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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Prof Psychol Res Pr. Author manuscript; available in PMC 2011 April 1.
Published in final edited form as:
Prof Psychol Res Pr. 2010 April 1; 41(2): 104–111.
doi:  10.1037/a0015805
PMCID: PMC2860327

Masculine Gender Role Conflict and Negative Feelings about Being Gay

Francisco J. Sánchez
UCLA School of Medicine
John S. Westefeld and William Ming Liu
University of Iowa


Professional psychologists who work with gay men have noted that traditional masculine ideals play a prominent role in the gay community whereby some endorse these traditional ideals and stigmatize effeminate behavior by other gay men. One hypothesis is that this behavior reflects negative feelings about being gay. This article examined this hypothesis by reporting the results of an online survey of 622 self-identified gay men. Participants completed the Gender Role Conflict Scale, Lesbian and Gay Identity Scale, the Social Desirability Scale, and questions related to the importance of masculinity. Results showed that most participants valued the public appearance of masculinity; and they ideally wished to be more masculine than they felt they were (Cohen’s d = 0.42). A multiple regression analysis showed that the degree to which they valued masculinity and were concerned with violating masculine ideals was positively related with negative feelings about being gay (Cohen’s f2 = .67). These findings highlight the importance of exploring the role that masculine ideals play in gay client’s lives given that negative feelings about oneself can adversely affect psychological well-being.

Keywords: Anti-femininity, Straight-acting, Internalized homophobia, Internalized heterosexism, Self-esteem

What do you need to do to prove how much self-loathing there is [among gay men]? Just pick up any newspaper that has personal ads in it and look at how many say, “No Fats…No Femmes…Straight-Acting Seeking Same…In the Closet…Do Not Believe in the Gay Lifestyle.” Do you ever see an ad for a heterosexual saying, “Please Don’t Act Straight?”

                           —Harvey Fierstein (actor and playwright)

This Fierstein quote (as cited in Baim & Wockner, 1998) highlights a contentious aspect of gay male life: Many gay men endorse traditional masculinity and deride effeminate behavior in other gay men (Bailey, 1996; Taywaditep, 2001). While this may surprise professional psychologists who do not actively engage with the gay community, it is a topic that has received substantial attention in the popular gay press (e.g., Bergling, 2001; Cummings, 1999; Rice, 2006) and among academic scholars (e.g., Levine, 1992; Nardi, 2000). More importantly, practitioners who work with gay men have noted that traditional masculinity plays a prominent role in the lives of some of their clients (Haldeman, 2006; Schwartzberg & Rosenberg, 1998).

These observers often suggest that gay men who are overly concerned with masculinity are compensating for feelings of inferiority stemming from their sexual orientation. Is this proposed link with traditional masculine ideals (henceforth referred to as masculinity/masculine for simplicity) accurate? If so, how can practitioners address this issue with gay men, especially since it is well established that negative feelings about the self adversely affect psychological well-being (e.g., Frost & Meyer, 2009; Szymanski & Gupta, 2009)?

The goal of this article is to examine this issue. To accomplish this, we first provide a review of the limited peer-reviewed research. Then we provide results from a survey examining the importance of masculinity among gay men and its relationship to feelings about being gay. Finally, we provide clinical implications based on the survey results.

The Importance of Masculinity among Gay Men

In the United States, the dominant masculine ideal is embodied by dated iconic images of men such as the rugged “Marlboro Man” who represents the tough, masculine persona of the American West (Pleck, 1995). O’Neil (1981a, 1981b) suggested that this idealized image stems from a fear of appearing feminine and “weak.” This fear perpetuates four ideal masculine standards: men should be successful, powerful, and competitive; men should conceal their emotions; men should avoid affection with other men; and men should put school/work before other interests. For many men, this masculine ideal becomes central to their identity and subsequently affects their self-concept and interpersonal relationships (O’Neil, 2008).

To date, most peer-reviewed studies on masculinity have focused on the experience of heterosexual men. The absence of research on gay men may partly be because they represent a small proportion of the male population—currently estimated at less than 3% (Laumann, Gagnon, Michael, & Michaels, 1994). Stereotypes may also play a role: Gay men are viewed as effeminate and thus unaffected by gender ideals (Kite & Deaux, 1987; Madon, 1997).

Regardless, our understanding of gay men’s experience with masculinity is limited. While as a group gay men are more gender nonconforming than heterosexual men (Bailey & Zucker, 1995), masculinity is important to many gay men—both personally and in evaluating other men. Studies of personal advertisements have repeatedly shown that many gay men stress masculinity (e.g., Bailey, Kim, Hills, & Linsenmeier, 1997; Bartholome, Tewksbury, & Bruzzone, 2000; Phua, 2002). This is reflected in emphasizing personal traits (e.g., muscularity, facial hair, and body art) and interests (e.g., “sports fanatic,” “gym rat” and “an outdoorsman”) while seeking such traits in potential mates. Furthermore, gay men’s assessment of a male target’s attractiveness decreases if the target’s personal advertisement is associated with stereotypically feminine interests and behaviors (Bailey et al., 1997).

