Is Body Appreciation a Moderator of Women's Satisfaction and Distress with the Body Changes that Occur after Breast Cancer Surgery? A One-Year Longitudinal Study.

Women with breast cancer show dissatisfaction with their appearance, a perception of loss of femininity and bodily integrity, and dissatisfaction with the outcome of the surgery. Body Appreciation (BA) is defined as positive attitudes toward one's body, beyond satisfaction and dissatisfaction with one's appearance. Although studies about the protective role of BA have increased, to the best of our knowledge, there are no published studies on the association between BA, body dissatisfaction, and distress in participants with breast cancer. The aims of this study are: (a) To analyze whether BA is a moderator of satisfaction with the body from before breast surgery to the one-year follow-up; and (b) to analyze whether BA is a moderator of distress from before breast surgery to the one-year follow-up. The sample consisted of 115 women diagnosed with breast cancer. Several hierarchical regression analyses were conducted. The results indicated that BA moderated the association between the appearance evaluation before the surgery and the appearance evaluation 12 months after the surgery. Although BA was a significative predictor of distress, it was not a moderator of distress from the moment before breast surgery to the one-year follow-up. This study highlights the importance of evaluating the construct of BA in participants with breast cancer using longitudinal designs and developing psychological interventions that focus on increasing BA.

Validation of the translated Negative Physical Self Scale in a sample of Asian women living in Canada.

OBJECTIVES: Body dissatisfaction is often linked to the internalization of Western beauty standards. Existing measures of body dissatisfaction, developed in Western societies, may fail to capture complex variations across ethnicities and cultures. The Negative Physical Self Scale (NPSS) assesses cognitive, affective, perceptual, and behavioural facets of body dissatisfaction. While unique in its consideration of Chinese ideals of body image, the NPSS has recently been translated and validated in a North American sample. The English-translated version of the NPSS has the potential to be an appropriate body dissatisfaction assessment tool for Asian women living in North America. The current study aims to validate the NPSS in an Asian female population living in Canada. METHODS: A sample of 899 undergraduate women residing in Canada with self-identified Asian ethnicity completed an online survey consisting of the NPSS and other measures of body dissatisfaction. RESULTS: An initial confirmatory factor analysis indicated that the four-factor structure of the NPSS, previously suggested in a primarily non-Asian North American sample, was a poor fit for the data. A second-order multidimensional model, based on a model proposed during the original development of the NPSS in a Chinese sample, indicated good fit once items were removed due to loadings < .60. High internal consistency between subscales and strong convergent validity with other measures were demonstrated. Notably, the NPSS Body Concern subscale demonstrated high convergence with other popular measures of body dissatisfaction and has the potential for use as a brief measure of body dissatisfaction among North American Asian females in clinical and research settings. CONCLUSIONS: The NPSS provides a valid assessment of body dissatisfaction among a sample of Asian women living in Canada, a specific subpopulation that has not been previously investigated. The findings highlight the importance of developing culturally sensitive measures of body dissatisfaction for differing ethnic and cultural groups.

Eating Disorder Risks Associated with Time Spent Using Social Media at an AMREC Population in the Coal Mining Region of Santa Catarina.

Comparing one's appearance to other people's and believing in an ideal body shape can negatively impact an individual. The probability of developing ED in individuals with high body dissatisfaction is higher than in the general population, leading to long-term emotional and metabolic damage. Populational studies on the prevalence of ED in Brazil are scarce in the literature. The research was carried out through the Google Forms website and evaluated risk of eating disorders through the Eating Attitude Test, degree of body dissatisfaction in the sample through the Body Shape Questionnaire and the Internet Addiction Test was used to evaluate time spent on the internet. The results showed that 84.5% of the sample were female and 62.3% of the individuals had eutrophic by the Body Mass Index. About 40.2% of the population studied had abnormal attitudes towards food, indicating a possible risk of developing ED, and 62.5% of the sample did not show body dissatisfaction. Regarding internet use, 10.8% had problematic internet use. The presence of risky eating attitudes was more prevalent in participants dissatisfied with their bodies. In addition, participants with problematic internet use had a higher risk for EDs.

Body dissatisfaction and beyond: Investigating attitudes towards calorie labels on UK food menus.

