring their "full self" into any one space. Similar to findings from Kidd et al. (2011), alienation from the LGBTQ communities appeared to have the greatest negative impact on participants, as it hindered their ability to develop romantic relationships and friendships with queer peers. In addition to contributing to this sense of dual alienation, the emphasis on image within LGBTQ communities may in fact exacerbate self-stigma of mental illness within this dually marginalized population. As sexual and gender minority experiences have historically been pathologized by psychiatric nosology (i.e., homosexuality before DSM-III-R and, arguably, the lingering presence of gender dysphoria in DSM-5), this heightened stigma toward those with mental illness may be a distancing mechanism, but this should be explored in future research. Also in line with participant reports in Kidd et al., participants described that, while they initially anticipated that those within queer communities would be less discriminatory toward other marginalized groups, this was not the case.

Participants described more experiences of mental health self-stigma than internalized homophobia or transphobia. These contrasting perspectives influenced their respective experiences of coming out. Qualitative findings converged with quantitative findings, indicating that participants reported comparatively higher rates of mental health self-stigma. Additionally, internalized homophobia and mental health self-stigma were significantly positively correlated. Due to the small sample size, these quantitative findings should be interpreted with caution. Nevertheless, the multimethod findings of this study both highlight the possibility of examining self-stigma using an intersectional framework, and suggest that it is important to examining shared underlying vulnerabilities in the development of internalized oppression.

Importantly, while several self-stigmatizing cognitions were reported in both qualitative and quantitative form, participants organically described more stigma-resistant beliefs than either form of self-stigma. Although beyond the scope of this article, many participants naturally turned to descriptions of coping and resilience in describing their various experiences of discrimination and internalized oppression. Most notably, participants emphasized the importance of LGBTQ-affirming mental health organizations that are (in one participant's words) "geared to this segment of the population because there's understanding in both areas of the individual, not only the LGBT part, the mental illness part too."

Due to the concealable nature of mental illness and sexual orientation (and in many cases, gender identity), unique psychosocial challenges arise in the context of disclosure (Quinn, 2006). Although the literature on "coming out" with mental illness has attempted to glean from the LGBTQ coming-out process, to the best of our knowledge our study is the first to compare these two experiences within a population possessing personal knowledge of both. When comparing these separate processes, participants reported the experience of coming out with mental illness as more challenging. This difference was attributed to three separate factors: (a) LGBTQ identity is often assumed, (b) differences in perceived quantity and quality of discrimination, and (c) differences in levels of self-stigma (discussed under "Domain 4: Coming Out"). Participants reported that others often assumed their queer identity due to their physical presentation or behaviors but stated that others could not "see [their] mental illness." This assumption of sexual or gender minority status, while based on stereotypes and broader presumptions, was described as largely advantageous. Although this perspective cannot be considered a global LGBTQ experience, participants described that these assumptions freed them of continually coming out. In contrast, participants described that their mental health diagnosis is not as readily assumed and must be more formally disclosed.

Descriptions of discrimination targeting participants' LGBTQ identity were often more overt and violent in nature. With that, the more subtle forms of discrimination targeting mental illness were described as more pervasive and emotionally taxing. The perception of damage of these two forms of discrimination may differ as a function of the relationship between perpetrator and victim; while mental health microaggressions were often perpetrated by friends and family members (consistent with the literature; Gonzales et al., 2015), LGBTQ-related microaggressions were usually perpetrated by strangers and acquaintances. Limited societal knowledge regarding the nature and experiences of mental illness compared to LGBTQ experiences also contributed to this perception of heightened discrimination and difficulty coming out. This sentiment was also conveyed by Kidd et al. (2011), but in the current study, participants noted a major factor contributing to this divergence: the quality of media and political representation of these two populations. Although participants described media and politics as playing an instrumental role in the amelioration of homophobia and transphobia (with exceptions), they were described as perpetuating mental health stigma.

Although coming out with mental illness was described as more challenging, the LGBTQ coming-out process was reported as being heavily influenced by other reference-group memberships. Participants described that heightened levels of homophobia within some of their racial or ethnic minority communities, social class communities, and religious communities significantly influenced their comfort with this process. This finding is consistent with the literature highlighting the significant impact of intersectional identities within LGBTQ communities (LaSala & Frierson, 2012; Meyer, 2010). Furthermore, as nearly 80% of participants were racial and/or ethnic minorities, perceptions of these acts of discrimination may have been moderated by these additional minority group memberships (Meyer, 2010).

In contrast, while some research suggests heightened levels of mental health stigma within African American communities (Rao, Feinglass, & Corrigan, 2007), participants did not readily speak to the intersectional significance of race and ethnicity when discussing experiences of mental health stigma. Future research should directly examine the role of additional intersectional identities and stigmata within this population. With that, these initial findings may suggest that certain forms of marginalization may more readily intersect than others.

Some limitations of this study should be emphasized. First, the study sample was relatively small and cannot be considered representative of all LGBTQ individuals with SMI. In particular, the third focus group only had two participants, potentially limiting the amount of data derived from this specific group. Second, the location of the study (an LGBTQ-affirming organization in New York City, known as a "progressive" city) limits the generalizability of these findings, as these participants may experience lower levels of stigma and self-stigma as a product of their environment (both immediate and extended). Although results of this study provide support that many intersectional experiences of stigma for queer individuals with SMI may generalize beyond White Canadians (Kidd et al., 2011), future research should continue to explore whether these experiences differ as a function of demographic characteristics or the sociopolitical climate of the area. Additionally, although the purpose of the study was to examine experiences of intersectional oppression, we often prompted participants to discuss each form of marginalization in isolation or to directly compare these experiences. By nature of this, the questions themselves may have impacted the participants' tendency to compartmentalize their experiences of marginalization. Last, we are aware that it is problematic to conflate experiences of LGBTQ individuals; future studies should aim to explore experiences specific to each subgroup.

Findings from this study suggest that future research should continue to examine stigma and self-stigma from an intersectional framework (accounting for multiple aspects of identity and marginalization), while remaining cognizant that individuals within these multiply marginalized populations may experience certain forms of oppression as more readily intersecting than others. These findings also provide additional support for the importance of developing more affordable and broadly accessible queer-friendly spaces and LGBTQ-affirming mental health settings. Also, comparative data on "coming out" could be used to inform the adaptation of interventions targeting mental health self-stigma for use in LGBTQ communities and mental health communities more broadly. Last, despite facing two or more forms of oppression, participants repeatedly endorsed stigma-resistant beliefs and several strong coping mechanisms (e.g. seeking social support). Mental health professionals should attempt to assess consumers' level of stigma resistance across varying marginalized identities (which may or may not correlate or draw upon one another) and utilize these preexisting cognitions in the treatment of this population.