Cumulative consequences of stigma: Possessing multiple concealable stigmatized identities is associated with worse quality of life

Abstract

Large health disparities exist between stigmatized and nonstigmatized groups. In addition to experiencing and anticipating greater discrimination, members of stigmatized groups also tend to demonstrate greater ruminative tendencies in response, which may lead to these poor health outcomes. Even among stigmatized groups, differences in the visibility of stigma lead to different mechanisms through which stigma takes its toll. Previous work has primarily focused on the impact of belonging to a single marginalized group; however, people often belong to multiple marginalized groups, and this likely affects both their health outcomes and their anticipation of stigma. In the current study, we focused on individuals with concealable stigmatized identities (CSIs)—socially stigmatized identities that are not immediately apparent to others—and created a measure of concealable marginalization that captures multiple group memberships. We predicted that those possessing a greater number of CSIs would anticipate more stigma from others, and, in turn, ruminate more about the stigma, which would negatively impact the health. Surveying N = 288 adults with CSIs, we found that possessing a greater number of marginalized concealable identities predicted worse self‐reported physical quality of life. These relationships were partially mediated by greater anticipated stigma and brooding rumination in regard to their CSI. This work illuminates a more complete picture of how living with CSIs can take its toll on health.

Full text

J Appl Soc Psychol. 2020;00:1–9. wileyonlinelibrary.com/journal/jasp
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1© 2020 Wiley Periodicals, Inc.
1 | INTRODUCTION
Stigma has been classified as a “fundamental cause” of health in-
equalities in that it limits access to health resources, affects multiple
health outcomes, and predicts worse health even when other inter-
vening mechanisms change (Hatzenbuehler, Phelan, & Link, 2013;
Link & Phelan, 1995). Hatzenbuehler and colleagues (2013) note that
researchers likely underestimate the negative effects of stigma on
health because they often focus on just one stigmatized identity or
one outcome or mechanism at a time. Similarly, others have called
for greater emphasis on the intersection of multiple identities in the
study of stigma (Williams & Fredrick, 2015), as well as in psychology
more broadly (Rosenthal, 2016). In the current work, we begin to
address this gap by considering how multiple marginalized identities
and multiple psychological mediators affect the physical quality of
life. To do so, we focus on a sample of people living with a conceal-
able stigmatized identity (CSI)—a socially stigmatized identity that is
not immediately apparent to others—and consider how possessing
multiple additional CSIs relates to greater anticipated stigma, brood-
ing rumination, and worse quality of life.
Received: 5 June 2019
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Revised: 17 October 2019
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Accepted: 10 January 2020
DOI: 10.1111/jasp.12656
ORIGINAL ARTICLE
Cumulative consequences of stigma: Possessing multiple
concealable stigmatized identities is associated with worse
quality of life
Mora A. Reinka1 | Bradley Pan-Weisz2 | Elizabeth K. Lawner1 | Diane M. Quinn1
1Department of Psychological Sciences,
University of Connecticut, Storrs, C T, USA
2Depar tment of Psychology, California State
University, Long Beach, Long Beach, CA,
USA
Correspondence
Mora A . Reinka, Depar tment of
Psychological Science s, University of
Connec ticut , Storrs , CT, 06521-1020, USA .
Email: mora.reinka@uconn.edu
Abstract
Large health disparities exist between stigmatized and nonstigmatized groups. In ad-
dition to experiencing and anticipating greater discrimination, members of stigma-
tized groups also tend to demonstrate greater ruminative tendencies in response,
which may lead to these poor health outcomes. Even among stigmatized groups,
differences in the visibility of stigma lead to different mechanisms through which
stigma takes its toll. Previous work has primarily focused on the impact of belonging
to a single marginalized group; however, people often belong to multiple marginalized
groups, and this likely affects both their health outcomes and their anticipation of
stigma. In the current study, we focused on individuals with concealable stigmatized
identities (CSIs)—socially stigmatized identities that are not immediately apparent to
others—and created a measure of concealable marginalization that captures multiple
group memberships. We predicted that those possessing a greater number of CSIs
would anticipate more stigma from others, and, in turn, ruminate more about the
stigma, which would negatively impact the health. Surveying N = 288 adults with
CSIs, we found that possessing a greater number of marginalized concealable identi-
ties predicted worse self-reported physical quality of life. These relationships were
partially mediated by greater anticipated stigma and brooding rumination in regard to
their CSI. This work illuminates a more complete picture of how living with CSIs can
take its toll on health.

