Deaf Stigma: Links Between Stigma and Well-Being Among Deaf Emerging Adults

Deaf Stigma: Links Between Stigma and Well-Being Among Deaf Emerging Adults Abstract Although stigma has been linked to suboptimal psychological and physical health outcomes in marginalized communities such as persons of color, sexual minorities, and people living with HIV/AIDS, no known research has examined these effects among deaf individuals. In the present research, we examine the associations between anticipated, enacted, and internalized stigma and psychological well-being (i.e., depressive symptoms, anxiety) and physical well-being (i.e., quality of life, alcohol use) among a sample of 171 deaf emerging adults. Furthermore, we consider whether trait resilience and benefit-finding moderate these effects. Enacted stigma, but not anticipated or internalized stigma, was related to worse depressive symptoms, anxiety, and quality of life. However, none of these variables predicted alcohol use and neither resilience nor benefit-finding moderated these effects. These findings are consistent with other research among marginalized populations, though they are also the first to suggest that experiences of discrimination are related to suboptimal well-being among deaf emerging adults. The discussion considers how these findings may illuminate the potential causes of disparities in well-being between hearing and deaf emerging adults. Deaf individuals experience worse psychological and physical health relative to their hearing counterparts (Fellinger, Holzinger, & Pollard, 2012; Fellinger, Holzinger, Sattel, & Laucht, 2008; Kvam, Loeb, & Tambs, 2007; van Eldik, 2005; Van Gent, Goedhart, Hindley, & Treffers, 2007). For example, higher rates of impulse control disorders, depressive symptoms, and developmental disorders have been recorded in deaf populations (Fellinger et al., 2012). Similarly, deaf individuals report worse rates of physical well-being and are less likely to utilize health care systems than hearing individuals (Alexander, Ladd, & Powell, 2012; Barnett & Franks, 2002; Barnett, McKee, Smith, & Pearson, 2011; Pick, 2013). We posit that deaf stigmatization may be related to the disparate outcomes of well-being reported by past research (Fellinger et al., 2012; Kvam, Loeb, & Tambs, 2007; Pick, 2013). Goffman (1963) defines stigma as a socially devalued identity that renders one less than fully human in the eyes of others. A person with one or more stigmatized identities often experiences discrimination based on the disparaged trait. Deaf stigma can be understood as the social ramifications of living in a society that labels deafness an impairment and operates in ways that exclude and devalue deaf people. It is important to emphasize that deaf stigma focuses solely on the hearing world’s perception of deafness as a disability and the frequent discrimination that deaf people often face as a result. While past research has reported deleterious outcomes of psychological and physical well-being among deaf individuals, no empirical investigations have examined whether and to what degree stigmatization is associated with poor well-being. Therefore, in the present study, we address this gap by examining the extent to which stigma contributes to poorer rates of well-being among deaf emerging adults than among hearing adults. Deaf Stigma Deaf individuals are frequently marginalized because their unique communication and accessibility needs often highlight their “otherness” from hearing people. Many deaf individuals rely on different languages and combinations of communication tactics unfamiliar to hearing people. For example, many deaf people use American Sign Language, a language to which most hearing individuals are unaccustomed. Other deaf people do use spoken English but must lip-read in order to understand people’s responses to them (Coryell, Holcomb, & Scherer, 1992; Georgia Tech Research Institute, 2007). Thus, the novelty of these communication tactics is likely experienced by most hearing individuals as disruptive to everyday social interactions (Goffman, 1963). Moreover, the hearing world tends to view being deaf as a disability, or a condition that induces hardship and isolation, rather than as an identity that also brings opportunity for personal growth and community (Padden & Humphries, 1988, 2005). Popular culture and media further magnify these beliefs, often portraying deaf people as comical, lonely, and embarrassing (Foss, 2014). These stereotypes and social portrayals perpetuate the tendency to reduce deaf individuals to their hearing impairment alone, rather than engage with them in a way that honors their full humanity. As a result, deaf individuals are often vulnerable to marginalization in many areas of their life. In the workplace, deaf individuals are fired, or not hired in the first place, at much higher rates than their hearing counterparts (Komesaroff, 2004). While much stigmatization is generated from strangers, family and close friends are often frequent perpetrators of mistreatment as well. Approximately 90% of deaf children are born to hearing parents, and approximately 80% of hearing parents do not learn sign language with their child (NIDCD, 2016). Because deaf children of hearing, non-signing parents often cannot understand or participate in spoken-voice conversations, they are often excluded from family discussions. Familial exclusion is so common, in fact, that deaf people colloquially use the term “dinner table syndrome” to describe the isolation one feels when eating dinner with hearing family members. Deaf individuals are often isolated and unable to join conversation because parents, siblings, or extended family do not make their spoken language accessible to deaf people (Hauser, O’Hearn, McKee, & Steider, 2010). Similarly, because many deaf students are enrolled in spoken-language classrooms without sign language interpreters, developing friendships with hearing, non-signing peers can be challenging (among children: Batten, Oakes, & Alexander, 2013). As a result, many deaf individuals experience significant isolation when their family and friends do not attempt to adapt or adjust to their communication needs (among youth: Charlson, Strong, & Gold, 1992; Kolod, 1994; Kushalnagar, Topolski, Schick, Edwards, Skalicky, & Patrick, 2010; among adults: Erdil & Ertosun, 2011; Hauser, O’Hearn, McKee, & Steider, 2010). Effects of Deaf Stigma on Well-Being Minority Stress Theory (Meyer, 2003) postulates that living with a socially marginalized identity such as being deaf creates chronic and acute stress that can injuriously impact psychological and physical health. In support of this general premise, research indicates that stigmatization can have deleterious effects among sexual minorities (Hatzenbuehler, 2011; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011), overweight individuals (Hatzenbuehler, Keyes, & Hasin, 2009), and other socially marginalized populations (Quinn & Chaudoir, 2009). Indeed, in a meta-analysis of almost 400 studies, experiences of discrimination were significantly related to poorer psychological well-being (e.g., depression, anxiety) among a wide array of stigmas such as mental illness, physical disability, HIV-positive status, and race (Schmitt, Branscombe, Postmes, & Garcia, 2014). Similarly, meta-analytic findings also suggest that experiences of discrimination are linked to poorer physical health and greater health compromising behaviors such as alcohol and drug use (hearing sample: Pascoe & Smart Richman, 2009). The present study examines three types of stigma: enacted, anticipated, and internalized stigma—all of which have been associated with low levels of well-being. Enacted stigma refers to past experiences of discrimination, or the extent to which an individual has been stigmatized in the past. Research has shown that enacted stigma predicts worse health-related outcomes (among hearing samples: Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Quinn & Chaudoir, 2009; among deaf samples: Chapman & Dammeyer, 2017). Anticipated stigma, or the degree to which individuals expect to be discriminated against in the future, has been linked with greater depressive symptoms and anxiety in both cross-sectional (Quinn & Chaudoir, 2009) and prospective (Chaudoir & Quinn, 2016) analyses among hearing people living with a variety of concealable stigmatized identities. Moreover, internalized stigma, or feelings of shame about one’s identity, has also been linked to poorer mental health among hearing people with stigmatized identities (Mak, Poon, Pun & Cheung, 2007), people living with HIV (Lee, Kochman, & Sikkema, 2002), and LGB-identified people (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008). Because experiences of past discrimination, expectations of future discrimination, and residual feelings of shame have each been linked to poor well-being, many scholars argue that each of these forms of stigma should be measured in empirical investigations (Earnshaw & Chaudoir, 2009). Although the types of stigmatization experienced in deaf communities have received considerable empirical attention (e.g., Foss, 2014; Kiger, 1997; Komesaroff, 2004), no known research has examined whether or to what degree deaf stigma is linked to poorer psychological and physical well-being. The purpose of the present study, therefore, is to address this gap and examine the degree to which anticipated, enacted, and internalized stigma predict poorer psychological, physical, and behavioral well-being among deaf emerging adults. Possible Mitigating Factors Of course, while stigma poses significant challenges for well-being, it also creates the opportunity to cultivate new and stronger coping skills, a deeper sense of purpose, and stronger bonds with similarly marginalized others (Frost, 2011). Indeed, research in the area of Deaf Gain argues that although deafness entails a loss of hearing, being deaf also benefits sensory perception, linguistic dexterity, and cultural connections (Bauman & Murray, 2014). From a Deaf Gain perspective, people celebrate being deaf as a social and cultural identity rather than a disability or impairment (Bauman & Murray, 2014; Ladd, 2003; Padden & Humphries, 1988, 2005). In the present study, we examine two types of psychological resources, resilience and benefit-finding, that might mitigate the deleterious effects of stigma on well-being. While there exist many definitions of resilience, we define it as one’s ability to “bounce-back” or thrive in the face of personal adversity (Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008). Because our research question investigates continuous experiences of discrimination across an emerging adult’s life, we find one’s ability