In 2022 the British government made calorie labels on menus a legal requirement to encourage healthier food choices while dining out. Yet, little research has explored perceptions of calorie labels on menus in the United Kingdom or tested whether there may be groups of people vulnerable to potential negative effects of calorie labels, such as those with body dissatisfaction. This between-subjects, convergent mixed-methods study addressed these enquiries. Participants were 562 adults who completed an online survey where hypothetical food orders were made from a menu. The study found that participants who viewed a menu with calorie labels ordered fewer calories. Quantitative results did not find that participants with higher levels of body dissatisfaction were at significantly greater odds of using calorie labels to order fewer calories. However, our qualitative (thematic) analysis revealed that experiences of calorie labels could be shaped by body image concerns. Themes further drew on how calorie labels were empowering, but there were also concerns about their oversimplicity. Findings are discussed in relation to implications for future calorie labelling policies. Given the inconsistent findings amongst the limited amount of literature investigating the role of body dissatisfaction in how calorie labels are used, future research is crucial. In the meantime, as a cautionary measure, clinicians involved in supporting individuals with body or food-related concerns should be aware of the challenges their clients may experience in facing calorie labels on menus when dining out.

Size Matters? Penis Dissatisfaction and Gun Ownership in America.

In this study, we formally examine the association between penis size dissatisfaction and gun ownership in America. The primary hypothesis, derived from the psychosexual theory of gun ownership, asserts that men who are more dissatisfied with the size of their penises will be more likely to personally own guns. To test this hypothesis, we used data collected from the 2023 Masculinity, Sexual Health, and Politics (MSHAP) survey, a national probability sample of 1,840 men, and regression analyses to model personal gun ownership as a function of penis size dissatisfaction, experiences with penis enlargement, social desirability, masculinity, body mass, mental health, and a range of sociodemographic characteristics. We find that men who are more dissatisfied with the size of their penises are less likely to personally own guns across outcomes, including any gun ownership, military-style rifle ownership, and total number of guns owned. The inverse association between penis size dissatisfaction and gun ownership is linear; however, the association is weakest among men ages 60 and older. With these findings in mind, we failed to observe any differences in personal gun ownership between men who have and have not attempted penis enlargement. To our knowledge, this is the first study to formally examine the association between penis size and personal gun ownership in America. Our findings fail to support the psychosexual theory of gun ownership. Alternative theories are posited for the apparent inverse association between penis size dissatisfaction and personal gun ownership, including higher levels of testosterone and constructionist explanations.

Translation and validation of a Romanian version of the Breast Appreciation Scale (BrAS).

The 9-item Breast Appreciation Scale (BrAS; Swami et al., 2022) is a recently developed instrument that assesses a woman's positive breasted experiences. To date, however, the psychometric properties of the BrAS have only been investigated in English-speaking women. Here, we report on the translation and validation of a novel, Romanian version of the BrAS. A total of 555 cisgender women from Romania completed a Romanian translation of the BrAS along with additional measures of body image and psychological well-being. Exploratory and confirmatory factor analysis identified a stable unidimensional model of the BrAS, with all nine items retained. Additionally, the Romanian BrAS evidenced complete invariance (i.e., through to latent mean invariance) across mothers and non-mothers, though mothers had higher observed scores than non-mothers. Evidence of convergent, concurrent, and incremental validity was very strong when based on observed BrAS scores, but slightly weaker when based on latent BrAS scores. In particular, greater latent breast appreciation was significantly associated with higher body appreciation, lower breast size dissatisfaction, and higher self-esteem. Overall, these results suggest that the psychometric properties of the Romanian BrAS are robust and that the instrument can be effectively deployed in this linguistic context.

Probing corporeal awareness in women through virtual reality induction of embreathment illusion.

We capitalized on the respiratory bodily illusion that we discovered in a previous study and called 'Embreathment' where we showed that breathing modulates corporeal awareness in men. Despite the relevance of the issue, no such studies are available in women. To bridge this gap, we tested whether the synchronization of avatar-participant respiration patterns influenced females' bodily awareness. We collected cardiac and respiratory interoceptive measures, administered body (dis)satisfaction questionnaires, and tracked participants' menstrual cycles via a mobile app. Our approach allowed us to characterize the 'Embreathment' illusion in women, and explore the relationships between menstrual cycle, interoception and body image. We found that breathing was as crucial as visual appearance in eliciting feelings of ownership and held greater significance than any other cue with respect to body agency in both women and men. Moreover, a positive correlation between menstrual cycle days and body image concerns, and a negative correlation between interoceptive sensibility and body dissatisfaction were found, confirming that women's body dissatisfaction arises during the last days of menstrual cycle and is associated with interoception. These findings have potential implications for corporeal awareness alterations in clinical conditions like eating disorders and schizophrenia.