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REINKA Et Al.
1.1 | Intersectional approaches
The term “intersectionality” is often credited to Dr. Kimberlé
Crenshaw (1989) in her seminal essay proposing that the burdens
Black women face are greater than that of their race or sex alone.
Although it began as a legal argument, the concept of intersection-
ality—that one must consider the whole of a person's identities to
best understand their experiences—has expanded into numerous
academic and applied disciplines, including psychology (Else-Quest
& Hyde, 2016; Rosenthal, 2016; Williams & Fredrick, 2015), pub-
lic health (Bowleg, 2012; Goodin et al., 2018), and even the com-
mon vernacular, as it was added to Webster's Dictionar y in 2017
(Merriam-Webster, 2017). Accordingly, researchers have recently
used an intersectional approach to study discrimination (e.g., Lewis
& Van Dyke, 2018; Liu & Wong, 2018; Sugarman et al., 2018), sexual
and domestic violence (e.g., Armstrong, Gleckman-Krut, & Johnson,
2018; Conwill, 2010; Powell, Hlavka, & Mulla, 2017), as well as physi-
cal and mental health (e.g., Dlugonski, Martin, Mailey, & Pineda,
2017; Goodin et al., 2018; Lewis & Van Dyke, 2018; Velez, Moradi, &
DeBlaere, 2014), among others.
Perhaps due to its roots as a study of the “double jeopardy” that
Black women face (Beal, 2008; Crenshaw, 1989), much of the work
within an intersectional framework focuses on visible stigmatized
identities, such as race and gender. While a number of studies ex-
amine the interactions between these visible identities and a con-
cealable identity, like sexual orientation (e.g., Mereish & Bradford,
2014) or mental illness (e.g., Torres, Mata-Greve, Bird, & Herrera
Hernandez, 2018), few studies have applied this line of inquiry
specifically to the effects of possessing multiple CSIs. Concealable
and visible stigmatized identities share many characteristics and
outcomes due to the broader nature and processes of stigma (see
Crocker, Major, & Steele, 1998; Goffman, 1963; Link & Phelan, 2001,
2014); however, the possibility of concealment uniquely af fects the
psychological experience of a CSI (e.g., Quinn & Chaudoir, 2009;
Quinn & Earnshaw, 2013). Therefore, it may be reasonable to expect
that the intersection of multiple CSIs, although perhaps resulting
in similar outcomes as visible stigmas (e.g., poor health; Grollman,
2014; Pachankis et al., 2018), would proceed through different
mechanisms.
1.2 | Anticipated stigma
One aspect of living with a CSI is anticipating when, where, and from
whom one will experience discrimination. Although anyone with a
devalued identity may evaluate the potential to face stigma, those
with a visible identity will know with some certainty another per-
son's reaction to them; if their interaction partner becomes with-
drawn or defensive, they may attribute such behavior to their skin
color, gender, or weight. Indeed, these individuals may even become
vigilant to such threatening cues in their environment (for a discus-
sion, see Steele, Spencer, & Aronson, 2002). For those with a con-
cealable stigma, however, they must anticipate what might happen
should their interaction partner discover their identity. The stigma-
tizing experience they fear has not yet occurred, but the stress—the
anticipated stigma—lies in the possibility that the interaction part-
ner may figure out that the individual is concealing something. As
Goffman (1963) puts it: those with a CSI are tasked with managing
information regarding their identity, whereas those with a visible
stigma are tasked with managing the nuance of social situations.
Indeed, for people with CSIs, one predictor of poorer health
is greater anticipated stigma (Quinn & Chaudoir, 2009; Quinn et
al., 2014), or the concern that one will be treated poorly if others
find out about a stigmatized identity. Previous work with CSIs has
shown that to the extent that people anticipate more devaluation
from others were they to reveal their identity—or come “out”—the
greater psychological distress (anxiety and depression; Chaudoir &
Quinn, 2016; Quinn & Chaudoir, 2009) and physical health symp-
toms (O’Donnell, Corrigan, & Gallagher, 2015; Quinn & Chaudoir,
2009) they report. Most of this previous research has focused on the
outcomes of anticipating stigma, largely as it relates to health and
well-being. However, it remains unclear what influences a person's
level of anticipated stigma regarding their CSIs.