to “bounce back” from discrimination and prejudice to be particularly relevant to the conversation. Importantly, research shows that resilience can diminish the effect of stigma on well-being in marginalized communities (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2015; Hawley, 2000). Benefit-finding is distinctly different from resilience, as it measures one’s tendency to identify personal benefits of a commonly stigmatized trait, such as deafness. Past research shows that benefit-finding has the ability to bolster psychological health in the face of medical adversity (e.g., cancer) and traumas (e.g., Antoni et al., 2001; Hegelson, Reynolds, & Tomich, 2006). As such, we believe it may contribute to the social adversity faced by deaf individuals in a hearing world. In the present research, we examine the possibility that bouncing back from discriminatory events and finding benefits in one’s deaf identity may moderate the impact of anticipated, enacted, and internalized stigma on well-being. Present Study In the current study, we examine the degree to which stigma is associated with poorer psychological, physical, and behavioral health among deaf emerging adults aged 18–29 (Arnett, 2000). Because social belonging concerns are most pronounced during this period of development, deaf emerging adults may be most sensitive to the impact of stigmatization. Previous research suggests that deaf individuals experience frequent discrimination and that deaf individuals experience worse well-being relative to their hearing counterparts (Barnett, Konstantina, Djemil, Brooks, & Terry, 2011; Foss, 2014; Kiger, 1997; Komesaroff, 2004; Kvam, Loeb, & Tambs, 2007; Pick, 2013; Smit & Henderson, 2010). However, to our knowledge, no quantitative research has explored whether stigma is associated with well-being. Our research is designed to address directly this gap and, in doing so, provide critical new information that may help researchers and practitioners understand the causes of extant health disparities noted among deaf populations. Consistent with past research, that anticipated, enacted, and internalized stigma would be related to greater depressive symptoms, anxiety, and alcohol use, but poorer quality of life. Furthermore, we hypothesized that resilience and benefit-finding would moderate these deleterious effects such that greater resilience and benefit-finding would provide protective, or “buffering,” effects for well-being. Method Participants We obtained approval from the Institutional Review Boards of both the College of the Holy Cross and Gallaudet University. We collected a convenience sample of 171 deaf emerging adults aged 18–29. All participants were current or recent students at Gallaudet University, a small, federally chartered university established for deaf and hard-of-hearing individuals. We asked participants about their deaf identity and presented several conventional identity labels used among the deaf community (e.g., deaf, Deaf, hard-of-hearing, d/Deafblind, etc.) The two options for deafness—“little-d” deaf and “capital-D” Deaf—differ because the latter suggests involvement with Deaf culture and sign language, while the former does not. The majority of participants (111; 65%) identified as Deaf, 9.3% (N = 16) identified as deaf, and 18.1% (N = 31) identified as hard-of-hearing (difficulty with hearing) only. All but seven participants who self-identified as Deaf indicated they preferred sign language to communicate. The remaining 13 (7.6%) either left the answer blank, preferred not to answer, or self-identified as “Other.” The majority of participants identified as female (N = 107; 62.5%). Most participants identified their race/ethnicity as white (N = 105; 61.4%); 9.4% (N = 16) identified as Hispanic or Latino, 7.0% (N = 12) as black or African American, 5.3% (N = 9) as multiracial, 2.9% (N = 5) as Arab/Arab-American/Middle Eastern, and 0.6% (N = 1) as Native Hawaiian/Other Pacific Islander. The mean age of the sample was 22.46 (SD = 4.20). The majority of the sample was current undergraduates (N = 125; 74.1%); 15.2% (N = 26) were current graduate students, and 7.0% (N = 12) were alumni of Gallaudet. Most participants identified as heterosexual/straight (N = 102; 59.6%) and 20.5% (N = 35) identified as lesbian/gay/bisexual. A total of 28.1% (N = 48) of the sample reported an annual family household income of under $40,000, 18.7% (N = 32) reported $40,000–$79,000, and 30.0% (N = 36) reported $80,000 or above. Procedure Gallaudet University students and alumni were recruited to participate in an Internet survey examining “the prevalence and types of stigma experienced in deaf/Deaf/hard-of-hearing communities and how these experiences can affect well-being.” Participants were recruited using e-mail circulations, hard-copy flyers on campus, social media, and personal referrals. After completing a consent form, participants were asked to complete self-report measures of well-being (i.e., depressive symptoms, anxiety, alcohol use), stigma, additional identity-related questions, and demographic information. It is important to note that the predictor and outcome measures were analyzed using a Flesch Kincaid scale of readability on Microsoft Word, which is designed to analyze the difficulty of English sentences. The results show that the measures read at approximately a fourth-grade reading level, which is the average reading level reported among deaf adults (Cawthon, 2004). Participants were debriefed, asked to provide peer referrals, and were remunerated with a $10 Amazon e-gift card. Measures Well-being Psychological, physical, and behavioral well-being was assessed with measures of depressive symptoms, anxiety, quality of life, and alcohol use. Depressive symptoms during the past week were assessed using the 10-item Center for Epidemiologic Studies – Depression scale (CESD; Radloff, 1977). Previous research has used this scale among deaf adults with high positive predictive value and confidence interval (PPV = 23, CI = 0.52) (Lewinsohn et al., 1997). Participants were asked to rate items such as “I was bothered by things that usually don’t bother me” and “I had trouble keeping my mind on what I was doing” using a 0 (Rarely or None of the Time) to 3 (Most or All of the Time) scale. Scale items were averaged (α = 0.76). Anxiety symptoms during the past week were assessed using the 6-item Stait-Trait Anxiety Inventory-Trait scale (STAI-T; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Past research has shown that the STAI-T scale is valid and reliable among deaf samples (Ambert-Dahan et al., 2017). Participants were asked to rate items such as “I felt tense” and “I felt upset” on a 1 (almost never) to 4 (all the time) scale. Scale items were averaged (α = 0.77). Quality of life was assessed using the 26-item World Health Organization’s Quality of Life scale (WHOQOL; Harper, 1991). Participants were asked to rate items such as “How satisfied are you with your health?” and “How satisfied are you with your ability to perform your daily living activities?” on a 1 (Very dissatisfied) to 5 (Very satisfied) scale. Scale items were averaged to create an aggregate quality of life score. Consistent with past research among deaf samples (Fellinger et al., 2005), the measure showed high internal reliability (α = 0.91). Alcohol use was assessed using the 10-item Alcohol Use Disorders Identification Test (AUDIT; Barbor, Higgins-Biddle, Saunders, & Monteiro, 2001). Participants were asked to rate items such as “How often do you have a drink containing alcohol?” on a 0 (never) to 4 (daily or almost daily). Scale items were summed according to procedures identified in Barbor et al. (2001). Past research has demonstrated that the AUDIT is reliable and sensitive among deaf people in the UK, accurately predicting alcohol dependency with 92.2% accuracy (Alcohol Research UK, 2005). Stigma Three measures were used to assess anticipated stigma, enacted stigma, and internalized stigma. Anticipated stigma, or the perceived likelihood of experiencing discrimination in the future, was assessed with an adapted 26-item measure used in previous research (Quinn & Chaudoir, 2009). Participants were asked to rate the likelihood that they would “not get hired for a job” or be “discouraged by a teacher from continuing education” because of their hearing status. Items were rated on a 1 (Unlikely to occur) to 7 (Extremely likely to occur) scale and were averaged (α = 0.79). Enacted stigma, or the degree to which participants experienced discrimination in the past, was assessed by asking participants to indicate whether they had experienced each of the 26 types of discrimination presented in the anticipated stigma measure (1 = Yes, this has actually happened to me vs. 0 = No, this has never happened to me) (Quinn & Chaudoir, 2009). Scale items were summed (α = 0.85). Internalized stigma, or the degree to which participants feel shame about their hearing status, was assessed with five items adapted from the negative self-image subscale from the HIV Stigma Scale (Berger, Ferrans, & Lashley, 2001). Participants were asked to rate items such as “Being d/Deaf/hard-of-hearing makes me feel like I am a bad person” and “I feel I’m not as good as others because I am deaf/Deaf/hard-of-hearing” on a 1 (Strongly disagree) to 7 (Strongly agree) scale. Items were averaged (α = 0.86). Because the variable was non-normally distributed, it was dichotomized on a median split. Psychological resources We also measured trait resilience and benefit-finding as potential psychological resources capable of buffering the deleterious effect of stigma on well-being. Resilience, or one’s ability to recover from a negative event, was assessed using the six-item Brief Resilience Scale (BRS; Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008). Participants were asked to rate items such as “I tend to bounce back quickly after hard times” and “It is hard for me to snap back when something bad happens” (reverse-coded) on a 1 (Strongly disagree) to 7 (Strongly agree) scale. Items were averaged (α = 0.64). Benefit-finding, or the degree to which people find benefits in the face of negative situations, was assessed using a 17-item scale to assess benefit-finding (Carver & Antoni, 2004). Participants were asked to rate items such as “Being d/Deaf/hard-of-hearing has taught me that everyone has a purpose in life” and “Being d/Deaf/hard-of-hearing has led me to meet people who have become some of my best friends” on a 1 (Not at all) to 5 (Extremely) scale. Items were averaged (α = 0.93). Demographics and deaf acculturation Participants reported their gender, hearing status, sexual orientation, year in college, race/ethnicity, and annual family household income. Participants