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dumb-cdc · 8 days ago

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Putting a P-value on Pain

"I've had this thought for a while now."

I wrote this line in a draft from October 2024. And four months later, I can still say that I've had this thought for a while now.

In grad school, a visiting lecturer candidly said to my class --all of us queer public health students-- that "no one will believe your pain until it has a p-value."

It was a sobering reflection on the state of medicine and public health back in 2022. It has been a sobering lesson in my personal and professional life since. And it is a truth we face more than ever in 2025.

No one will believe your pain until it has a p-value.

For my master's thesis, I assessed the state of the literature on cardiometabolic risk in LGBT populations, with a specific focus on diabetes. In my final semester, I changed faculty advisors because I was tired of being told to care less about my research because I'm "not going to win a Nobel Prize for it." His words, from a man who could barely remember that I was his advisee for 2.5 years. The advisor I settled on was similarly uninterested in my research, forcing me to painstakingly explain what the hell I was even doing-- such as explaining that the theoretical concept of stress (a concept the entire LGBT Health department ran on) and cortisol are two different things. In 2025, the only faculty member who gave a shit doesn't even work there anymore.

Real cool stuff.

And a pretty status quo implementation of DEI that everyone against identity politics is so afraid of. AKA virtue signaling DEI practices that end up being incredibly useless and/or nonexistent, and carried out by people who are deeply inept and/or nonexistent.

All that said, I eked out a paper that I was proud of. And the findings are relevant to the current presidential administration's destruction of DEI in science. A trojan horse for the true end-goal: destroying America's scientific pursuits in the health and wellness of marginalized populations.

Destroying p-values.

Which brings us back to the truth handed down to me by a Black trans scientist: No one will believe your pain until it has a p-value.

When researchers observe health disparities and terrible outcomes in marginalized groups of people —but did not or could not measure the reason why— researchers end up positing that the reason is Minority Stress™️. This concept is defined as the stress burden of minority status, or the chronic stress of being positioned as a marginalized person in America. Stress makes you sick; stress takes a toll on the body. Stress kills.

In the LGBT Health literature, we love pointing to Minority Stress™️ as a possible confound, bitching and moaning about it in the discussion section of our papers, and then going ¯\_(ツ)_/¯ rather than devising a real, tangible way to measure Minority Stress™️. We'd rather leave it as a confound and kick the can down the road for someone else to deal with. And the joke is that no one wants to deal with it.

The few people who are trying to measure Minority Stress™️ are doing so within the framework of Stigma, asking: How do these stressors play out in the real world and how do they impact real people? Real people in real communities? Real people living inside real bodies?

It's a monumental task, but a necessary one to move the literature forward out of its current trappings of circular logic and poor research methodology.

So let's talk about 3 things that together would move the literature forward:

Minority Stress

Experienced Intersectional Stigma (EIS)

Allostatic Load

I'm going to copy/paste from my paper in the spirit of not being redundant in my labor outside of streamlining the jargon and citations. If you don't want to read academic text, skip ahead. My advisors already told me that no one cares, so you won't hurt my feelings.

1. Minority Stress

The minority stress model is heavily employed in the LGBT Health literature and continues to be developed and iterated upon [1][2]. Minority stress is a framework for understanding how anticipated, perceived, and experienced discrimination and victimization negatively impact the health of LGBT persons, driving health disparities and poor health outcomes [2][3]. In the LGBT physical health literature, the minority stress model positions the stress burden of minority status as both an exposure and a mediating variable on pathways producing observed physical health disparities in LGBT persons [3]. Minority stress can be conceptualized as a multilevel contributor to health disparities, impacting LGBT persons through proximal minority stressors (e.g. internalized homophobia, concealing LGBT status) and distal minority stressors (e.g. harassment, rejection) [3][4]. In a population health framework, minority stressors are created within and interact with “downstream” intermediate determinants of health (e.g. neighborhood- or community- level physical environment, healthcare service access) and “upstream” distal determinants of health (e.g. poverty, structural stigma, policy bias) [5]. Of the 19 articles included in this review, 10 referenced minority stress as a possible explanation for cardiometabolic health disparities observed in LGBT samples [4][6][7][8][9][10][11][12][13][14]. Of these studies, 8 posited that minority stress was an unmeasured covariate when traditional risk factors could not fully explain significant health differences between LGBT and non-LGBT persons for: diabetes [7][9][11][12], overweight and obesity [8][14], cardiovascular disease [8], myocardial infarction [6][8], and stroke [8][10]. The 2 remaining studies directly measured minority stress as an exposure in samples of sexual minority (LGB) cisgender men.