Work on two similar concepts suggests that previous expe-
riences of discrimination based on different social identities may
prime people to anticipate more discrimination in the future. First,
stigma consciousness refers to an individual's expectation that
their actions will be interpreted through the lens of group-based
stereotypes (Pinel, 1999). Similar to anticipated stigma, stigma
consciousness is often conceptualized as an individual difference
trait; however, it is positively correlated with previous experiences
of discrimination (although the directionality of the relationship is
unclear; Pinel, 1999, 2004). Moreover, stigma consciousness can be
situationally heightened by reminders of prejudicial behavior (Pinel,
2004). Related work on the concept of status-based rejection sen-
sitivity, where people come to expect rejection from others based
on their stigmatized identity, shows that greater rejection sensitiv-
ity is also related to more experiences of discrimination in the past
(Mendoza-Denton, Downey, Purdie, Davis, & Pietrzak, 20 02). From
both ideas, we can extrapolate that for people living with stigma,
possessing more marginalized identities has likely exposed them to
more experiences of lifetime discrimination and perhaps provides
more consistent reminders of prejudicial attitudes. These cumulative
experiences likely lead people with CSIs to rationally anticipate more
stigma in the future. Although it may be rational to anticipate future
stigma in light of past stigma, this process can become maladaptive if
such anticipation becomes too frequent and repetitive.
1.3 | Brooding rumination
Brooding rumination—a maladaptive coping style of emotion regula-
tion marked by repetitive, self-focused thoughts—acts as one pathway
through which stigma negatively affects health (Hatzenbuehler, Nolen-
Hoeksema, & Dovidio, 2009). Past research has found that rumina-
tion is highly correlated with psychological distress (Lewis, Milletich,

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REINK A Et Al.
Mason, & Derlega, 2014), specifically depressive symptomology, both
cross-sectionally, and as a cross-lagged predictor (Moberly & Watkins,
2008; Treynor, Gonzalez, & Nolen-Hoeksema, 2003). In addition, in-
creased brooding rumination has been strongly connected to worse
physical health (Ottaviani et al., 2016; Sansone & Sansone, 2012), likely
through the increased wear and tear of an extended somatic stress
response (Verkuil, Brosschot, Gebhardt, & Thayer, 2010).
While most people engage in this form of passive coping
at least some of the time (Moberly & Watkins, 20 08; Treynor
et al., 2003), previous research has shown that stigmatized indi-
viduals ruminate at a greater rate than their nonstigmatized peers
(Timmins, Rimes, & Rahman, 2017). Moreover, for these individu-
als, brooding rumination appears to be a common response to stig-
ma-related stress (Hatzenbuehler et al., 2009; Lewis et al., 2014).
By spending time ruminating about experiences of discrimination,
people—especially those expecting to face stigma again—may feel
that they are arming themselves for future misfortunes (Watkins
& Baracaia, 2001). However, past work has examined brooding
after experienced stigma; anticipated stigma has yet to be tested
as a stigma-related stressor that may prompt brooding rumination.
Moreover, it is possible that those who possess a greater number
of stigmatized identities ruminate more, as they may have more
previous experience with stigma as well as anticipate more stigma
in the future. Unfortunately, as mentioned before, this short-
term coping response can lead to long-term health consequences
(Ottaviani et al., 2016; Sansone & Sansone, 2012; Verkuil et al.,
2010).
1.4 | Hypotheses
We take as our starting point that (a) having a greater number of CSIs
will have an accumulating negative ef fect on self-reported physical
quality of life (QOL). This should conceptually replicate the findings of
previous survey studies that found possessing multiple marginalized
identities was related to poorer self-rated health and gre ater functional
limitations (Grollman, 2014; Pachankis et al., 2018). In addition, we pre-
dict that (b) possession of a greater number of CSIs will correspond
with greater anticipated stigma. Furthermore, anticipated stigma has
been found to be predictive of greater psychological distress (Chaudoir
& Quinn, 2016; Quinn & Chaudoir, 2009), and brooding rumination
can be triggered by stigma-related stress (Hatzenbuehler et al., 2009).