also completed a subscale of the Deaf Acculturation scale (α = 0.92) (Maxwell-McCaw & Zea, 2011). Because we were interested in the extent to which participants identified with the deaf community, we utilized the deaf subscale instead of the full deaf and hearing acculturation scale. Items on the measure asked participants to rate statements on a 1 (Strongly Disagree) to 5 (Strongly Agree) scale, and items included prompts such as “I feel that I am a member of the deaf community” and “I would prefer that my closest friends be deaf.” Analytical Approach Complete data were available for all mean stigma and outcome variables (see Table 1 for bivariate correlations). However, some data were missing for mean resilience (N = 3; 1.8%) and benefit-finding (N = 6; 3.5%) and for dummy-coded sexual orientation (N = 12; 7.0%), race (N = 15; 8.8%), and gender (N = 9; 5.3%). All data were missing completely at random (Little’s test χ2(86) = 106.10, p = .07) and cases with missing data were excluded listwise from analyses. Kolmogorov–Smirnov test and graphical inspection using Quantile–Quantile plots were used in order to assess normality of all study variables. With the exception of internalized stigma noted above, all variables were normally distributed. Table 1. Bivariate correlations between predictor and outcome variables   1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00    1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00  Notes: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed). Table 1. Bivariate correlations between predictor and outcome variables   1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00    1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00  Notes: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed). In order to test our hypotheses, we conducted a series of hierarchical linear regressions testing the associations between anticipated, enacted, and internalized stigma and each of our four outcome measures. In Step 1, we included demographic variables and deaf acculturation as covariates if their bivariate correlation with the outcome measure was marginally or statistically significant (p < .10). And, in Step 2, we included the centered main effects of anticipated, enacted, and internalized stigma. It is important to note that because internalized stigma was non-normally distributed, it was dichotomized on a median split when included in regressions. In order to test whether resilience moderated the significant effects of the stigma variables on each of the outcome measures, we conducted a second set of hierarchical linear regressions which also tested the centered main effect of resilience at Step 2 and the resilience × stigma interaction effect(s) for each of the significant stigma variables. Finally, we replicated this set of regressions, testing whether benefit-finding moderated the significant effects of the stigma variables on each of the outcomes measured. Results Descriptive Statistics Participants reported moderate levels of depressive symptoms (M = 1.01, SD = 0.52), with 67.8% of the sample scoring at or above the scale threshold for significant depressive symptoms. Similarly, participants reported moderate anxiety levels (M = 2.26, SD = 0.57) and moderately good quality of life (M = 3.60, SD = 0.58). Almost one quarter (24.0%) of participants reported potentially dangerous alcohol use and dependency (i.e., AUDIT score greater than 8; Barbor et al., 2001). Participants reported moderate levels of anticipated stigma (M = 3.19, SD = 1.47) and enacted stigma (M = 9.38, SD = 5.05), but relatively low levels of internalized stigma (M = 1.89, SD = 1.50). Participants reported moderate levels of resilience (M = 3.33, SD = 3.12) and relatively high benefit-finding (M = 3.99, SD = 4.11). Inferential Statistics Depressive Symptoms. We regressed sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual; LGB) and race/ethnicity (0 = White, 1 = Nonwhite), anticipated stigma, enacted stigma, and internalized stigma on depressive symptoms (see Table 2). At Step 1, LGB and nonwhite participants reported greater depressive symptoms than heterosexual and white participants, β = .33, p = .000 and β =.17, p = .03, respectively. At Step 2, enacted stigma predicted greater depressive symptoms, β = .34, p = .000, but neither anticipated stigma nor internalized stigma was significantly related to depressive symptoms. Table 2. Regression predicting depressive symptoms (N = 152) Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 2. Regression predicting depressive symptoms (N = 152) Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = −.20, p = .01, but no resilience × enacted stigma interaction. In our test of benefit-finding, we found no main effect of benefit-finding and found a marginally significant benefit-finding × enacted stigma interaction effect, β = −.12, p = .09. Follow up simple effects analyses indicate that the deleterious association between enacted stigma and depressive symptoms was slightly mitigated at +1 SD above the mean of benefit-finding, β = .36, p = .00, relative to −1 SD below the mean, β = .39, p = .00. Anxiety We regressed sexual orientation, anticipated stigma, enacted stigma, and internalized stigma on anxiety (see Table 3). At Step 1, LGB participants reported greater anxiety than heterosexual participants, β = .22, p = .01. At Step 2, enacted stigma predicted greater anxiety, β = .28, p = .01. Anticipated stigma marginally predicted greater anxiety, β = .15, p = .07, but internalized stigma was not significant. Table 3. Regression predicting anxiety (N = 159) Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on anxiety and were therefore excluded from this table: gender, race, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 3. Regression predicting anxiety (N = 159) Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on anxiety and were therefore excluded from this table: gender, race, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = −.19, p = .02, but no resilience × enacted stigma interaction. In our test of benefit-finding, we found a marginally significant main effect of benefit-finding, β = −.14, p = .06 and also a marginally significant benefit-finding × enacted stigma interaction effect, β = −.13, p = .08. Follow up simple effects analyses indicate that the deleterious association between enacted stigma and anxiety was slightly mitigated at +1 SD above the mean of benefit-finding, β = .27, p = .009, relative to −1 SD below the mean, β = .43, p = .00. Quality of life We regressed sexual orientation, deaf acculturation, anticipated stigma, enacted stigma, and internalized stigma on quality of life (see Table 4). At Step 1, LGB participants reported poorer quality of life than heterosexual participants, β = −.27, p = .01, as did those with greater deaf acculturation, β = .17, p = .02. At Step 2, enacted stigma predicted poorer quality of life, β = −.25, p = .01. Internalized stigma marginally predicted poorer quality of life, β = −.13, p = .07, but anticipated stigma did not reliably predict quality of life. Table 4. Regression predicting quality of life (N = 159) Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on quality of life and were therefore excluded from this table: gender, race, hearing status, age, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 4. Regression predicting quality of life (N = 159) Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on quality of life and were therefore excluded from this table: gender, race, hearing status, age, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = .25, p = .001, but not resilience × enacted stigma interaction. In our test of benefit-finding, we found no main effect of benefit-finding, nor did we find benefit-finding × enacted stigma interaction. Alcohol use We regressed deaf acculturation, anticipated stigma, enacted stigma, and internalized stigma on alcohol use (see Table 5). At Step 1, participants who reported greater acculturation in the deaf community reported marginally greater alcohol use, β = .15, p = .07. At Step 2, none of the stigma variables predicted alcohol use. Table 5. Regression predicting alcohol consumption behavior (N = 156) Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Notes: *p < .05, **p < .01, ***p < .001. Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, sexual orientation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 5. Regression predicting alcohol consumption behavior (N = 156) Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Notes: *p < .05, **p < .01, ***p < .001. Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, sexual orientation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Discussion While research demonstrates that stigma can have deleterious consequences for well-being among marginalized communities such as African-Americans, sexual minorities, and individuals living with other stigmatized identities (Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Quinn & Chaudoir, 2009), no known research has considered how stigma is related to well-being among deaf individuals. In order to address this gap, we conducted a survey to investigate whether anticipated, enacted, and internalized stigma predict well-being in a sample of deaf emerging adults. In brief, we found that enacted stigma, but not anticipated or internalized stigma, reliably predicted greater depressive symptoms, greater anxiety, and poorer quality of life. None of our stigma variables predicted alcohol use. Our findings support the hypothesis that enacted stigma, or past experiences of discrimination, are particularly deleterious to well-being among deaf emerging adults. These findings corroborate past cross-sectional research conducted among other marginalized groups (e.g., Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Mays & Cochran, 2001; Quinn & Chaudoir, 2009). Of particular note, the present findings align with studies that also offer a comparative test of the effects of anticipated, enacted, and internalized stigma. For example, enacted stigma has been shown to predict greater depressive symptoms among rural sexual minorities (Marsack & Stephenson, 2017) and poor physical health among people living with HIV/AIDS (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013). Thus, the present findings add to the growing number of studies that support the premise that experiences of discrimination are often stronger predictors of poor well-being when compared to anticipated and internalized stigma. However, we found little support for the hypothesis that anticipated or internalized stigma reliably predicts poorer well-being. Past research using a tripartite stigma measurement approach has generally found support for the deleterious