Enhancing body image satisfaction and well-being among early adolescents: Feasibility and preliminary outcomes of the mind. body. voice. program.

Although most research has emphasized high-school and college-aged women, body dissatisfaction and eating disorder behavior are also a concern for middle-school girls. We partnered with Girls Inc., a community-based organization to explore feasibility and preliminary outcomes of the mind. body. voice. (m.b.v.) program with a middle-school-aged cohort. The program was collaboratively designed with youth, focusing on body image satisfaction, disordered eating risk factors, and mental health and well-being. The work occurred during the COVID-19 pandemic, offering a unique opportunity to assess the promise of the program under difficult extenuating circumstances. In an open-trial design, we assessed change from pre- to post-program administered with two cohorts, one delivered remotely in 2020 (n = 17) and one in-person in 2021 (n = 13). Findings indicated that participation in the m.b.v. program was associated among both cohorts with significant decreases in negative body judgment and adherence to cultural appearance biases, and significant increases in body awareness, agency, and positive self-regard, as well as significant reductions in negative affect. Results support the feasibility and promise of both remote and in-person administration of the program targeting young adolescents, and in partnership with a well-established community-based organization.

#WhatIEatInADay: The effects of viewing food diary TikTok videos on young adults' body image and intent to diet.

The rise of short-form video content has prompted research into its impact on body image; however, little remains known regarding the effects of exposure to food-related content of this type. The present study aimed to fill this gap in the literature by conducting a between-subjects experiment (N = 316) examining the effects of exposure to low-calorie versus high-calorie "What I Eat in A Day" food diary TikTok videos on young adults' body appreciation, body dissatisfaction, and diet intentions. Additionally, this study sought to explore how social comparison and mood might affect participants' responses to these videos. Results indicate that social comparison mediated the relationship between video type (low- vs high- calorie) and positive mood, such that low-calorie videos increased upward social comparison and decreased positive mood, and high-calorie videos increased downward social comparison and increased positive mood. Positive direct effects of positive mood on body appreciation and diet intentions occurred, and a negative direct effect on body dissatisfaction was found. Additionally, positive mood mediated the path from social comparison to diet intentions. These findings highlight the importance of further research into the nuanced impacts of food diary social media content on young adults' body image and behaviors.

Passive social networking sites use and disordered eating behaviors in adolescents: The roles of upward social comparison and body dissatisfaction and its sex differences.

Previous research has indicated a link between social networking site (SNS) use and eating behaviors, but the underlying mechanisms have not been well explored. This study investigated the role of upward social comparison and body dissatisfaction in the relationship between passive SNS use and disordered eating (DE) behaviors, as well as sex differences. A total of 744 middle school students (51.6% female, Mage = 12.87 years, SD = 0.68) completed self-report questionnaires regarding passive SNS use, upward social comparison, body dissatisfaction, and DE behaviors. Results revealed that: 1) girls reported significantly higher levels of passive SNS use, body dissatisfaction, and DE behaviors than boys; 2) passive SNS use was a significant predictor of DE behaviors both sexes; 3) body dissatisfaction mediated the relationship between passive SNS use and DE behaviors for girls; 4) the chain mediating effects of upward social comparison and body dissatisfaction between passive SNS use and DE behaviors were found only among adolescent girls; 5) Compared to boys, body dissatisfaction in girls is more significantly related to DE behaviors, and upward social comparison is more closely related to body dissatisfaction in girls. These findings suggest that passive SNS use, rather than general SNS use, was related to body dissatisfaction and eating concerns. Interventions targeting specific passive SNS users may be an effective avenue for the prevention and management of body-related concerns and disordered eating behavior in adolescent girls.

Attachment style to body dissatisfaction, restrained eating, and disordered eating in adolescent girls: Differential weight communication mediators.