Therefore, we expect that (c) greater anticipated stigma will predict
more brooding rumination. Finally, in line with previous work (e.g.,
Sansone & Sansone, 2012), (d) more brooding rumination will predict
poorer physical QOL. In addition to testing direct effects, we hypoth-
esize a mediated model such that the link between multiple CSIs and
worse physical QOL will be mediated by increased anticipated stigma
and brooding rumination. See Figure 1 for the full mediational model.
2 | METHOD
2.1 | Participants
Participants were recruited as part of a larger study examining CSIs
(Quinn, Weisz, & Lawner, 2017; see the Supplemental Materials for
the full list of survey measures) through Amazon's Mechanical Turk
platform. After initial, online written consent, 288 “workers” (122
men, 165 women, 1 other; 236 White, 52 nonWhite identifying in-
dividuals) completed the 10-min survey in exchange for $1. Sample
size was determined by planned SEM analyses for the larger study
(see Kline, 2005), but post hoc power analyses using Monte Carlo
simulations (Schoemann, Boulton, & Shor t, 2017) reveal that, with
N = 288, we have virtually 100% power to detect the indirect paths
in which we are interested.
In order to screen into the study, participants had to report
possessing at least one of three CSIs—chronic illness (n = 113),
FIGURE 1 Unstandardized regression coefficients and standard errors (in parentheses) of the relationship between the possession of
M-CSI and physical quality of life, through anticipated stigma and brooding rumination, while controlling for CSI outness, race/ethnicity,
gender, and age. Total effect is printed in light gray . Solid lines represent significant pathways; dashed lines represent nonsignificant paths.
**p < .01

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sexual orientation (n = 69), or history of mental illness (n = 106).
These three CSIs were chosen specifically because they are
known to be fairly common, but also vary in their level of social
stigmatization (see Pachankis et al., 2018). However, many par-
ticipants (58%) repor ted possessing more than one of these three
CSIs. In these cases, in order to reduce testing burden and ensure
equal time commitment for all individuals, participants chose the
CSI they found most important to their self-concept; they then
answered the stigma-related questions (anticipated stigma and
brooding rumination) in reference to that CSI. Recent research has
shown that the identity an individual rates as their most import-
ant has the largest impact on their wellbeing (Rodriguez-Seijas,
Burton, Adeyinka, & Pachankis, 2019). See Table 1 for full partic-
ipant characteristics. The University of Connecticut Institutional
Review Board approved all procedures prior to data collection in
accordance with the Belmont Report.
2.2 | Measures
2.2.1 | Multiple concealable stigmatized identities
scale (M-CSI)
We constructed a concealable identity scale as our primary independ-
ent variab le to best capture t he potential effects of pos sessing multiple
CSIs, similar to other health models’ conceptualizations of personal
resource s (e.g., Johnson et al., 2010) or additive models of intersec tion-
ality (e.g., Reidpath & Chan, 2005; for a discussion, see Else-Quest &
Hyde, 2016). To do this, we constructed the M-CSI scale such that we
tallied1 each CSI that participant s repor ted possessing from a demo-
graphic list: mental illness, addiction,2 sexual orientation, sexual as-
sault, family abuse history, homelessness, and incarceration history.
Al th ough we conside r ch ro nic illne ss es and ca nc er to be CSIs, give n th e
physical nature of our dependent variable, we did not include these
tallies in our scale to avoid conflating predictor and outcome. Howeve r,
results were substantively the same with or without their inclusion.
1 There is m uch debate in the i ntersectio nality liter ature about whe ther the conce pt
works additively or multiplicatively—that is, examining the statistical interactions of
variou s identit ies (for a review, se e Else-Qu est & Hyde, 2016). As oth ers have note d
(Rodri guez-Seij as et al., 2019), a multi plicat ive approach qu ickly become s cumbersome
with inc reasing ident ities examine d. With our sam ple size, we d o not have enough po wer
to do a clus ter analysis (e. g., Pach ankis et al., 2018) t o help us id entif y what combinati on
of concea lable identit ies are the most “ harmful” in ter ms of their impac t on health.
