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. 2025 Dec;16(1):2479396.
doi: 10.1080/20008066.2025.2479396. Epub 2025 Jun 19.

Identity in turmoil: Investigating the morally injurious dimensions of minority stress

Andrew A Nicholson  1   2   3   4   5 , Sandhya Narikuzhy  2   5 , Jakub Wolf  6 , Mina Pichtikova  5   7 , Magdalena Siegel  6 , James Mirabelli  8 , Taylor Hatchard  5   9 , Niki Hosseini-Kamkar  2   3 , Ella Bawagan  2 , Sophia L Roth  10 , Christina Mutschler  1 , Ruth A Lanius  11   12 , Fardous Hosseiny  2 , Kristen Eckstrand  13 , Brigitte Lueger-Schuster  6
Affiliations

Identity in turmoil: Investigating the morally injurious dimensions of minority stress

Andrew A Nicholson et al. Eur J Psychotraumatol. 2025 Dec.

Abstract
in English, Spanish

Background: Sexual and gender minorities (SGMs) are at an increased risk for developing mental health disorders due to their socially stigmatized identities. Minority stress (i.e. discrimination, identity nondisclosure, internalized stigma) has been shown to impact mental health outcomes among SGMs. Both distal and proximal minority stressors may serve as potentially morally injurious events (PMIEs), which may lead to moral injury and trauma/stressor-related symptoms. Critically, minority stress-related moral injury among SGMs has never before been explored using a mixed-methods approach.Methods: Thirty-seven SGM participants with diverse minority identities participated in the study. Using a convergent parallel mixed-methods design, we conducted semi-structured qualitative interviews, performed clinical assessments, and administered a comprehensive battery of quantitative measures. Here, we modified the Moral Injury Event Scale (MIES) for use with SGMs. Qualitative themes were extracted and then converged with MIES scores to investigate differential thematic presentations based on the quantitative intensity of SGM-related PMIEs.Results: Data analysis indicated four core themes related to moral injury among SGMs: shame (internalizing stigma), guilt, betrayal/loss of trust, and attachment injuries (rejection, altered sense-of-self, and social cognition). The qualitative presentation of these themes differed depending on MIES severity. Attachment injuries emerged as a unique core feature of moral injury among SGMs, whereby the remaining core themes align with previous moral injury research. Furthermore, quantitative analyses revealed that the level of exposure to and intensity of minority stress-related PMIEs was positively associated with hazardous alcohol use and trauma-related symptoms.Conclusions: This is the first mixed-methods study to investigate minority stressors as PMIEs, highlighting how these experiences may contribute to symptoms of moral injury among SGMs. Moral injury may serve as a valuable framework for better understanding trauma-related symptoms and mental health disparities among SGMs. These findings have the potential to inform novel treatment interventions aimed at addressing mental health burdens among SGMs.

Antecedentes: Las minorías sexuales y de género (SGMs, por sus siglas en inglés) tienen un mayor riesgo de desarrollar trastornos de salud mental debido a sus identidades socialmente estigmatizadas. De hecho, se ha demostrado que el estrés de las minorías (es decir, la discriminación, la opresión, las microagresiones, la no divulgación de la identidad y el estigma internalizado) impacta directamente en los resultados de salud mental de las SGMs. Es importante destacar que tanto los factores de estrés de minoría distales como los proximales pueden actuar como eventos potenciales moralmente perjudiciales (PMIE, por sus siglas en inglés), lo que puede conducir a lesiones morales y síntomas relacionados con el trauma o el estrés. Sin embargo, hasta ahora, nunca se había explorado las características fundamentales del daño moral relacionado con el estrés de las minorías en las SGMs utilizando un enfoque de métodos mixtos.