While the convergent findings from these studies are intriguing, studies examining personal advertisements are limited because of the potential self-selection bias of men who post advertisements. However, studies that used interviews and surveys found similar trends in the importance that gay men place on masculinity (e.g., Boyden, Carroll, & Maier, 1984; Halkitis, Moeller, & Deraleau, 2008). For instance, Skidmore, Linsenmeier, and Bailey (2006) found that gay men rated masculine gay men as significantly more likeable than feminine gay men (Cohen’s d = 2.02, or over 2 standard deviations higher). Qualitative studies have also found that masculinity is a desirable trait leading some to identify with particular groups (e.g., the leather subculture) or to engage in behaviors that enhance their masculine persona (e.g., using anabolic steroids to boost muscularity) (Halkitis, Green, & Wilton, 2004; Hennen, 2005; Mosher, Levit, & Manley, 2006; Sánchez, Greenberg, Liu, & Vilain, 2009).

Although masculinity is unimportant to some (Riggle, Whitman, Olson, Rostosky, & Strong, 2008), masculinity plays a prominent role in the lives of many gay men (Sánchez et al, 2009). Yet, it is uncertain how important masculinity is to gay men and how they perceive their own masculinity. Such knowledge would add to our understanding of gay men’s experience with masculinity; however, examining the relationship between concerns over violating masculine ideals and feelings about being gay has greater implications. This brief literature review now turns to this topic.

Masculinity and Negative Feelings about Being Gay

While many gay men espouse masculinity, traditional masculine ideals exclude gay men because a core standard for this ideal prohibits affectionate behavior with other men (O’Neil, 1981a, 1981b). This apparent contradiction has led some scholars to propose that gay men have a different conception of masculinity (Connell, 2005; Pleck, 1995). Yet, some scholars have noted that since the early 20th century there have been gay men who have rigidly emphasized traditional masculinity and stigmatized effeminate gay men (Chauncey, 1994; Mosse, 1996). A variety of reasons have been offered for this trend. For instance, Harry (1983) suggested that childhood ridicule leads many gay men to “defeminize” their behavior and conform to stereotypical masculinity to avoid being alienated. Signorile (1997) believed that the HIV/AIDS epidemic perpetuated the emphasis on masculinity—especially through bodybuilding—because gay men wanted to deflect the sick and weak image associated with the disease. Bailey (1996) proposed that because most gay men find effeminate men unattractive, many gay men behave in rigidly masculine ways in order to feel desirable to other gay men and to attract masculine men.

One of the more contentious hypotheses regarding gay men who are concerned with masculinity is that they have internalized homophobic or heterosexist attitudes (Szymanski, Kashubeck-West, & Meyer, 2008). This perspective has been debated within the gay community (cf. Rice, 2006; Alvear, 2004), but even professional psychologists who work with gay men have noted this hypothesis. For instance, Schwartzberg and Rosenberg (1998) believed that gay men “who bear great shame regarding their sexuality express strong discomfort with effeminate gay men, projecting onto them their own fears of female identification” (p. 270). Likewise, Haldeman (2006) noted that it has “been observed that a gay man’s tolerance of his effeminate gay brothers is actually a barometer of his own security” (p. 308).

These clinical impressions are noteworthy because if concerns over violating masculine ideals is indicative of how a man feels about being gay, then there may be important implications for his psychological well-being. For instance, people who feel negatively about themselves report more symptoms of depression and anxiety when compared to people who feel positively about themselves (Frost & Meyer, 2009; Szymanski & Gupta, 2009). Negative feelings about the self contribute to social isolation, which impedes social support (Cruza-Guet et al., 2008; Potoczniak et al., 2007; Sheets & Mohr, 2009). Additionally, feeling negatively about being gay may impede one’s ability to intimately connect with other gay men as they represent what he dislikes about himself (Balsam & Mohr, 2007). Yet, empirical research relating concerns over violating masculine ideals and negative feelings about being gay is lacking.

The few studies that have focused on gay men have examined how concerns over masculine ideals are related to symptoms of depression and anxiety (Simonsen, Blazina, & Watkins, 2000), body image and muscularity concerns (Halkitis et al., 2008; Kimmel & Mahalik, 2005), high risk behaviors (Hamilton & Mahalik, 2009), and relationship dissatisfaction (Wade & Donis, 2007; Wester, Pionke, & Vogel, 2005). Only one peer-reviewed study has directly considered how concerns over violating masculine ideals are related to negative feelings about one’s sexual orientation (Szymanski & Carr, 2008). A limitation of this study, however, is that the study combined the experience of gay, bisexual, and “unsure” men (N = 210).