Body dissatisfaction and eating behaviors are disproportionately elevated amongst adolescent girls. Family relationships represent a context in which adolescent girls' body image issues emerge. Thus, we integrated attachment and confirmation theories to examine whether weight related supportive messages (i.e., acceptance and challenge) mediated the relationship between attachment style (i.e., anxiety and avoidance) and body image outcomes (i.e., body dissatisfaction (BD), restrained eating (RE), and disordered eating (DE)). Acceptance refers to weight related support that is characterized by warmth and accepting messages; challenge refers to weight related support that is characterized by instrumental assistance and problem-solving messages. A sample of 106 adolescent girls, ages 11 to 21, completed self-report measures on attachment (Relationship Structures Questionnaire), acceptance and challenge (weight related Parental Behavior Questionnaire), body dissatisfaction (Eating Disorders Inventory), and eating behaviors (Dutch Eating Behavior Questionnaire; Eating Disorder Diagnostic Scale). Attachment anxiety directly related to all body image outcomes, whereas attachment avoidance only directly related to RE. Attachment avoidance only related to BD and DE indirectly through perceived acceptance. Those with high anxiety endorsed lower perceived challenge, whereas avoidant individuals endorsed lower perceived acceptance and challenge. We concluded that attachment dimension characteristics to be either hyperactivated regarding relationships (i.e., anxiety), or deactivated and distant (i.e., avoidance), are associated with how individuals perceive support, and in turn, are related to body image and eating behavior outcomes. Further, we clarify the differential roles of acceptance and challenge. Although both supportive, acceptance encompasses a layer of warmth that is more meaningful in body image, particularly for avoidantly attached individuals. By integrating qualities of attachment and supportive weight communication, we reveal that potential pathways of attachment to body image and eating behaviors.

Development of a visual-perceptual method to assess body image: A cross-cultural validation in Canadian and Spanish women.

The objectives of this study were (a) to explore the preliminary cross-cultural validity of a visual-perceptual method to assess body image; (b) to examine potential differences and similarities in body image phenomena between women from two Western countries (i.e., Canada and Spain). 201 self-identified women participated in this cross-sectional study. Ideal, normal, and self-perceived body sizes were assessed using a visual-perceptual method, whereas body dissatisfaction was measured using both a visual-perceptual method and a questionnaire. Visual-perceptual body dissatisfaction was significantly correlated with questionnaire body dissatisfaction, suggesting a preliminary convergent validity between the two assessment methods. Women in both countries were dissatisfied with their bodies. Compared to their self-perceived body, all women chose a significantly thinner visual representation of their "normal" and ideal body. These results may suggest a shift towards the "thin" body as not only ideal, but also normative. This study provides the first evidence for the cross-cultural validity of a visual-perceptual body image assessment tool. The results of the current study confirm the presence of "normative discontent", and suggest more cross-country similarities than differences among women from these two Western societies.

Daily instability in body dissatisfaction in individuals with and without eating disorders.

Body dissatisfaction (BD) includes negative thoughts and feelings about one's body shape. Although typically assessed as a trait, BD has been found to fluctuate within a day. The present study examined whether daily instability in BD differs according to trait BD, eating disorder (ED) diagnosis, and engagement in maladaptive exercise. Participants with EDs (n = 166) and controls (n = 44) completed a self-report measure of trait BD and reported BD and engagement in maladaptive exercise five times daily for 14 days as part of an ecological momentary assessment protocol. BD instability was calculated as adjusted mean squared successive difference. On average across assessments, participants with EDs reported a 16% change in their BD ratings between consecutive assessments, which was significantly higher than the 12% change in controls. Trait BD was significantly inversely associated with BD instability in individuals with EDs, but not in controls. BD instability did not differ across ED diagnoses or between days with versus without maladaptive exercise. Findings suggest that BD is a dynamic state that varies within a day, especially in participants with EDs. Further research is needed to clarify whether this heightened instability in BD is a clinically relevant factor underlying ED symptoms.

Exploring the associations between muscularity teasing and eating and body image disturbances in Chinese men and women.