2. Experienced Intersectional Stigma (EIS)

In the first study, Mereish & Goldstein (2020) conducted an online survey among sexual minorities and found that proximal minority stressors were directly associated with higher odds of diabetes (p<0.01) and hypertension (p<0.05), as well as lower odds of physical activity (p<0.05); proximal stress was measured with the 5-item Revised Internalized Homophobia Scale. ** Note: All findings are statistically significant. (n = 670). ** The second study builds upon the minority stress model, investigating associations between experienced intersectional stigma (EIS) and multiple health outcomes in a cohort of sexual minority (LGB) cisgender men. Friedman et al., (2022) defined EIS as incidents having ≥2 identity-related attributions to the stigma and measured EIS to investigate differential types of stigma experienced by multiply marginalized persons (e.g. Black and gay or gay and HIV positive). EIS was measured using the 2-stage version of the Major Experiences of Discrimination Scale. Sexual minority status was significantly associated with experienced stigma: sexuality was the top identity targeted for stigmatization (35.2% of all incidents), with 71% of all stigma experienced in adulthood attributed to sexuality. Of those reporting EIS, 58.3% reported sexuality and another identity. EIS had major consequences on cardiometabolic health: those who reported EIS had significantly higher odds of diabetes (AOR = 1.40, 95% CI, 1.27-1.53), dyslipidemia (AOR = 1.11, 95% CI, 1.03-1.19), hypertension (AOR = 1.30, 95% CI, 1.23-1.38), and health care underutilization (AOR = 1.76, 95% CI, 1.61-1.93) [15]. ** Note: All findings are statistically significant. (n = 1,806). Compared to LGB cisgender men who did NOT report EIS, LGB cisgender men who reported EIS had: 40% higher odds of diabetes (projected range: 27-53%), 11% higher odds of dyslipidemia (projected range: 3-19%), 30% higher odds of hypertension (projected range: 23-38%), 76% higher odds of engaging healthcare at a lower rate/level than needed (projected range: 61-93%). ** Mereish & Goldstein (2020) and Friedman et al. (2022) demonstrate that, when measured in the study design, minority stress can be located in the body’s physiology and statistically associated with health disparities in LGBT persons. Such studies tangibly move the LGBT physical health literature forward in grounding minority stress in the empirical evidence of allostatic load, “the cumulative wear and tear on the body resulting from chronic exposure to stress” [9]. Allostatic load is rich ground for exploring cardiometabolic health in LGBT populations and bridging gaps in the literature between psychosocial and biological phenomena.

3. Allostatic Load

** Note: […] continued from the last paragraph above. ** Of the articles included in this review, three discussed minority stress and allostatic load as connected factors in cardiometabolic health [9][10][11]. Allostatic load is the cumulative result of bodily dysregulation in response to stressors; a high allostatic load will induce biological responses and physiologic pathways that increase disease risk [5]. In the context of type 2 diabetes and cardiometabolic health, high allostatic load has detrimental consequences: dysregulated biological pathways increase insulin resistance [9]; stress hormones inhibit insulin production and trigger the body to metabolize glucose in a heightened “flight or fight” mode [11]; epigenetic changes increase type 2 diabetes risk and worsen cardiometabolic risk factors [10]; and maladaptive coping behaviors increase the prevalence of behavioral cardiometabolic risk factors [9]. Establishing an empirical understanding of the association between bodily dysregulation and minority stress would advance the LGBT physical health literature in explaining disease burden in LGBT persons through a biopsychosocial framework; that is, elucidating the interactions of biological, psychological, and social factors and their resulting health impact.

tl;dr being positioned as a minority in America is a silent killer unto itself-- the experience of being marginalized 24/7 dysregulates the body and degrades it in statistically significant ways. In the medical sense, the body becomes more fragile.

Imagine that the body is a gearbox: a series of circular wheels that are different sizes, move in different directions, move at different rates, require/exert different amounts of force, and are aligned so that they interconnect, functioning as a cohesive unit. Varying levels of bodily dysregulation is akin to altering any of these elements in the gearbox. The whole system will degrade over time, more acutely and significantly based on the accrued damage-- the cumulative wear and tear on the system.

Let's move this metaphor into the human body through the concept of epigenetics, which is often used to describe the empirical ways in which the external factors (environmental, behavioral, psychological, etc.) change our physiology all the way down to the molecular level.

Real cool stuff.

Stress dysregulates the body and changes us in foundational ways, literally changing the building blocks of what keeps us alive: DNA. One aspect of epigenetics is the concept of DNA methylation. Stress changes the patterns by which methyl groups (small carbon molecules) attach to our DNA. DNA hangs out in our cells wrapped around balls of proteins-- until it is time to unwind into the recognizable double-helix strand that can be unzipped and duplicated. Methyl groups keep DNA compressed around these proteins, wound up tight and inaccessible. This effectively turns OFF spans of DNA that were previously ON (able to be unzipped and duplicated).

Disrupting DNA through methylation can have devastating consequences. For example, there are stretches of DNA that downstream turn ON/OFF genes that slow down the growth of cancer cells or instead turn ON/OFF genes that dramatically speed up this growth. From an epigenetics angle alone, we can observe some far-reaching consequences of chronic stress-- from the cellular level to tissues to organs to organ systems. The wear and tear on the body compounds until it kills the entire organism ¯\_(ツ)_/¯

On a more macro level, where we investigate community and population -level outcomes, the health consequences of bodily dysregulation start to confront us in perplexing ways: How come healthy LGBT people are having strokes when less healthy cis- and straight- people aren't? Why do queer women have a 40% higher risk of breast cancer at younger ages when cancer risk traditionally increases with age? Why do LGBT people with diabetes have completely different risk profiles than what we've come to expect after decades of treatment and research?