Regard less, we tested a f our-way interact ion model in an explorat ory ana lysis betwee n
four CS Is in our conceal able sti gma scale (ment al illness, ad diction, sex ual identity, an d
put the r emainin g four into one “tr aumatic life hi story” cate gory) in order to p redict
physic al quality of lif e. The four-CSI mo del, as oppose d to our 7-item M-CSI , was chosen
for a semb lance of parsim ony in an already co mplicated int eraction mo del. While this
test was likely still underpowered, no interactions between any of the identities were
signif icantl y associa ted with phys ical QOL whe n control ling for CSI ou tness , age, race,
and gend er, all βs < |.35|, all ps > .12.
2 Accordi ng to the DSM-5, addi ctions are con sidere d a mental i llness (Amer ican
Psychi atric A ssociat ion, 2013). Howeve r, we decided t o separate addi ction into its o wn
catego ry bec ause of the extr a stigma atta ched to it compar ed to nonsubst ance use
menta l illnes ses (Bar ry, McGinty, Pesc osolido, & Gold man, 2014; Schome rus et al., 2011).
Result s were substan tively the sam e if we colla psed add iction into our t allies for men tal
illnes s and if we separat ed them.
TABLE 1 Summary of participant characteristics
Characteristic
Tot al N = 288
n (%)
Gender
Male 122 (42.4%)
Female 165 (57.3%)
Other 1 (.3%)
Race
White 236 (81.9%)
Asian 24 (8 .3%)
Black 16 (5.6%)
Latino 6 (2.1%)
Native American 2 (.7%)
Other/mixed 4 (1.4%)
CSIsa
Mental illness 206 (71.5%)
Addiction 121 (42. 0%)
Cancer history 34 (11 .8%)
Chronic illness 149 (51.7%)
Minority sexual orientation 102 (35.4%)
Physically or emotionally abusive family 114 (39.6%)
Previous jail or prison time 19 (6. 6%)
Sexual assault history 77 (26.7%)
Homeless (current or previously) 38 (13 .2%)
Education
Some high school 2 (.7%)
Graduated high school 36 (12 .5%)
Some college 92 (31.9%)
Associate's degree 21 (7.3%)
Bachelor's degree 105 (36.5%)
Master's degree 28 (9.7%)
Professional degree 2 (.7%)
Doctorate degree 2 (.7%)
Income
<$30 k 88 (30.6%)
$30,000–$39,999 42 (14. 6%)
$40,000–$49,999 35 (12 .2%)
$50,000–$69,999 54 (18.8%)
$70,000–$79,999 20 (6.9%)
$80,000–$89,999 13 (4.5%)
$90,000–$99,999 9 (3.1%)
>$100k 27 (9.4%)
Employed
Yes 276 (95.8%)
No 12 (4.2%)
Abbreviation: CSI, concealable stigmatized identity.
aPercentages sum to more than 100% because participants were allowed
to indicate as many CSIs as they possessed, but they responded to further
questions on the one CSI they indicated was most important to them.

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Our sample ranged from 0–7 points on this scale, with a mean of 2.35
(SD = 1.51). Table 2 provides a full list of included CSIs.
2.2.2 | Anticipated stigma
Participants completed a 15-item scale of anticipated stigma (Quinn
& Chaudoir, 2009) regarding expected outcomes if others knew about
their CSI (e.g., being “treated with less respect than other people”)
from 1 = not at all likely to 7 = extremely likely. Participants generally
felt outcomes were “slightly likely,” M = 2.68, but with some consider-
able variability, SD = 1.42; standardized α =.958.
2.2.3 | Brooding rumination
Participants completed the 5-item brooding subscale of the Ruminative
Response Scale (Treynor et al., 2003) as a frequency measure of brooding
rumination. The instructions were modified to specifically reference the
individual's CSI: “People think and do many different things when they
are reminded of [their CSI]. Below is a list of possibilities,” followed by
the standard items (e.g., “Think about a recent situation, wishing it had
gone better”). Participants responded on a scale from 1 = almost never
to 4 = almost always; M = 2.07, SD =.744; standardized α =.857.