This study described muscularity teasing in both men and women and explored its associations with eating and body image disturbances in adults from China. A total of 900 Chinese adults (50% women) were recruited online. Correlation and regression analyses were conducted to examine the relationships between muscularity teasing and a battery of measures on eating and body image disturbances. Gender differences in the associations were examined. Men reported more muscularity teasing than women (31.6% men vs. 15.6% women; χ2(1,N = 900) = 31.99, p < .001). Muscularity teasing was significantly and positively correlated with all measures in both men and women. Muscularity teasing explained significant, unique variance in all measures for men and women, except for body fat dissatisfaction in women, beyond covariates (i.e., age, body mass index, and weight teasing). The relationships between muscularity teasing and eating and body image disturbances were generally stronger in men than women. Findings further suggest that muscularity teasing is an important factor related to eating and body image disturbances in men and women, but muscularity teasing might be more detrimental to men's eating behaviors and body image. Future research is needed to further explore the directionality and mechanisms of the links between muscularity teasing and eating and body image disturbances.

Psychometric evaluation of a revised version of the body appreciation scale-2 for autistic adults (BAS-2A).

Emerging evidence points to unique conceptualisations of positive body image in autistic individuals. However, there are no existing measures of positive body image that have been developed or validated for use with autistic adults. To rectify this, we developed a revised version of the BAS-2 - the BAS-2A - and examined its factorial validity and psychometric properties in a sample of autistic adults from the United Kingdom. Based on the results of exploratory factor analysis and scale purification, we extracted a 12-item, unidimensional model of BAS-2A scores in a first split-subsample (n = 273). Confirmatory factor analysis supported the unidimensional model of BAS-2A scores in a second split-subsample (n = 277). BAS-2A scores presented adequate composite reliability, measurement invariance across gender identity, and patterns of construct validity. For both women and men, BAS-2A scores correlated positively with self-esteem, well-being, quality of life, and adaptive coping, and inversely with dietary restraint, weight/shape overvaluation, body dissatisfaction, and depression. Finally, BAS-2A scores demonstrated incremental validity, predicting self-esteem over-and-above body dissatisfaction. However, temporal stability of the BAS-2A over three weeks was not supported. These results support the BAS-2A as a psychometrically robust measure of body appreciation for use in autistic adults from the United Kingdom.

The impact of fitspiration comments on adult women's body dissatisfaction and negative affect.

The present study examined the impact of writing different types of comments in response to fitspiration (fitness inspiration) images on women's body dissatisfaction and negative affect. Women (N = 256) from the general population (age range: 18 to 49) were randomized to write one of three types of comments on the same fitspiration images: appearance (comment on the woman's appearance), functionality (comment on what the woman's body can do), or background (comment on the image background). Participants completed measures of state body dissatisfaction and negative affect pre- and post-exposure and measures of appearance comparison and functionality appreciation post-exposure. After controlling for pre-body dissatisfaction due to a baseline difference among groups, there was no difference among groups in body dissatisfaction at post-exposure. Negative affect decreased from pre- to post-exposure across all groups, but there was no difference by group or interaction by time and group. The background group reported lower state appearance comparison than the appearance group. There were no group differences in functionality appreciation. Our results suggest that commenting on image backgrounds might decrease appearance comparison relative to making appearance comments and that writing comments on appearance, functionality, or the background in response to fitspiration may be beneficial for mood.

A pre-post evaluation of the impact of the Embrace Kids film on children's and adults' body image and self-compassion.

Given the prevalence of body dissatisfaction among young people, which tends to persist into adulthood, a need exists for large-scale interventions that address this problem. Film has been identified as a resource that is well-suited to large-scale dissemination, which can achieve broad impact and reach. Embrace Kids, a film aimed at improving young people's body image, is one such resource. To evaluate the film's impact on body image, 55 children (M = 10.59, SD = 1.49) and 47 adults (M = 43.75, SD = 8.54) were recruited from the Australian general public to complete a brief survey before and after viewing the film. After viewing the film, significant increases in state body appreciation, state functionality appreciation and state self-compassion were reported for children (d = 0.46 - 0.61) and adults (d = 0.88 - 1.08). They supported the safety of the film by indicating that it did not make them more concerned about their appearance. Findings provide initial support for the film as a scalable intervention that can be safely task-shifted to non-professional audiences. Future research directions include comparing the effect of Embrace Kids against a control film, and testing the longitudinal impact of the film on trait body image.

Eating Disorder Symptomatology Among Young Adult Cigarette and E-Cigarette Users.