Thus, in order to examine the link between masculinity and negative feelings about being gay, we surveyed a larger sample of only gay-identified men. Our aim was to assess how important it was for gay men that both they and their same-sex partners be perceived as masculine in public. We also sought to gauge self-perceived masculinity and the degree to which that self-rating met one’s ideal self-rating. Finally, we sought to examine whether concerns with violating masculinity were associated with negative feelings about being gay.

The Survey

We used three published measures. The first was the 37-item Gender Role Conflict Scale (O’Neil, Helms, Gable, David, & Wrightsman, 1986), which has been validated for use with gay men (Wester et al., 2005). This measure consists of four subscales that assess the degree to which men experience internal conflict and concerns related to violating traditional masculine norms. The 13-item Success, Power, and Competition subscale assesses the degree to which a man emphasizes personal achievement and control-authority over others (e.g., “I worry about failing and how it affects my doing well as a man.”). The 10-item Restrictive Emotionality subscale assesses the extent to which a man is uncomfortable with emotional self-disclosure (e.g., “I do not like to show my emotions to other people.”). The 8-item Restrictive Affectionate Behavior Between Men subscale assesses a man’s discomfort with emotional and physical affection with other men (e.g., “Affection with other men makes me tense.”). The 6-item Conflict Between Work and Family Relations subscale assesses the distress a man experiences from balancing demands from work/school and family/leisure life (e.g., “My career, job, or school affects the quality of my leisure or family life.”). Respondents used a 5-point scale (1 = strongly disagree; 5 = strongly agree) to rate their agreement with each item where higher scores suggest more conflict and concern than lower scores.

The second measure was the Lesbian and Gay Identity Scale (Mohr & Fassinger, 2000). We specifically used the four subscales that comprise the Negative Gay-Identity Index (NGI): The 6-item Need for Privacy subscale measures how private people feel their sexual orientation should be (e.g., “I keep careful control over who knows about my relationships.”). The 5-item Need for Acceptance subscale measures one’s sensitivity to social stigmatization (e.g., “I think a lot about how my sexual orientation affects the way people see me.”). The 5-item Internalized Homonegativity subscale measures the degree to which people evaluate their sexual orientation negatively (e.g., “I wish I were heterosexual.”). The 5-item Difficult Process subscale measures the degree to which people feel their gay identity development has been difficult (e.g., “Admitting to myself that I am a gay man has been a very painful process.”). A 7-point scale (1 = disagree strongly; 7 = agree strongly) is used to respond to each item. Responses are averaged for the four subscales and the averages are used to derive the NGI. Mohr and Fassinger (2000) conceptualized the NGI as reflecting how negatively someone feels about being gay with higher scores suggesting more negative feelings than lower scores.

The final published measure was the 13-item Marlowe-Crowne Social Desirability Scale (Reynolds, 1982). Given the personal nature of the questions, we used this scale to control for the tendency to answer questions in a socially desirable way. Respondents answered true or false to each item (e.g., “No matter who I’m talking to, I’m always a good listener.”) and higher total scores suggest greater concern with appearing socially desirable.

Additionally, four questions were included on a demographic form to gauge the importance of masculinity and to gauge self-ratings of masculinity—femininity. First the men used a 7-point scale (1 = not at all important; 7 = extremely important) to respond to two questions: “How important is it to you that you appear masculine in public?” and, “How important is it to you that your partner (or anyone you may be dating) appear masculine in public?” Next, the men used a masculine—feminine scale (1 = extremely feminine; 7 = extremely masculine) to gauge how masculine—feminine they believed they were, and then to gauge how masculine—feminine they would ideally like to be. Sex researchers (e.g., Skidmore et al., 2006) often use this dichotomous type of scale (versus an orthogonal scale) in order to reflect the common notion that people are on either side of such a continuum.

We used the suggestions offered by Gosling, Vazier, Srivastara, and John (2004) in constructing and monitoring the online survey (e.g., monitoring IP addresses to guard against repeat responders). With the assistance of electronic mailing list managers, an email solicitation was sent out to a variety of organizations, university centers, and community agencies associated with the gay community. The solicitation specified that the study was for self-identified gay men over the age of 18 and who were citizens of and lived in the United States. housed the consent form and survey. After completing the survey, they were offered an opportunity to enter a drawing for one of three $35.00 gift certificates.