association between anticipated stigma and depressive symptoms and physical health (Earnshaw et al., 2013; Marsack & Stephenson, 2017; Whitehead, Shaver, & Stephenson, 2016). Given that the present results are the first to assess a deaf sample, these findings may point to underlying differences in whether and to what degree anticipated stigma is related to well-being relative to their effects in other marginalized groups. For example, relative to a sample of similarly aged individuals living with a variety of concealable stigmatized identities (e.g., mental illness, sexual minority status), the current sample experienced over four times as much enacted stigma (M = 9.38 vs. M = 1.78) but only slightly higher anticipated stigma (M = 3.19 vs. M = 2.63) using the exact same measurement scales (Chaudoir & Quinn, 2016). Thus, given that deaf emerging adults appear to experience significantly higher rates of discrimination (but similar expectations of the likelihood of future rejection relative to other marginalized emerging adults), the relative burden of expecting future discrimination may simply have been diminished in this community. We found null effects for the deleterious association between internalized stigma and well-being, which partially replicates previous research. Previous studies using a tripartite stigma measurement approach have shown mixed findings (Marsack & Stephenson, 2017; Whitehead, Shaver, & Stephenson, 2016). The present null effects may be due to the fact that the majority of this sample reported low rates of internalized stigma while few reported high numbers. Indeed, many deaf people feel proud of their language, culture, and community (Bauman & Murray, 2014), such that they do not internalize or adopt negative social attitudes towards themselves for being deaf. Thus, the lack of internalized stigma effects may simply represent a floor effect generated by the prevalence of deaf-positive attitudes in this community. We used a median split to work with the non-normalized distribution, which may have also suppressed any effect by reducing variability. Additional research is needed, of course, to corroborate this possibility. Alcohol use was unrelated to any of the stigma variables in this sample of deaf emerging adults. Past research suggests that experiences of marginalization predict higher rates of substance abuse among sexual minorities (Hatzenbuehler, Corbin, & Fromme, 2008), perhaps as a way to cope with discrimination when they are socially isolated and have few other adaptive coping strategies available (Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009). Whereas sexual minority emerging adults tend to report greater alcohol use than their heterosexual peers, deaf adolescents tend to consume less alcohol than their hearing counterparts (Pinquart & Pfeiffer, 2015). Moreover, because our participants were all current or recent members of a majority-deaf educational community, these individuals may not have experienced the type of social isolation that often leads marginalized individuals to cope with stigma-related stress through alcohol use. From this perspective, the present null findings may not be particularly surprising. Finally, we found little support for the hypothesis that resilience or benefit-finding might “buffer,” or moderate, the deleterious association between enacted stigma and well-being. It is possible that the poor reliability of the scale may explain why it did not moderate the effects of stigma on the outcome measures. The null effect may also be the consequence of the current study’s operational definition of resilience as beliefs about one’s propensity to effectively cope with general, rather than deaf-specific, adversity. The use of a deaf-specific measure of resilience may have offered a stronger test of the moderating effect of this construct. Some research has begun investigating this topic, and more should be done to explore this possibility (Kurtz, Hauser, & Listman, 2016; Listman, Rogers, & Hauser, 2011). Although we used a deaf-specific, adapted measure of benefit-finding—a key individual difference measure capable of mitigating the deleterious effects of negative life events on well-being (e.g., Antoni et al., 2001; Helgeson, Reynolds, & Tomich, 2006)—this psychological resource did not prove a reliable buffer in the present sample. One possibility for this finding is that few participants in this sample actually viewed their deafness as a negative trait, rendering the construct validity of this scale relatively weak in this sample. This interpretation aligns with the relatively low levels of internalized stigma observed in this sample and broader notions of deaf gain (Bauman & Murray, 2014). Limitations The present findings should be considered within the context of several methodological limitations. The correlational study design precludes us from drawing causal conclusions about the effect of enacted stigma on well-being. Future research should examine casual relationships (that were beyond the scope of this correlational study) between experiences of discrimination and poorer well-being among deaf individuals in order to replicate the effect demonstrated in many other marginalized populations (for a review, see Pascoe & Smart Richman, 2009). Additionally, several of the scales used here have not previously been used among deaf samples; however, the variables were interrelated in the hypothesized directions. These relationships suggest that the scales, while applied to a novel population, were reliable and valid in this sample just as they have been in other marginalized communities. It is important for future experimental research to continue to examine and refine these measurements in deaf samples. Furthermore, while our sample was characterized by relatively strong diversity in racial identity, sexual orientation, and socioeconomic status, our findings may only generalize to deaf emerging adults who are current or recent members of an exclusively deaf learning or social community. Such an environment not only reduces barriers to education, but also provides a unique cultural experience in which deaf emerging adults live in community with other deaf and hard-of-hearing peers. As a result, individuals from the Gallaudet community may be more integrated into Deaf culture and enjoy greater social, structural, and psychological supports that may mitigate stigma-related stress (and, therefore, effects of stigma) than other emerging adults not in such a community. Given that many deaf emerging adults either attend colleges where they are the statistical minority or do not attend college at all, additional research is needed to understand the extent to which the present findings generalize beyond the highly unique and supportive cultural context typically experienced among students at Gallaudet University. Conclusions and Implications On the whole, deaf individuals experience poorer psychological and physical health relative to their hearing counterparts (e.g., Fellinger, Holzinger, Sattel, & Laucht, 2008; Van Gent, Goedhart, Hindley, & Treffers, 2007). The present research raises the possibility that the concomitant social marginalization of deaf people might be associated to these disparities. In other words, extant mental and physical health disparities may be less attributable to biological differences than to the distal effects of regularly being excluded, isolated, and discriminated against (Foss, 2014; Kiger, 1997; Komesaroff, 2004). Because this is the first known quantitative assessment of the link between stigma and well-being among deaf individuals, this study is also among the first pieces of empirical evidence to support such an assertion. However, just as prevailing explanations of mental health disparities among sexual minorities evolved from essentialism in the 1970s to social constructionism in modern research (DeLamater & Hyde, 1998), we contend that so, too, will the arc of deaf stigma research evolve over time. As additional research documents the deleterious effects of stigma towards deaf individuals, we suspect that researchers and practitioners will gain greater precision in identifying how both auditory differences and social vulnerabilities uniquely contribute to experiences of being deaf in emerging adulthood and beyond. In a world designed for the hearing majority, deaf emerging adults are often “othered.” The present results suggest that such treatment can take a toll on deaf emerging adults’ well-being in ways that could potentially contribute to disparate outcomes. At the same time, the present findings also suggest that efforts to diminish discrimination, whether promulgated by individual community members or institutional structures, are important steps in reversing these effects. Funding This research was funded by grants from Psi Chi and the Center for Liberal Arts in the World at the College of the Holy Cross. Conflicts of Interest No conflicts of interest were reported. Acknowledgments Thanks go to K.J. 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Palo Alto, CA: Consulting Psychologists Press van Eldik, T. ( 2005). Mental health problems of dutch youth with hearing loss as shown on the youth self report. American Annals of the Deaf , 150, 11– 16. doi:10.1353/aad.2005.0024 Google Scholar CrossRef Search ADS   Van Gent, T., Goedhart, A. W., Hindley, P. A., & Treffers, P. D. A. ( 2007). Prevalence and correlates of psychopathology in a sample of deaf adolescents: Psychopathology in deaf adolescents. Journal of Child Psychology and Psychiatry , 48, 950– 958. doi:10.1111/j.1469-7610.2007.01775.x Google Scholar CrossRef Search ADS   Whitehead, J., Shaver, J., & Stephenson, R. ( 2016). Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS One , 11, e0146139. doi:10.1371/journal.pone.0146139 Google Scholar CrossRef Search ADS   © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Journal of Deaf Studies and Deaf Education Oxford University Press

Deaf Stigma: Links Between Stigma and Well-Being Among Deaf Emerging Adults

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Abstract