2.2.4 | Physical QOL
Participants also completed the World Health Organization Brief Quality
of Life (WHO QOL) 7-item physical wellbeing subscale. Items assess
health from the perspective of QOL, using items such as, “Do you
have enough energy for everyday life?” By focusing on QOL rather
than medicalized symptoms, we can more confidently capture well-
being across a broad adult population. Answers are standardized to
a 1–5 scale, with higher scores indicating greater perceived QOL (The
WHOQOL Group, 1998; M = 3.67, SD =.795; standardized α =.874) .
2.2.5 | Outness
Finally, given that anticipated stigma presumes a concealed CSI, we
included as a control variable how “out” participants were about their
CSI to eight different individuals in their life, including parents, siblings,
friends, partners, and coworkers (Mohr & Fassinger, 2000), from which
an average outness score was calculated. Participants indicated the
level of the other person's knowledge from 1 = does not know at all
to my knowledge, to 5 = knows and we've talked about it, with an op-
tion to indicate if the specified person was not in their life (M = 3.80,
SD = 1.03; standardized α = .869). Unsurprisingly, outness was corre-
lated with anticipated stigma, r(286) = −.276, p < .001 (see Table 3 for
correlations between the measures). However, the following results
still stand without this covariate, and in fact are even a little stronger,
making this a relatively conservative inclusion.
3 | RESULTS
3.1 | Data-analytic plan
To address our hypotheses, we conducted our analyses in three
steps. First, we aimed to demonstrate a direct negative relationship
TABLE 2 Identities included in the CSIs scale
CSI N (%)
Mental illnessa206 (71.5%)
Anxiety disorder 131 (45.5%)
Major depression 112 (38.9%)
Bipolar disorder 37 (12.8%)
Cutting or self-mutilation 34 (11 .8%)
Eating disorder 31 (10. 8%)
Trauma disorder/PTSD 30 (10 .4%)
Obsessive-compulsive disorder 27 (9.4%)
Personality disorder 14 (4.9%)
Schizophrenia 3 (1.0%)
Other (participant provided) 5 (1.7%)
Addictiona121 (42. 0%)
Alcohol 66 (22.9%)
Drugs 55 ( 19.1 %)
Gambling 27 (9.4%)
Other (participant provided) 23 (8.0%)
Minority sexual orientationa102 (35.4%)
Bisexual 70 (24.3%)
Gay/ Le sb ia n 29 (10.1%)
Transgender 4 (1.4%)
Other (participant provided) 9 (3.1%)
Sexual assault historya77 (26.7%)
Victim of rape 47 (16. 3%)
Victim of childhood sexual abuse 49 (17.0%)
Physically or emotionally abusive family 114 (39.6%)
Previous jail or prison time 19 (6. 6%)
Homeless (current or previously) 38 (13.2%)
Abbreviation: CSI, concealable stigmatized identity.
aPercentages sum to more than 100% because participants were
allowed to indicate as many CSIs as they possessed.
TABLE 3 Correlations coefficients for variables of interest
Measure 123 4
1: M-CSI –
2: Outness −.111 –
3: Anticipated stigma .290** −.276** –
4: Brooding rumination .179** −.124* .456** –
5: Physical QOL −.237** −.032 −.270** −. 43 6**
*p < .05; **p < .01.

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between number of CSIs possessed (M-CSI) and physical QOL using
standard linear regression. Second, we tested whether possession
of multiple CSIs predicted greater anticipated stigma and greater
rumination. Next, we examined our prediction that anticipated
stigma mediated the relationship between the M-CSI and the coping
patterns of brooding rumination (Figure 2). Third and finally, given
the strong link between brooding and poor health (e.g., Sansone &
Sansone, 2012), we included both the anticipated stigma and brood-
ing rumination as serial mediators to help explain the relationship
between multiple CSIs and physical QOL (Figure 1). Of course, just
because an identity could be concealable does not necessarily mean
that it is; therefore, all analyses included outness as a covariate. For
analyses examining physical QOL as an outcome, we also included
age, gender, and race/ethnicity as covariates due to the general re-
lationship between these variables and health, as well as history of
cancer or chronic illness. The pattern of results held with and with-
out the covariates. Mediations were conducted in the PROCESS
macro for SPSS (version 2.16; Hayes, 2013) with 95% bias-corrected
confidence intervals for indirect effects derived from 5,000 boot-
strapped samples.