Métodos: Treinta y siete participantes SGM con diversas identidades raciales y étnicas interseccionales participaron en el estudio. Usando un diseño de métodos mixtos paralelos convergentes, realizamos entrevistas cualitativas semiestructuradas para examinar experiencias interseccionales con factores de estrés de minoría. También administramos evaluaciones clínicas semiestructuradas y una batería de medidas cuantitativas para evaluar síntomas relacionados con la salud mental. Aquí, modificamos la Escala de Eventos de Daño Moral (MIES, por sus siglas en inglés) para su uso con SGMs. Se extrajeron temas cualitativos relacionados con el daño moral y luego se integraron con las puntuaciones de MIES para investigar diferencias en la presentación temática según la intensidad cuantitativa de los PMIE relacionados con las SGMs.

Resultados: Nuestro estudio reveló cuatro temas principales relacionados con el daño moral en las SGMs: vergüenza (internalización del estigma), culpa, traición/pérdida de confianza, lesiones en el apego (rechazo, alteración del sentido de sí mismo y cognición social). Cabe destacar que la presentación cualitativa de estos temas varió según la gravedad de MIES. Las lesiones en el apego surgieron como una característica distintiva del daño moral en las SGMs, mientras que los demás temas principales se alinean con estudios previos sobre daño moral en otras poblaciones. Además, los análisis cuantitativos revelaron que el nivel de exposición e intensidad de los PMIE relacionados con el estrés de minoría se asociaron positivamente con el consumo riesgoso de alcohol y los síntomas relacionados con el trauma.

Keywords: Estrés de las minorías; Minority stress; attachment injuries; betrayal; culpa; daño moral; gender minorities; guilt; lesiones en el apego; minorías de género; minorías sexuales; moral injury; sexual minorities; shame; traición; vergüenza.

Plain language summary

The study identified four core themes related to moral injury among sexual and gender minorities: shame, guilt, betrayal/loss of trust, and attachment injuries.The intensity of minority stress-related moral injury was positively associated with hazardous alcohol use and trauma-related symptoms.This is the first mixed-methods study to explore dimensions of moral injury related to minority stress among sexual and gender minorities.

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Conflict of interest statement

No potential conflict of interest was reported by the author(s).

Figures

Figure 1.
Figure 1.
Summary of convergent parallel mixed-methods design. Abbreviations: MIES = moral injury event scale, PMIEs = potentially morally injurious events, SGM = sexual and gender minority.
Figure 2.
Figure 2.
Life Events Checklist for DSM-5. Notes: Each row corresponds to an event type, each column corresponds to the way in which a participant experienced the event (e.g. happened directly to them, witnessed it, learned about it happening to a close family member or close friend etc.), and each cell represents the percentage of respondents for the given category. The color intensity represents the percentage value, with red indicating higher percentages. Results were rounded to zero decimal places. All participants had either directly or indirectly experienced one of the events mentioned in the LEC-5.
Figure 3.
Figure 3.
Mental health diagnostic profile of the sample as captured by the DART. Notes: Figure 3 represents the results of the DART clinical assessment for the sample. Orange bars represent participants who met criteria for a probable mental health disorder diagnosis, yellow bars represent participants who were subthreshold, and grey bars represent participants who did not meet criteria. Abbreviations: DART = Diagnostic Assessment Research Tool.
Figure 4.
Figure 4.
MIES severity & shame. Note: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of shame are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.
Figure 5.
Figure 5.
MIES severity & guilt. Notes: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of guilt are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.
Figure 6.
Figure 6.
MIES severity & betrayal/loss of trust. Notes: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of betrayal/loss of trust are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.
Figure 7.
Figure 7.
MIES severity & attachment injuries. Note: This figure displays participants’ scores on the SGM-modified MIES, organized from low to high scores (measuring exposure to and perceived intensity of SGM-based PMIEs). Individuals belonging to the low group are highlighted in green and those in the high group are denoted in orange. Participants whose quotes are highlighted in the results section below to illustrate themes of attachment injuries are indicated with arrows in the graph above. Abbreviations: MIES = Moral Injury Event Scale, PMIEs = Potentially Morally Injurious Events.
Figure 8.
Figure 8.
Morally injurious dimensions of minority stress. Note: Summary illustration of the four core components of moral injury that were identified in the current study as being related to minority stress among SGMs. Illustration designed by Hey Chels Studio Inc.
See this image and copyright information in PMC

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