Abstract Although stigma has been linked to suboptimal psychological and physical health outcomes in marginalized communities such as persons of color, sexual minorities, and people living with HIV/AIDS, no known research has examined these effects among deaf individuals. In the present research, we examine the associations between anticipated, enacted, and internalized stigma and psychological well-being (i.e., depressive symptoms, anxiety) and physical well-being (i.e., quality of life, alcohol use) among a sample of 171 deaf emerging adults. Furthermore, we consider whether trait resilience and benefit-finding moderate these effects. Enacted stigma, but not anticipated or internalized stigma, was related to worse depressive symptoms, anxiety, and quality of life. However, none of these variables predicted alcohol use and neither resilience nor benefit-finding moderated these effects. These findings are consistent with other research among marginalized populations, though they are also the first to suggest that experiences of discrimination are related to suboptimal well-being among deaf emerging adults. The discussion considers how these findings may illuminate the potential causes of disparities in well-being between hearing and deaf emerging adults. Deaf individuals experience worse psychological and physical health relative to their hearing counterparts (Fellinger, Holzinger, & Pollard, 2012; Fellinger, Holzinger, Sattel, & Laucht, 2008; Kvam, Loeb, & Tambs, 2007; van Eldik, 2005; Van Gent, Goedhart, Hindley, & Treffers, 2007). For example, higher rates of impulse control disorders, depressive symptoms, and developmental disorders have been recorded in deaf populations (Fellinger et al., 2012). Similarly, deaf individuals report worse rates of physical well-being and are less likely to utilize health care systems than hearing individuals (Alexander, Ladd, & Powell, 2012; Barnett & Franks, 2002; Barnett, McKee, Smith, & Pearson, 2011; Pick, 2013). We posit that deaf stigmatization may be related to the disparate outcomes of well-being reported by past research (Fellinger et al., 2012; Kvam, Loeb, & Tambs, 2007; Pick, 2013). Goffman (1963) defines stigma as a socially devalued identity that renders one less than fully human in the eyes of others. A person with one or more stigmatized identities often experiences discrimination based on the disparaged trait. Deaf stigma can be understood as the social ramifications of living in a society that labels deafness an impairment and operates in ways that exclude and devalue deaf people. It is important to emphasize that deaf stigma focuses solely on the hearing world’s perception of deafness as a disability and the frequent discrimination that deaf people often face as a result. While past research has reported deleterious outcomes of psychological and physical well-being among deaf individuals, no empirical investigations have examined whether and to what degree stigmatization is associated with poor well-being. Therefore, in the present study, we address this gap by examining the extent to which stigma contributes to poorer rates of well-being among deaf emerging adults than among hearing adults. Deaf Stigma Deaf individuals are frequently marginalized because their unique communication and accessibility needs often highlight their “otherness” from hearing people. Many deaf individuals rely on different languages and combinations of communication tactics unfamiliar to hearing people. For example, many deaf people use American Sign Language, a language to which most hearing individuals are unaccustomed. Other deaf people do use spoken English but must lip-read in order to understand people’s responses to them (Coryell, Holcomb, & Scherer, 1992; Georgia Tech Research Institute, 2007). Thus, the novelty of these communication tactics is likely experienced by most hearing individuals as disruptive to everyday social interactions (Goffman, 1963). Moreover, the hearing world tends to view being deaf as a disability, or a condition that induces hardship and isolation, rather than as an identity that also brings opportunity for personal growth and community (Padden & Humphries, 1988, 2005). Popular culture and media further magnify these beliefs, often portraying deaf people as comical, lonely, and embarrassing (Foss, 2014). These stereotypes and social portrayals perpetuate the tendency to reduce deaf individuals to their hearing impairment alone, rather than engage with them in a way that honors their full humanity. As a result, deaf individuals are often vulnerable to marginalization in many areas of their life. In the workplace, deaf individuals are fired, or not hired in the first place, at much higher rates than their hearing counterparts (Komesaroff, 2004). While much stigmatization is generated from strangers, family and close friends are often frequent perpetrators of mistreatment as well. Approximately 90% of deaf children are born to hearing parents, and approximately 80% of hearing parents do not learn sign language with their child (NIDCD, 2016). Because deaf children of hearing, non-signing parents often cannot understand or participate in spoken-voice conversations, they are often excluded from family discussions. Familial exclusion is so common, in fact, that deaf people colloquially use the term “dinner table syndrome” to describe the isolation one feels when eating dinner with hearing family members. Deaf individuals are often isolated and unable to join conversation because parents, siblings, or extended family do not make their spoken language accessible to deaf people (Hauser, O’Hearn, McKee, & Steider, 2010). Similarly, because many deaf students are enrolled in spoken-language classrooms without sign language interpreters, developing friendships with hearing, non-signing peers can be challenging (among children: Batten, Oakes, & Alexander, 2013). As a result, many deaf individuals experience significant isolation when their family and friends do not attempt to adapt or adjust to their communication needs (among youth: Charlson, Strong, & Gold, 1992; Kolod, 1994; Kushalnagar, Topolski, Schick, Edwards, Skalicky, & Patrick, 2010; among adults: Erdil & Ertosun, 2011; Hauser, O’Hearn, McKee, & Steider, 2010). Effects of Deaf Stigma on Well-Being Minority Stress Theory (Meyer, 2003) postulates that living with a socially marginalized identity such as being deaf creates chronic and acute stress that can injuriously impact psychological and physical health. In support of this general premise, research indicates that stigmatization can have deleterious effects among sexual minorities (Hatzenbuehler, 2011; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011), overweight individuals (Hatzenbuehler, Keyes, & Hasin, 2009), and other socially marginalized populations (Quinn & Chaudoir, 2009). Indeed, in a meta-analysis of almost 400 studies, experiences of discrimination were significantly related to poorer psychological well-being (e.g., depression, anxiety) among a wide array of stigmas such as mental illness, physical disability, HIV-positive status, and race (Schmitt, Branscombe, Postmes, & Garcia, 2014). Similarly, meta-analytic findings also suggest that experiences of discrimination are linked to poorer physical health and greater health compromising behaviors such as alcohol and drug use (hearing sample: Pascoe & Smart Richman, 2009). The present study examines three types of stigma: enacted, anticipated, and internalized stigma—all of which have been associated with low levels of well-being. Enacted stigma refers to past experiences of discrimination, or the extent to which an individual has been stigmatized in the past. Research has shown that enacted stigma predicts worse health-related outcomes (among hearing samples: Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Quinn & Chaudoir, 2009; among deaf samples: Chapman & Dammeyer, 2017). Anticipated stigma, or the degree to which individuals expect to be discriminated against in the future, has been linked with greater depressive symptoms and anxiety in both cross-sectional (Quinn & Chaudoir, 2009) and prospective (Chaudoir & Quinn, 2016) analyses among hearing people living with a variety of concealable stigmatized identities. Moreover, internalized stigma, or feelings of shame about one’s identity, has also been linked to poorer mental health among hearing people with stigmatized identities (Mak, Poon, Pun & Cheung, 2007), people living with HIV (Lee, Kochman, & Sikkema, 2002), and LGB-identified people (Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008). Because experiences of past discrimination, expectations of future discrimination, and residual feelings of shame have each been linked to poor well-being, many scholars argue that each of these forms of stigma should be measured in empirical investigations (Earnshaw & Chaudoir, 2009). Although the types of stigmatization experienced in deaf communities have received considerable empirical attention (e.g., Foss, 2014; Kiger, 1997; Komesaroff, 2004), no known research has examined whether or to what degree deaf stigma is linked to poorer psychological and physical well-being. The purpose of the present study, therefore, is to address this gap and examine the degree to which anticipated, enacted, and internalized stigma predict poorer psychological, physical, and behavioral well-being among deaf emerging adults. Possible Mitigating Factors Of course, while stigma poses significant challenges for well-being, it also creates the opportunity to cultivate new and stronger coping skills, a deeper sense of purpose, and stronger bonds with similarly marginalized others (Frost, 2011). Indeed, research in the area of Deaf Gain argues that although deafness entails a loss of hearing, being deaf also benefits sensory perception, linguistic dexterity, and cultural connections (Bauman & Murray, 2014). From a Deaf Gain perspective, people celebrate being deaf as a social and cultural identity rather than a disability or impairment (Bauman & Murray, 2014; Ladd, 2003; Padden & Humphries, 1988, 2005). In the present study, we examine two types of psychological resources, resilience and benefit-finding, that might mitigate the deleterious effects of stigma on well-being. While there exist many definitions of resilience, we define it as one’s ability to “bounce-back” or thrive in the face of personal adversity (Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008). Because our research question investigates continuous experiences of discrimination across an emerging adult’s life, we find one’s ability to “bounce back” from discrimination and prejudice to be particularly relevant to the conversation. Importantly, research shows that resilience can diminish the effect of stigma on well-being in marginalized communities (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2015; Hawley, 2000). Benefit-finding is distinctly different from resilience, as it measures one’s tendency to identify personal benefits of a commonly stigmatized trait, such as deafness. Past research shows that benefit-finding has the ability to bolster psychological health in the face of medical adversity (e.g., cancer) and traumas (e.g., Antoni et al., 2001; Hegelson, Reynolds, & Tomich, 2006). As such, we believe it may contribute to the social adversity faced by deaf individuals in a hearing world. In the present