3.2 | Findings
As expected, those who reported possessing a greater number of
CSIs reported worse physical QOL , b = −.141, SE = .031, t(281) =
−4.15, p < .001. In addition, higher scores on the M-CSI were related
to greater anticipated stigma, b = .246, SE = .052, t(285) = 4.61, p <
.001, and more brooding rumination, b = .083, SE = .029, t(285) =
2.870, p = .004, regarding their CSI.
Crucially, anticipated stigma was not only positively associ-
ated with brooding rumination, b = .233, SE = .030, t(284) = 7.78,
p < .001, but also fully mediated the relationship between the
M-CSI and brooding rumination, as indicated by the bootstrapped
confidence intervals, b = .057, SE = .016 [.030, .093]—possess-
ing more CSIs predicted more anticipated stigma, which, in turn,
predicted more brooding rumination. Once anticipated stigma
was included as a mediator, the relationship between the M-CSI
and brooding rumination was no longer significant, direct effect
b = .025, SE = .027, t(284) = .932, p = .352. As shown in Figure 2,
while those possessing a greater number of CSIs were more likely
to ruminate about their CSI, this can be fully explained by the fact
that they were also likely to anticipate more stigma regarding their
most important CSI.
Finally, we extended this mediation model a step further to
co nsi der th e heal t h effe c t s of su c h a proc ess . As show n in Figu re 1,
we constructed a serial mediation model with the M-CSI scale
specified as the exogenous predictor variable, anticipated stigma
and bro od in g ru mination sp ecif ie d as mediat or s, and physic al QOL
specified as the endogenous outcome variable. Those who pos-
sessed a greater number of CSIs reported anticipating more stigma
if others knew of their C SI, b = .202, SE = .053 t(281) = 3.85, p
< .001, and in turn, those who anticipated more stigma reported
more brooding rumination when thinking about their CSI, b = .232,
SE = .030, t(280) = 7.61, p < .001. Consistent with a wealth of
previous work, greater brooding rumination was associated with
worse physical QOL, b = −.393, SE = .061, t(279) = −6.78, p < .001.
Importantly, anticipated stigma and brooding rumination partially
mediated the relationship between the M-CSI and physical QOL,
total effect b = −.141, SE = .031, t(281) = −4.61, p < .001; direct
effect b = −.097, SE = .028, t(279) = −3.45, p < .001. Bootstrapped
confidence intervals confirmed the significant indirect effect, b =
−.018, SE = .007 [−.036, −.007]. The full model accounted for 30%
of the variance in physical QOL.
We have thus far found support for a cross-sectional mediation
model showing that number of CSIs is associated with greater antic-
ipated stigma, which, in turn, is associated with greater brooding ru-
mination tendencies and, finally, may lead to poor health outcomes.
This mediational sequence has support in previous literature, summa-
rized above. However, it is possible that membership in concealable
stigmatized groups may interact with anticipated stigma to predict
an increase in brooding rumination. While the outcome would essen-
tially be the same, the mathematical relationship would be different.
However, when we tested this possibility, again controlling for outness,
the M-CSI and anticipated stigma did not interact to predict rumina-
tion, b = .012, SE = .017, t(283) = .704, p = .482. Given this null result,
it is then unsurprising that the M-CSI also did not moderate the medi-
ation effect of brooding rumination between anticipated stigma and
FIGURE 2 Unstandardized regression coefficients and standard errors (in parentheses) demonstrating the relationship between the
possession of M-CSI and brooding rumination tendencies, controlling for CSI outness, as fully mediated by anticipated stigma. Total effect is
printed in light gray text. **p < .01

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REINK A Et Al.
physical QOL, controlling for outness, race, gender, and age: index of
moderated mediation b = −.005, SE = .008 [−.021, .009].
4 | DISCUSSION
In order to gain a greater understanding of how stigma af fects health,
we examined whether possessing multiple CSIs was related to worse
reported physical quality of life, and, furthermore, whether this re-
lationship was mediated through the specific psychological mecha-
nisms of greater anticipated stigma and greater brooding rumination.
Our predictions were supported: Within a sample of adult s with CSIs,
people possessing multiple CSIs reported more anticipated stigma and
greater brooding rumination. People possessing multiple CSIs also re-
ported lower physical qualit y of life, and this relationship was partially
mediated by anticipated stigma and brooding rumination.