Dr. Rupa Marya and Raj Patel released a fascinating book in April 2024 titled "Inflamed: Deep Medicine and the Anatomy of Injustice." Dr. Marya discusses her book on this podcast episode of New Books in Medicine. She is someone deeply involved in movement work and interested in locating stress in the body-- specifically seeking to locate chronic stress caused by marginalization in oppressed bodies. And explaining why and how we are dying from it.

I wish for this work to be integrated into the field of LGBT Health more broadly: To take together the scientific evidence of allostatic load in the medical sciences and the growing body of literature around stigma in the behavioral health sciences, and combine the two.

Why?

Because no one will believe your pain until it has a p-value.

Citations

[1] Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 38-56.

[2] Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological bulletin, 129(5), 674.

[3] Flentje, A., Clark, K. D., Cicero, E., Capriotti, M. R., Lubensky, M. E., Sauceda, J., Neilands, T. B., Lunn, M. R., & Obedin-Maliver, J. (2022). Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships. Annals of Behavioral Medicine, 56(6), 573-591. https://doi.org/10.1093/abm/kaab051

[4] Mereish, E. H., & Goldstein, C. M. (2020). Minority Stress and Cardiovascular Disease Risk Among Sexual Minorities: Mediating Effects of Sense of Mastery. Int J Behav Med, 27(6), 726-736. https://doi.org/10.1007/s12529-020-09919-z

[5] Diaz-Thomas, A. M., Golden, S. H., Dabelea, D. M., Grimberg, A., Magge, S. N., Safer, J. D., Shumer, D. E., & Stanford, F. C. (2023). Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab, 108(7), 1533-1584. https://doi.org/10.1210/clinem/dgad124

[6] Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circ Cardiovasc Qual Outcomes, 12(4), e005597. https://doi.org/10.1161/circoutcomes.119.005597

[7] Beach, L. B., Elasy, T. A., & Gonzales, G. (2018). Prevalence of Self-Reported Diabetes by Sexual Orientation: Results from the 2014 Behavioral Risk Factor Surveillance System. LGBT Health, 5(2), 121-130. https://doi.org/10.1089/lgbt.2017.0091

[8] Caceres, B. A., Jackman, K. B., Edmondson, D., & Bockting, W. O. (2020). Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014–2017 BRFSS. Journal of behavioral medicine, 43(2), 329-338. https://doi.org/10.1007/s10865-019-00102-8

[9] Corliss, H. L., VanKim, N. A., Jun, H. J., Austin, S. B., Hong, B., Wang, M., & Hu, F. B. (2018). Risk of type 2 diabetes among lesbian, bisexual, and heterosexual women: Findings from the nurses’ health study II [Article]. Diabetes Care, 41(7), 1448-1454. https://doi.org/10.2337/dc17-2656

[10] Diaz, M. A., & Rosendale, N. (2023). Exploring Stroke Risk Factors and Outcomes in Sexual and Gender Minority People [Article]. Neurology: Clinical Practice, 13(1). https://doi.org/10.1212/CPJ.0000000000200106

[11] Liu, H., Chen, I. C., Wilkinson, L., Pearson, J., & Zhang, Y. (2019). Sexual Orientation and Diabetes During the Transition to Adulthood. LGBT Health, 6(5), 227-234. https://doi.org/10.1089/lgbt.2018.0153

[12] Newlin Lew, K., Dorsen, C., & Long, T. (2018). Prevalence of Obesity, Prediabetes, and Diabetes in Sexual Minority Men: Results From the 2014 Behavioral Risk Factor Surveillance System. Diabetes Educ, 44(1), 83-93. https://doi.org/10.1177/0145721717749943

[13] Rivera, A. S., Plank, M., Davis, A., Feinstein, M. J., Rusie, L. K., & Beach, L. B. (2022). Assessing widening disparities in HbA1c and systolic blood pressure retesting during the COVID-19 pandemic in an LGBTQ+-focused federally qualified health center in Chicago: a retrospective cohort study using electronic health records. BMJ Open Diabetes Res Care, 10(6). https://doi.org/10.1136/bmjdrc-2022-002990

[14] Stupplebeen, D. A., Eliason, M. J., LeBlanc, A. J., & Sanchez-Vaznaugh, E. V. (2019). Differential Influence of Weight Status on Chronic Diseases by Reported Sexual Orientation Identity in Men. LGBT Health, 6(3), 126-133. https://doi.org/10.1089/lgbt.2018.0167

[15] Friedman, M. R., Liu, Q., Meanley, S., Haberlen, S. A., Brown, A. L., Turan, B., Turan, J. M., Brennan-Ing, M., Stosor, V., Mimiaga, M. J., Ware, D., Egan, J. E., & Plankey, M. W. (2022). Biopsychosocial Health Outcomes and Experienced Intersectional Stigma in a Mixed HIV Serostatus Longitudinal Cohort of Aging Sexual Minority Men, United States, 2008‒2019. American journal of public health, 112, S452-S462.

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