Objective: Tobacco use is elevated among individuals with eating disorders (EDs). Yet, further research is needed to understand associations between cigarette and e-cigarette use patterns and ED symptomatology. To gain a more comprehensive understanding of tobacco use and EDs, this study characterized ED symptomatology and tobacco use patterns, including exclusive cigarette use, e-cigarette use, dual use, and nonuse. Method: Young adults aged 18-24 years who self-reported exclusive cigarette, e-cigarette, dual, or nonuse (N = 2500) were recruited via Lucid, an online survey management company. Participants completed questionnaires assessing body dissatisfaction, global ED psychopathology, binge eating and self-induced vomiting frequency, and demographics. ED diagnostic groups included: anorexia nervosa (AN), bulimia spectrum eating disorders (BSED), atypical AN, and night eating syndrome (NES). Results: Multinomial logistic models revealed those with AN were more likely to be dual users, those with atypical AN were more likely to be exclusive e-cigarette users, and participants with a BSED or NES were more likely to be exclusive e-cigarette or dual users, compared to those without an ED. General linear models suggested body dissatisfaction and global ED psychopathology were higher among exclusive e-cigarette and dual users, while binge eating and self-induced vomiting frequencies were greater among all tobacco use groups compared to nonusers. Discussion: Our findings suggest young adults with ED symptomatology were more likely to be users of e-cigarettes exclusively or dual users. It will be necessary to examine how these associations manifest using longitudinal and clinical populations in future research.

Adverse childhood experiences, low self-esteem, and salient stimulus response in eating disorders.

BACKGROUND: Adverse childhood experiences (ACEs) are elevated in individuals with eating disorders (EDs), but how the neurobiology of EDs and ACEs interact is unclear. METHODS: Women 18-45 years old with anorexia nervosa (AN, n = 38), bulimia nervosa (BN, n = 32), or healthy controls (n = 60) were assessed for ACEs and ED behaviours and performed a taste-conditioning task during brain imaging. Mediation analyses tested relationships between ACE score, self-esteem, and ED behaviours. RESULTS: ACE scores were elevated in EDs and correlated positively with body mass index (p = 0.001), drive for thinness (p = 0.001), and body dissatisfaction (p = 0.032); low self-esteem mediated the relationship between ACEs and body dissatisfaction, drive for thinness, and bulimia severity. ACE scores correlated negatively (FDR-corrected) with unexpected, salient stimulus receipt in AN (substantia nigra) and BN (anterior cingulate, frontal and insular cortex, ventral striatum, and substantia nigra). When ACE scores were included in the model, unexpected stimulus receipt brain response was elevated in EDs in the anterior cingulate and ventral striatum. CONCLUSIONS: ACEs attenuate unexpected salient stimulus receipt response, which may be a biological marker for altered valence or hedonic tone perception in EDs. Low self-esteem mediates the relationships between ACEs and ED behaviours. Adverse childhood experiences should be assessed in biological studies, and their effects targeted in treatment.

Changes in Gender Dysphoria, Interpersonal Minority Stress, and Mental Health Among Transgender Youth After One Year of Hormone Therapy.

PURPOSE: Cross-sectional studies have identified a strong link between interpersonal minority stress and mental health among transgender youth. However, very little is known about how experiences of minority stress change over time and how these changes relate to mental health. Further, few quantitative studies have examined the extent to which changes in gender dysphoria drive the improvements witnessed in mental health following gender-affirming medical treatment. METHODS: Transgender youth (N = 115; age 12-18) completed measures of interpersonal minority stress (e.g., family and peer support, parent support of gender, victimization), body dissatisfaction, and mental health (e.g., depression, anxiety, psychosocial functioning) at baseline and one year after initiating medical treatment with a multidisciplinary gender-affirming program. RESULTS: Significant reductions in body dissatisfaction, victimization, depression, and anxiety were found along with improvements in parent gender-related nonaffirmation and psychosocial functioning. Higher levels of baseline family support, parent gender-related acceptance, and lower levels of baseline victimization were associated with better mental health at one-year follow-up. Reductions in body dissatisfaction were also associated with fewer symptoms of depression and better psychosocial functioning and follow-up. DISCUSSION: Results provide further confirmation of the broad, short-term benefits of gender-affirming hormone therapy and highlight the importance of monitoring youth's experience of dysphoria while receiving treatment. Results also continue to highlight the importance of family support and suggest some forms of minority stress improve over time; however, the relationship between short-term changes in minority stress and mental health may be more complex.