It is important to note that this is a cross-sectional sur vey, there-
fore the order of the variables and the direction of causality cannot be
established. In other words, while the order of our variables fits previ-
ous literature, it is possible that several of these outcomes may be
caught in a feedback loop. For example, perhaps brooding rumination
decreases quality of life, but worsening QOL will in turn increase
brooding rumination. It is also possible that our measure of multiple
concealable stigma does not reflect the true or whole experience of
every participant. For example, we weighed each identity equally3 in
our M-CSI scale, although we recognize that different identities may
be more or less central or salient to the self (Quinn et al., 2014). Even
the use of an additive scale, albeit a deliberative and theoretically
driven choice,1,3, may not capture the multidimensionality of an indi-
vidual's experience. Indeed, the methods for quantifying intersection-
ality are largely not agreed upon (see Else-Quest & Hyde, 2016). In
addition, in determining CSIs, participants were provided a research-
er-generated list of possible identities to check of f (see Table 2), and
therefore we may not have captured ever y CSI that every participant
possessed or was important to them (e.g., [non]religious identification;
Abbot & Mollen, 2018). Finally, our sample was predominantly White,
educated, and, as this research was conducted through online collec-
tion systems, internet savvy. It will be important to replicate these re-
sults with a more diverse sample in the future.
The current work does, however, build upon previous research
that has tested parts of the theorized causal chain, with longitudinal
work showing that anticipated stigma predicts changes in depression
over time (Chaudoir & Quinn, 2016) and that greater rumination pre-
dicts changes in health over time (Nolen-Hoeksema, Stice, Wade, &
Bohon, 2007). Previous research had not strung all the links together,
focusing on the impact of multiple marginalizations within a sample
of those concerned about concealable stigmatized identities, rather
than visible identities. We have now done that. There are, however,
many questions left to answer. We cannot say for certain exactly why
it is that people with multiple CSIs tend to anticipate more stigma or
ruminate more than their peers with fewer CSIs. It could be, in line
with work on stigma consciousness and status-based rejection sen-
sitivity, that people with more CSIs have had more experiences with
discrimination and are thus are wise to expect it (e.g., Grollman, 2014;
Mendoza-Denton et al., 2002; Pinel, 2004). In this way, anticipated
stigma may be used as an adaptive strategy to avoid future discrimi-
nation. Although outside the scope of this study, it would be import-
ant to test if anticipating stigma truly is protective, or only leads to
negative outcomes such as the brooding rumination examined here. It
could also be that to the extent that greater marginalization is related
to fewer material resources available to deal with discrimination (e.g.,
ability to change jobs or move housing locations), rumination is an eas-
ily available coping strategy. Although perhaps adaptive in the short
term, it could be that as one spends more time and energy anticipat-
ing and ruminating on potential or past experiences with stigma, the
stress may itself harm physical QOL (see Verkuil et al., 2010). Further
research is necessary to elucidate the mechanisms at play behind this
pattern of results.
Finally, it should be noted that a significant direct effect from
possession of multiple CSIs to physical QOL remains once the in-
direct effects are accounted for, replicating previous work showing
that possessing multiple marginalized identities is associated with
poorer self-reported health (Grollman, 2014). This is impor tant to
note because it reflects that, whereas individual psychological mech-
anisms such as anticipated stigma and rumination may account for
one pathway from stigma to health, there are many other pathways,
including social structures and institutional discrimination, that im-
pact people's health and that are not captured in the psychological
study of individuals. Only when multiple levels of discrimination are
taken into account can the full power of social stigma on health be
recognized (Hatzenbuehler et al., 2013).
ACKNOWLEDGMENTS
We would like to thank the editor and anonymous reviewers for their
helpful and insightful feedback, as well as Gabriel Camacho for his
remarks on early drafts of this project.
ORCID
Mora A. Reinka https://orcid.org/0000-0001-9903-2966
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SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Reinka MA, Pan-Weisz B, Lawner EK,
Quinn DM. Cumulative consequences of stigma: Possessing
multiple concealable stigmatized identities is associated with
worse quality of life. J Appl Soc Psychol. 2020;00:1–9.
https ://doi.or g/10.1111/ jasp.12656