Multilevel Intersectional Stigma and Mental Health, Mental Help-Seeking Attitudes, and Mental Healthcare Behaviors Among Black Sexual Minority Emerging Adults

Background: Black queer people face intersectional stigma that cannot be adequately captured by single-axis discrimination measures. Although the independent impact of various stressors on mental health is documented, the collective impact of multilevel intersectional stigma on mental health and mental healthcare engagement, including help-seeking attitudes and service utilization, remains under-examined.

Methods: A cross-sectional online survey was administered to 466 Black sexual minority emerging adults (ages 18–29; M = 23.9 years; 78% cisgender women, 11% transgender and gender diverse (TGD), 11% cisgender men). Multilevel intersectional stigma was assessed using the Intersectional Discrimination Index (InDI), capturing anticipated, everyday, and major (institutional) discrimination, alongside the LGBT People of Color Microaggressions Scale. Mental health outcomes included depression (PHQ-9), anxiety (GAD-7), and psychological well-being (SPWB-18). Mental healthcare engagement was assessed via help-seeking attitudes (MHSAS) and four past-year behavioral indicators: wanted, sought, received, and delayed services. Hierarchical multiple regression and logistic regression analyses were conducted.

Results: Each stigma type was independently associated with adverse mental health outcomes, aligning with minority stress theory. After accounting for all other stigma types, intersectional microaggressions (β = .16, p < .05) and everyday discrimination (β = .15, p < .05) remained significantly associated with depression, and this pattern held for anxiety as well (microaggressions: β = .14, p < .05; everyday discrimination: β = .19, p < .01). Anticipated discrimination was the only stigma type that remained significantly associated with lower psychological well-being in the full model (β = -.25, p < .001). For mental healthcare help-seeking attitudes, major discrimination was most strongly associated in the full model (β = -.19, p < .01). TGD participants reported significantly higher rates of microaggressions (M = 2.56 vs. 1.58 for cisgender women, p < .001) and anticipated discrimination (M = 3.55 vs. 2.90, p < .001) than their cisgender peers.

In regard to mental healthcare utilization, Everyday discrimination was the most consistently associated stigma type, with higher odds of wanting (OR = 1.11), seeking (OR = 1.07), and receiving mental healthcare services (OR = 1.08). All stigma types were independently associated with delaying care, with anticipated discrimination showing the strongest association (OR = 1.51, p < .001).

Implications: These findings reveal a paradox in which intersectional stigma increases Black queer emerging adults' perceived need for mental healthcare while also creating barriers to access. This tension is vital for social work practitioners to understand and address. Clients may seek care while holding unfavorable attitudes toward help-seeking and delaying services, not because of a lack of motivation or intent but because of intersectional oppression. The results highlight the inadequacy of single-axis approaches in research and practice. Clinicians must conduct intersectional assessments that consider the effects of racism, heterosexism, and cisgenderism and address intersectional barriers to services.