research, we examine the possibility that bouncing back from discriminatory events and finding benefits in one’s deaf identity may moderate the impact of anticipated, enacted, and internalized stigma on well-being. Present Study In the current study, we examine the degree to which stigma is associated with poorer psychological, physical, and behavioral health among deaf emerging adults aged 18–29 (Arnett, 2000). Because social belonging concerns are most pronounced during this period of development, deaf emerging adults may be most sensitive to the impact of stigmatization. Previous research suggests that deaf individuals experience frequent discrimination and that deaf individuals experience worse well-being relative to their hearing counterparts (Barnett, Konstantina, Djemil, Brooks, & Terry, 2011; Foss, 2014; Kiger, 1997; Komesaroff, 2004; Kvam, Loeb, & Tambs, 2007; Pick, 2013; Smit & Henderson, 2010). However, to our knowledge, no quantitative research has explored whether stigma is associated with well-being. Our research is designed to address directly this gap and, in doing so, provide critical new information that may help researchers and practitioners understand the causes of extant health disparities noted among deaf populations. Consistent with past research, that anticipated, enacted, and internalized stigma would be related to greater depressive symptoms, anxiety, and alcohol use, but poorer quality of life. Furthermore, we hypothesized that resilience and benefit-finding would moderate these deleterious effects such that greater resilience and benefit-finding would provide protective, or “buffering,” effects for well-being. Method Participants We obtained approval from the Institutional Review Boards of both the College of the Holy Cross and Gallaudet University. We collected a convenience sample of 171 deaf emerging adults aged 18–29. All participants were current or recent students at Gallaudet University, a small, federally chartered university established for deaf and hard-of-hearing individuals. We asked participants about their deaf identity and presented several conventional identity labels used among the deaf community (e.g., deaf, Deaf, hard-of-hearing, d/Deafblind, etc.) The two options for deafness—“little-d” deaf and “capital-D” Deaf—differ because the latter suggests involvement with Deaf culture and sign language, while the former does not. The majority of participants (111; 65%) identified as Deaf, 9.3% (N = 16) identified as deaf, and 18.1% (N = 31) identified as hard-of-hearing (difficulty with hearing) only. All but seven participants who self-identified as Deaf indicated they preferred sign language to communicate. The remaining 13 (7.6%) either left the answer blank, preferred not to answer, or self-identified as “Other.” The majority of participants identified as female (N = 107; 62.5%). Most participants identified their race/ethnicity as white (N = 105; 61.4%); 9.4% (N = 16) identified as Hispanic or Latino, 7.0% (N = 12) as black or African American, 5.3% (N = 9) as multiracial, 2.9% (N = 5) as Arab/Arab-American/Middle Eastern, and 0.6% (N = 1) as Native Hawaiian/Other Pacific Islander. The mean age of the sample was 22.46 (SD = 4.20). The majority of the sample was current undergraduates (N = 125; 74.1%); 15.2% (N = 26) were current graduate students, and 7.0% (N = 12) were alumni of Gallaudet. Most participants identified as heterosexual/straight (N = 102; 59.6%) and 20.5% (N = 35) identified as lesbian/gay/bisexual. A total of 28.1% (N = 48) of the sample reported an annual family household income of under $40,000, 18.7% (N = 32) reported $40,000–$79,000, and 30.0% (N = 36) reported $80,000 or above. Procedure Gallaudet University students and alumni were recruited to participate in an Internet survey examining “the prevalence and types of stigma experienced in deaf/Deaf/hard-of-hearing communities and how these experiences can affect well-being.” Participants were recruited using e-mail circulations, hard-copy flyers on campus, social media, and personal referrals. After completing a consent form, participants were asked to complete self-report measures of well-being (i.e., depressive symptoms, anxiety, alcohol use), stigma, additional identity-related questions, and demographic information. It is important to note that the predictor and outcome measures were analyzed using a Flesch Kincaid scale of readability on Microsoft Word, which is designed to analyze the difficulty of English sentences. The results show that the measures read at approximately a fourth-grade reading level, which is the average reading level reported among deaf adults (Cawthon, 2004). Participants were debriefed, asked to provide peer referrals, and were remunerated with a $10 Amazon e-gift card. Measures Well-being Psychological, physical, and behavioral well-being was assessed with measures of depressive symptoms, anxiety, quality of life, and alcohol use. Depressive symptoms during the past week were assessed using the 10-item Center for Epidemiologic Studies – Depression scale (CESD; Radloff, 1977). Previous research has used this scale among deaf adults with high positive predictive value and confidence interval (PPV = 23, CI = 0.52) (Lewinsohn et al., 1997). Participants were asked to rate items such as “I was bothered by things that usually don’t bother me” and “I had trouble keeping my mind on what I was doing” using a 0 (Rarely or None of the Time) to 3 (Most or All of the Time) scale. Scale items were averaged (α = 0.76). Anxiety symptoms during the past week were assessed using the 6-item Stait-Trait Anxiety Inventory-Trait scale (STAI-T; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Past research has shown that the STAI-T scale is valid and reliable among deaf samples (Ambert-Dahan et al., 2017). Participants were asked to rate items such as “I felt tense” and “I felt upset” on a 1 (almost never) to 4 (all the time) scale. Scale items were averaged (α = 0.77). Quality of life was assessed using the 26-item World Health Organization’s Quality of Life scale (WHOQOL; Harper, 1991). Participants were asked to rate items such as “How satisfied are you with your health?” and “How satisfied are you with your ability to perform your daily living activities?” on a 1 (Very dissatisfied) to 5 (Very satisfied) scale. Scale items were averaged to create an aggregate quality of life score. Consistent with past research among deaf samples (Fellinger et al., 2005), the measure showed high internal reliability (α = 0.91). Alcohol use was assessed using the 10-item Alcohol Use Disorders Identification Test (AUDIT; Barbor, Higgins-Biddle, Saunders, & Monteiro, 2001). Participants were asked to rate items such as “How often do you have a drink containing alcohol?” on a 0 (never) to 4 (daily or almost daily). Scale items were summed according to procedures identified in Barbor et al. (2001). Past research has demonstrated that the AUDIT is reliable and sensitive among deaf people in the UK, accurately predicting alcohol dependency with 92.2% accuracy (Alcohol Research UK, 2005). Stigma Three measures were used to assess anticipated stigma, enacted stigma, and internalized stigma. Anticipated stigma, or the perceived likelihood of experiencing discrimination in the future, was assessed with an adapted 26-item measure used in previous research (Quinn & Chaudoir, 2009). Participants were asked to rate the likelihood that they would “not get hired for a job” or be “discouraged by a teacher from continuing education” because of their hearing status. Items were rated on a 1 (Unlikely to occur) to 7 (Extremely likely to occur) scale and were averaged (α = 0.79). Enacted stigma, or the degree to which participants experienced discrimination in the past, was assessed by asking participants to indicate whether they had experienced each of the 26 types of discrimination presented in the anticipated stigma measure (1 = Yes, this has actually happened to me vs. 0 = No, this has never happened to me) (Quinn & Chaudoir, 2009). Scale items were summed (α = 0.85). Internalized stigma, or the degree to which participants feel shame about their hearing status, was assessed with five items adapted from the negative self-image subscale from the HIV Stigma Scale (Berger, Ferrans, & Lashley, 2001). Participants were asked to rate items such as “Being d/Deaf/hard-of-hearing makes me feel like I am a bad person” and “I feel I’m not as good as others because I am deaf/Deaf/hard-of-hearing” on a 1 (Strongly disagree) to 7 (Strongly agree) scale. Items were averaged (α = 0.86). Because the variable was non-normally distributed, it was dichotomized on a median split. Psychological resources We also measured trait resilience and benefit-finding as potential psychological resources capable of buffering the deleterious effect of stigma on well-being. Resilience, or one’s ability to recover from a negative event, was assessed using the six-item Brief Resilience Scale (BRS; Smith, Dalen, Wiggins, Tooley, Christopher, & Bernard, 2008). Participants were asked to rate items such as “I tend to bounce back quickly after hard times” and “It is hard for me to snap back when something bad happens” (reverse-coded) on a 1 (Strongly disagree) to 7 (Strongly agree) scale. Items were averaged (α = 0.64). Benefit-finding, or the degree to which people find benefits in the face of negative situations, was assessed using a 17-item scale to assess benefit-finding (Carver & Antoni, 2004). Participants were asked to rate items such as “Being d/Deaf/hard-of-hearing has taught me that everyone has a purpose in life” and “Being d/Deaf/hard-of-hearing has led me to meet people who have become some of my best friends” on a 1 (Not at all) to 5 (Extremely) scale. Items were averaged (α = 0.93). Demographics and deaf acculturation Participants reported their gender, hearing status, sexual orientation, year in college, race/ethnicity, and annual family household income. Participants also completed a subscale of the Deaf Acculturation scale (α = 0.92) (Maxwell-McCaw & Zea, 2011). Because we were interested in the extent to which participants identified with the deaf community, we utilized the deaf subscale instead of the full deaf and hearing acculturation scale. Items on the measure asked participants to rate statements on a 1 (Strongly Disagree) to 5 (Strongly Agree) scale, and items included prompts such as “I feel that I am a member of the deaf community” and “I would prefer that my closest friends be deaf.” Analytical Approach Complete data were available for all mean stigma and outcome variables (see Table 1 for bivariate correlations). However, some data were missing for mean resilience (N = 3; 1.8%) and benefit-finding (N = 6; 3.5%) and for dummy-coded