The influence of minority stress on the neurobiological correlates of executive functioning

Marginalized groups, including 2SLGBTQIA+ populations (2-spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and/or gender minorities), have not been well represented in medical, psychological, and neuroscientific research and are often further stigmatized within the research context (1). With their novel neuroimaging design, a recent investigation by Wang and colleagues (2) is noteworthy for their focus on sexual minority individuals from a non-Western society, especially when considering the overrepresentation of W.E.I.R.D. (Western, educated, industrialized, rich and democratic) samples in research (3). This study examined neuropsychological differences between sexual minority and heterosexual male-identifying Chinese residents. Critically, however, the overall narrative depicts an apparent deficit in executive functioning among sexual minority men without presenting substantial evidence to support the authors’ claims. In response to this neuroimaging study, our central concern is that the authors have omitted measures of minority stress from their analyses and have made conclusions that may further perpetuate stigma associated with these marginalized groups.

More specifically, the authors fail to acknowledge the pervasive emotional and cognitive toll of chronic oppression and marginalization associated with stigmatized sexual minority identities when discussing cognitive performance [i.e., on the Wisconsin Card Sort Task (WCST)]. Indeed, minority stress (1) refers to insidious stressors that sexual, gender, and racial/ethnic minority individuals experience because of their historically marginalized and stigmatized identities. Such stressors can include structural (e.g., laws and societal attitudes) and individual forms of discrimination and prejudice (1), in addition to proximal stressors such as internalized homonegativity, moral affect, sexual orientation concealment, and rejection sensitivity (4). Of critical importance, it has been proposed that exposure to minority stressors accounts for the disproportionally higher levels of adverse mental health outcomes among sexual minority groups (5) by disrupting transdiagnostic neurobiological stress pathways (6,7). As 2SLGBTQAI+ individuals may have heightened exposure to minority specific stressors and insidious trauma related to chronic oppression (8), accounting for minority stress when conducting research with these communities is paramount. Unfortunately, in the study by Wang and colleagues, minority stress was neither acknowledged, assessed, nor controlled for in the analyses. A recent systematic review by Nicholson and colleagues examined the impact of minority stress on structural and functional brain connectivity, highlighting the importance of incorporating minority stress exposure levels associated with multidimensional minority identities within research designs. This narrative synthesis suggests that sexual minority stress exposure may be associated with aberrant functional connectivity within intrinsic brain networks. Critically, this review suggests minority stress may have several shared neuropsychological pathways with posttraumatic stress disorder (PTSD) and stress-related disorders, which may be an underlying mechanism associated with disproportionally higher adverse mental health outcomes among sexual minorities. With respect to the Wang et al. (2) study, failure to consider minority stress exposure as a potential explanation/mechanism for their reported findings is a significant oversight. Omission of these alternative explanations, regardless of assessment inclusion, creates a risk of misattribution and can lead to harmful inferences, as seen within this article.

Noteworthy is that the authors only report an association between WCST performance and sexual orientation scores, where cognitive measures did not correlate with connectivity alterations observed among sexual minority men. Critically, sexual orientation was assessed using the Kinsey Scale. Notably, the Kinsey Scale conflates or omits different aspects of sexual orientation, assumes sexual orientation is linear (rather than multidimensional), and polarizes heterosexual and homosexual desires as trade-offs (9,10). Further shortcomings of the Kinsey Scale include inadequately capturing sexual and gender minority participants’ sexual orientation, particularly for plurisexual and/or gender minority participants (11). In the Wang et al. (2) study, the authors grouped participants with differing degrees of same-gender attraction (i.e., from 4 to 6 on the Kinsey Scale) into a “homosexual” group. This ignores important within-group differences in sexual minority populations, such as differences between bisexually and monosexually (i.e., gay) identified people. The authors’ inferences are based on the notion that all sexual minority men identify as gay, which might not necessarily be the case (e.g., participants scoring four on the Kinsey Scale might identify as bisexual and experience different minority stressors). The assumed linearity of sexuality (heterosexual to homosexual) would effectively render bi- or other plurisexual people (located on the midpoints of the scale) analytically invisible. The current conclusions drawn by the authors go beyond the evidence presented in the study given that the authors did not control for minority stress exposure and non-linear presentations of sexuality and gender, among other variables identified in the limitations section such as intelligence quotients, social extraversion, and differing Kinsey Scale scores. The current interpretation of results represents a problematic approach concerning conducting and presenting research with marginalized populations and may potentially harm this community. Not acknowledging and accounting for other potential factors that could explain deficits in cognitive functioning, the possible misattribution of deficits to identity rather than psychological stress may serve to perpetuate stigma.

In conclusion, the numerous points presented within this response raise questions about the validity of the presented results and their interpretation. Specifically, the authors concluded that deficits in executive functioning are associated with sexual orientation without considering alternative factors. As stated at the outset, there is an astounding lack of minority representation in neuroscientific literature, and the authors’ intentions to expand this literature are commendable. However, it cannot be overlooked that when conducting research with historically oppressed groups, the ethical duty of the researcher to run sensitive and responsible research is paramount. From what Wang and colleagues reported, we feel that the considerations regarding the impact of minority-related stressors were not adequately weighed in the study design and believe that the published work without highlighting these crucial limitations may add further harm and stigma to the 2SLGBTQIA+ community.

Acknowledgments

The authors are grateful to all the members of the Promoting Recognition and Inclusivity Across St. Joseph’s Healthcare Hamilton and McMaster (PRISM) for Sexual, Gender, and Intersectional Minorities Committee for their support in the conceptualization and preparation of this letter to the editor. The authors recognize and acknowledge that this work was conducted on the traditional territories of the Mississauga and Haudenosaunee nations, and within the lands protected by the Dish With One Spoon wampum agreement.

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-22-206/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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