sexual orientation (N = 12; 7.0%), race (N = 15; 8.8%), and gender (N = 9; 5.3%). All data were missing completely at random (Little’s test χ2(86) = 106.10, p = .07) and cases with missing data were excluded listwise from analyses. Kolmogorov–Smirnov test and graphical inspection using Quantile–Quantile plots were used in order to assess normality of all study variables. With the exception of internalized stigma noted above, all variables were normally distributed. Table 1. Bivariate correlations between predictor and outcome variables   1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00    1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00  Notes: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed). Table 1. Bivariate correlations between predictor and outcome variables   1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00    1  2  3  4  5  6  7  1. Center for Epidemiological Studies – Depression Scale  1.00              2. State-Trait Anxiety Inventory  .73**  1.00            3. World Health Organization – Quality of Life Scale  −.65**  −.65**  1.00          4. Alcohol Use Disorders Identification Test  .04  −.03  −.01  1.00        5. Anticipated Stigma  .28**  .32**  −.28**  .08  1.00      6. Enacted Stigma  .36**  .33**  −.34**  .09  .51**  1.00    7. Internalized Stigma  .11  .10  −.19*  .14  .10  .10  1.00  Notes: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed). In order to test our hypotheses, we conducted a series of hierarchical linear regressions testing the associations between anticipated, enacted, and internalized stigma and each of our four outcome measures. In Step 1, we included demographic variables and deaf acculturation as covariates if their bivariate correlation with the outcome measure was marginally or statistically significant (p < .10). And, in Step 2, we included the centered main effects of anticipated, enacted, and internalized stigma. It is important to note that because internalized stigma was non-normally distributed, it was dichotomized on a median split when included in regressions. In order to test whether resilience moderated the significant effects of the stigma variables on each of the outcome measures, we conducted a second set of hierarchical linear regressions which also tested the centered main effect of resilience at Step 2 and the resilience × stigma interaction effect(s) for each of the significant stigma variables. Finally, we replicated this set of regressions, testing whether benefit-finding moderated the significant effects of the stigma variables on each of the outcomes measured. Results Descriptive Statistics Participants reported moderate levels of depressive symptoms (M = 1.01, SD = 0.52), with 67.8% of the sample scoring at or above the scale threshold for significant depressive symptoms. Similarly, participants reported moderate anxiety levels (M = 2.26, SD = 0.57) and moderately good quality of life (M = 3.60, SD = 0.58). Almost one quarter (24.0%) of participants reported potentially dangerous alcohol use and dependency (i.e., AUDIT score greater than 8; Barbor et al., 2001). Participants reported moderate levels of anticipated stigma (M = 3.19, SD = 1.47) and enacted stigma (M = 9.38, SD = 5.05), but relatively low levels of internalized stigma (M = 1.89, SD = 1.50). Participants reported moderate levels of resilience (M = 3.33, SD = 3.12) and relatively high benefit-finding (M = 3.99, SD = 4.11). Inferential Statistics Depressive Symptoms. We regressed sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual; LGB) and race/ethnicity (0 = White, 1 = Nonwhite), anticipated stigma, enacted stigma, and internalized stigma on depressive symptoms (see Table 2). At Step 1, LGB and nonwhite participants reported greater depressive symptoms than heterosexual and white participants, β = .33, p = .000 and β =.17, p = .03, respectively. At Step 2, enacted stigma predicted greater depressive symptoms, β = .34, p = .000, but neither anticipated stigma nor internalized stigma was significantly related to depressive symptoms. Table 2. Regression predicting depressive symptoms (N = 152) Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 2. Regression predicting depressive symptoms (N = 152) Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Variable  B(SE)  β  Model test  Step 1      F(2, 151) = 11.25, p = .001, Adj. R2 = .12   Sexual orientation  .36 (.08)  .33***     Race  .19 (.09)  .17*    Step 2      F(5, 151) = 11.07, p = .001, Adj. R2 = .25   Anticipated stigma  .03 (.03)  .07     Enacted stigma  .03 (.01)  .34***     Internalized stigma  −.01 (.08)  −.01    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = −.20, p = .01, but no resilience × enacted stigma interaction. In our test of benefit-finding, we found no main effect of benefit-finding and found a marginally significant benefit-finding × enacted stigma interaction effect, β = −.12, p = .09. Follow up simple effects analyses indicate that the deleterious association between enacted stigma and depressive symptoms was slightly mitigated at +1 SD above the mean of benefit-finding, β = .36, p = .00, relative to −1 SD below the mean, β = .39, p = .00. Anxiety We regressed sexual orientation, anticipated stigma, enacted stigma, and internalized stigma on anxiety (see Table 3). At Step 1, LGB participants reported greater anxiety than heterosexual participants, β = .22, p = .01. At Step 2, enacted stigma predicted greater anxiety, β = .28, p = .01. Anticipated stigma marginally predicted greater anxiety, β = .15, p = .07, but internalized stigma was not significant. Table 3. Regression predicting anxiety (N = 159) Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on anxiety and were therefore excluded from this table: gender, race, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 3. Regression predicting anxiety (N = 159) Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Variable  B (SE)  β  Model test  Step 1      F(1, 158) = 7.784, p = .01, Adj. R2 = .04   Sexual orientation  .26 (.06)  .22**    Step 2      F(4, 158) = 9.283, p = .00, Adj. R2 = .17   Anticipated stigma  .07 (.04)  .15     Enacted stigma  .03 (.01)  .28**     Internalized stigma  .02 (.09)  .02    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on anxiety and were therefore excluded from this table: gender, race, hearing status, age, deaf acculturation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = −.19, p = .02, but no resilience × enacted stigma interaction. In our test of benefit-finding, we found a marginally significant main effect of benefit-finding, β = −.14, p = .06 and also a marginally significant benefit-finding × enacted stigma interaction effect, β = −.13, p = .08. Follow up simple effects analyses indicate that the deleterious association between enacted stigma and anxiety was slightly mitigated at +1 SD above the mean of benefit-finding, β = .27, p = .009, relative to −1 SD below the mean, β = .43, p = .00. Quality of life We regressed sexual orientation, deaf acculturation, anticipated stigma, enacted stigma, and internalized stigma on quality of life (see Table 4). At Step 1, LGB participants reported poorer quality of life than heterosexual participants, β = −.27, p = .01, as did those with greater deaf acculturation, β = .17, p = .02. At Step 2, enacted stigma predicted poorer quality of life, β = −.25, p = .01. Internalized stigma marginally predicted poorer quality of life, β = −.13, p = .07, but anticipated stigma did not reliably predict quality of life. Table 4. Regression predicting quality of life (N = 159) Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on quality of life and were therefore excluded from this table: gender, race, hearing status, age, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 4. Regression predicting quality of life (N = 159) Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Variable  B (SE)  β  Model test  Step 1      F(2, 158) = 8.846, p = .001, Adj. R2 = .09   Sexual orientation  −.30 (.09)  −.27**     Deaf acculturation  .15 (.07)  −.17*    Step 2      F(5, 158) = 10.06, p = .001, Adj. R2 = .22   Anticipated stigma  −.6 (.03)  −.14     Enacted stigma  −.03 (.01)  .25**     Internalized stigma  −.14 (.08)  −.13    Notes: *p <. 05, **p <. 01, ***p <. 001. Sexual orientation (0 = heterosexual, 1 = lesbian, gay, bisexual). The following variables had null effects on quality of life and were therefore excluded from this table: gender, race, hearing status, age, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. In our test of the possible moderating effect of resilience, we found a significant main effect of resilience, β = .25, p = .001, but not resilience × enacted stigma interaction. In our test of benefit-finding, we found no main effect of benefit-finding, nor did we find benefit-finding × enacted stigma interaction. Alcohol use We regressed deaf acculturation, anticipated stigma, enacted stigma, and internalized stigma on alcohol use (see Table 5). At Step 1, participants who reported greater acculturation in the deaf community reported marginally greater alcohol use, β = .15, p = .07. At Step 2, none of the stigma variables predicted alcohol use. Table 5. Regression predicting alcohol consumption behavior (N = 156) Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Notes: *p < .05, **p < .01, ***p < .001. Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, sexual orientation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Table 5. Regression predicting alcohol consumption behavior (N = 156) Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Variable  B (SE)  β  Model test  Step 1      F(2, 155) = 3.64, p = .02, Adj. R2 = .03   Race  −1.31 (.91)  −.12     Deaf acculturation  1.25 (.69)  .15    Step 2      F(5, 155) = 2.24, p = .05, Adj. R2 = .04   Anticipated stigma  1.39 (.70)  −.13     Enacted stigma  −.03 (.38)  −.01     Internalized stigma  .11 (.10)  −.11    Notes: *p < .05, **p < .01, ***p < .001. Race (0 = white, 1 = nonwhite). The following variables had null effects on depressive symptoms and were therefore excluded from this table: gender, hearing status, age, sexual orientation, family socioeconomic status, educational background, first language learned, language most used, and language most preferred. Discussion While research demonstrates that stigma can have deleterious consequences for well-being among marginalized communities such as African-Americans, sexual minorities, and individuals living with other stigmatized identities (Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Quinn & Chaudoir, 2009), no known research has considered how stigma is related to well-being among deaf individuals. In order to address this gap, we conducted a survey to investigate whether anticipated, enacted, and internalized stigma predict well-being in a sample of deaf emerging adults. In brief, we found that enacted stigma, but not anticipated or internalized stigma, reliably predicted greater depressive symptoms, greater anxiety, and poorer quality of life. None of our stigma variables predicted alcohol use. Our findings support the hypothesis that enacted stigma, or past experiences of discrimination, are particularly deleterious to well-being among deaf emerging adults. These findings corroborate past cross-sectional research conducted among other marginalized groups (e.g., Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Hatzenbuehler, Phelan, & Link, 2013; Lehavot & Simoni, 2011; Mays & Cochran, 2001; Quinn & Chaudoir, 2009). Of particular note, the present findings align with studies that also offer a comparative test of the effects of anticipated, enacted, and internalized stigma. For example, enacted stigma has been shown to predict greater depressive symptoms among rural sexual minorities (Marsack & Stephenson, 2017) and poor physical health among people living with HIV/AIDS (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013). Thus, the present findings add to the growing number of studies that support the premise that experiences of discrimination are often stronger predictors of poor well-being when compared to anticipated and internalized stigma. However, we found little support for the hypothesis that anticipated or internalized stigma reliably predicts poorer well-being. Past research using a tripartite stigma measurement approach has generally found support for the deleterious association between anticipated stigma and depressive symptoms and physical health (Earnshaw et al., 2013; Marsack & Stephenson, 2017; Whitehead, Shaver, & Stephenson, 2016). Given that the present results are the first to assess a deaf sample, these findings may point to underlying differences in whether and to what degree anticipated stigma is related to well-being relative to their effects in other marginalized groups. For example, relative to a sample of similarly aged individuals living with a variety of concealable stigmatized identities (e.g., mental illness, sexual minority status), the current sample experienced over four times as much enacted stigma (M = 9.38 vs. M = 1.78) but only slightly higher anticipated stigma (M = 3.19 vs. M = 2.63) using the exact same measurement scales (Chaudoir & Quinn, 2016). Thus, given that deaf emerging adults appear to experience significantly higher rates of discrimination (but similar expectations of the likelihood of future rejection relative to other marginalized emerging adults), the relative burden of expecting future discrimination may simply have been diminished in this community. We found null effects for the deleterious association between internalized stigma and well-being, which partially replicates previous research. Previous studies using a tripartite stigma measurement approach have shown mixed findings (Marsack & Stephenson, 2017; Whitehead, Shaver, & Stephenson, 2016). The present null effects may be due to the fact that the majority of this sample reported low rates of internalized stigma while few reported high numbers. Indeed, many deaf people feel proud of their language, culture, and community (Bauman & Murray, 2014), such that they do not internalize or adopt negative social attitudes towards themselves for being deaf. Thus, the lack of internalized stigma effects may simply represent a floor effect generated by the prevalence of deaf-positive attitudes in this community. We used a median split to work with the non-normalized distribution, which may have also suppressed any effect by reducing variability. Additional research is needed, of course, to corroborate this possibility. Alcohol use was unrelated to any of the stigma variables in this sample of deaf emerging adults. Past research suggests that experiences of marginalization predict higher rates of substance abuse among sexual minorities (Hatzenbuehler, Corbin, & Fromme, 2008), perhaps as a way to cope with discrimination when they are socially isolated and have few other adaptive coping strategies available (Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009). Whereas sexual minority emerging adults tend to report greater alcohol use than their heterosexual peers, deaf adolescents tend to consume less alcohol than their hearing counterparts (Pinquart & Pfeiffer, 2015). Moreover, because our participants were all current or recent members of a majority-deaf educational community, these individuals may not have experienced the type of social isolation that often leads marginalized individuals to cope with stigma-related stress through alcohol use. From this perspective, the present null findings may not be particularly surprising. Finally, we found little support for the hypothesis that resilience or benefit-finding might “buffer,” or moderate, the deleterious association between enacted stigma and well-being. It is possible that the poor reliability of the scale may explain why it did not moderate the effects of stigma on the outcome measures. The null effect may also be the consequence of the current study’s operational definition of resilience as beliefs about one’s propensity to effectively cope with general, rather than deaf-specific, adversity. The use of a deaf-specific measure of resilience may have offered a stronger test of the moderating effect of this construct. Some research has begun investigating this topic, and more should be done to explore this possibility (Kurtz, Hauser, & Listman, 2016; Listman, Rogers, & Hauser, 2011). Although we used a deaf-specific, adapted measure of benefit-finding—a key individual difference measure capable of mitigating the deleterious effects of negative life events on well-being (e.g., Antoni et al., 2001; Helgeson, Reynolds, & Tomich, 2006)—this psychological resource did not prove a reliable buffer in the present sample. One possibility for this finding is that few participants in this sample actually viewed their deafness as a negative trait, rendering the construct validity of this scale relatively weak in this sample. This interpretation aligns with the relatively low levels of internalized stigma observed in this sample and broader notions of deaf gain (Bauman & Murray, 2014). Limitations The present findings should be considered within the context of several methodological limitations. The correlational study design precludes us from drawing causal conclusions about the effect of enacted stigma on well-being. Future research should examine casual relationships (that were beyond the scope of this correlational study) between experiences of discrimination and poorer well-being among deaf individuals in order to replicate the effect demonstrated in many other marginalized populations (for a review, see Pascoe & Smart Richman, 2009). Additionally, several of the scales used here have not previously been used among deaf samples; however, the variables were interrelated in the hypothesized directions. These relationships suggest that the scales, while applied to a novel population, were reliable and valid in this sample just as they have been in other marginalized communities. It is important for future experimental research to continue to examine and refine these measurements in deaf samples. Furthermore, while our sample was characterized by relatively strong diversity in racial identity, sexual orientation, and socioeconomic status, our findings may only generalize to deaf emerging adults who are current or recent members of an exclusively deaf learning or social community. Such an environment not only reduces barriers to education, but also provides a unique cultural experience in which deaf emerging adults live in community with other deaf and hard-of-hearing peers. As a result, individuals from the Gallaudet community may be more integrated into Deaf culture and enjoy greater social, structural, and psychological supports that may mitigate stigma-related stress (and, therefore, effects of stigma) than other emerging adults not in such a community. Given that many deaf emerging adults either attend colleges where they are the statistical minority or do not attend college at all, additional research is needed to understand the extent to which the present findings generalize beyond the highly unique and supportive cultural context typically experienced among students at Gallaudet University. Conclusions and Implications On the whole, deaf individuals experience poorer psychological and physical health relative to their hearing counterparts (e.g., Fellinger, Holzinger, Sattel, & Laucht, 2008; Van Gent, Goedhart, Hindley, & Treffers, 2007). The present research raises the possibility that the concomitant social marginalization of deaf people might be associated to these disparities. In other words, extant mental and physical health disparities may be less attributable to biological differences than to the distal effects of regularly being excluded, isolated, and discriminated against (Foss, 2014; Kiger, 1997; Komesaroff, 2004). Because this is the first known quantitative assessment of the link between stigma and well-being among deaf individuals, this study is also among the first pieces of empirical evidence to support such an assertion. However, just as prevailing explanations of mental health disparities among sexual minorities evolved from essentialism in the 1970s to social constructionism in modern research (DeLamater & Hyde, 1998), we contend that so, too, will the arc of deaf stigma research evolve over time. As additional research documents the deleterious effects of stigma towards deaf individuals, we suspect that researchers and practitioners will gain greater precision in identifying how both auditory differences and social vulnerabilities uniquely contribute to experiences of being deaf in emerging adulthood and beyond. In a world designed for the hearing majority, deaf emerging adults are often “othered.” The present results suggest that such treatment can take a toll on deaf emerging adults’ well-being in ways that could potentially contribute to disparate outcomes. At the same time, the present findings also suggest that efforts to diminish discrimination, whether promulgated by individual community members or institutional structures, are important steps in reversing these effects. Funding This research was funded by grants from Psi Chi and the Center for Liberal Arts in the World at the College of the Holy Cross. Conflicts of Interest No conflicts of interest were reported. Acknowledgments Thanks go to K.J. 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Published: May 31, 2018

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