A total of 622 surveys were included in the analysis. The mean age was 36.81 (SD = 10.39; range = 18–80 years-old) and the mean number of years openly identifying as gay was 15.53 (SD = 9.94; range = 0–63 years openly gay). The men were well educated (79.1% had at least a bachelor’s degree) and the median individual income bracket was between $45,000–54,999. Racial/ethnic composition was as follows: 83.6% White (Non-Latino), 6.8% Hispanic/Latino, 4.0% Asian American, 1.9% African American, 1.0% Native American. All reported being U.S. citizens living in the U.S.: West (42.9%), Midwest (27.3%), South (21.9%), and Northeast (7.4%). Sixty-four percent reported being in a significant same-sex romantic relationship, with 66.4% of this subset cohabiting with their same-sex partner.

Importance and Degree of Masculinity

The first goal was to assess the importance of masculinity. Figure 1 shows the distribution for the two questions assessing the importance of appearing masculine in public, and the importance that one’s partner appear masculine in public. For most, appearing masculine was important where 55.1% rated the item between 5 and 7 whereas 26.2% rated the item between 1 and 3. In addition, most reported that it was important that their partner appear masculine in public where 54.0% rated the item between a 5 and 7 compared to 29.3% who rated the item between 1 and 3. These items were highly correlated (r = .77, p < .001) suggesting that the degree to which masculinity was important for the self also reflected the degree to which one valued masculinity in a romantic partner.

Figure 1
Distribution of Ratings on Importance of Masculinity

We also wanted to determine how masculine—feminine the men felt they were and how masculine—feminine they would ideally like to be. As a group, most perceived themselves to be more masculine than feminine where 67.7% rated themselves between 5 and 7 compared to 8.2% who rated themselves between 1 and 3. Furthermore, most wished to be more masculine than feminine where 79.3% rated the item between a 5 and 7, and only 2.7% rated this item between a 1 and 3. A figure of these distributions is available online.

Finally, to determine if they ideally wished to be more or less masculine, we conducted a paired sample t-test comparing self-ratings of masculinity—femininity with ratings of ideal masculinity—femininity. On average, the men wanted to be more masculine than they felt they were: t(621) = -10.98, p < .001. We used a conservative formula to estimate the effect size while controlling for the correlation between these two items (Dunlap, Cortina, Vaslow, & Burke, 1996). Consequently, Cohen’s d = 0.42, suggesting a small to medium size difference between ideal and current self-ratings of masculinity (Cohen, 1992). Overall, the gay men valued the appearance of masculinity and they wanted to be more masculine.

Masculine Ideals and Feelings about being Gay

Our next goal was to examine the relationship between concerns over masculinity and negative feelings about being gay. Table 1 presents the partial correlations between the variables, controlling for social desirability. Additional tables that include zero-order correlations and 95% confidence intervals are available online. All variables related to masculinity were positively correlated with negative feelings about being gay. In particular, three variables accounted for a significant amount of variance (or r-squared) in NGI scores: concerns with being affectionate with other men accounted for 34%, concerns with expressing emotions accounted for 20%, and the importance of appearing masculine in public accounted for 17%.

Table 1
Partial Correlation between the Variables

Finally, we were interested in determining which variables best predicted negative feelings about being gay by conducting a multiple regression analysis. In order to control for the effects of social desirability, scores from the Social Desirability Scale were entered in Step 1. The four Gender Role Conflict Scale subscale scores and the rating on the importance of masculinity were simultaneously entered as predictors in Step 2 with scores on the NGI serving as the criterion variable. The multiple coefficient of determination showed that 40% of the variance was explained by the linear combination of the predictor variables (see Table 2). Although each predictor was significantly correlated with the NGI, only scores on three of the scales significantly contributed to the regression model: Restrictive Affectionate Behavior Between Men subscale scores, Conflict Between Work and Family Relations subscale scores, and the rating of importance of appearing masculine in public. Thus, internal conflict about being affectionate with other men, difficulty balancing one’s work/school and family/leisure life, and the importance of appearing masculine predict negative feelings about being gay.

Table 2
Regression Coefficients on Negative Gay-Identity Index

Implications for Practice

Numerous studies have shown how heterosexual men are affected by masculine ideals. Yet, few studies have focused on gay men. The purpose of this survey was to extend our understanding of how gay men are affected by masculine ideals. Our results, coupled with those from Szymanski and Carr (2008), suggest that gay men who are more concerned about violating traditional masculine ideals feel more negatively about being gay than those less concerned.

As a whole, four main findings have important clinical implications. The first important finding is that masculinity—however gay men define it—is an important construct for many gay men. Journalists and scholars have written about this fact. Furthermore, researchers have indirectly measured the importance of masculinity based on mate seeking behaviors (Bailey et al., 1997) and reactions to effeminate gay men (Skidmore et al., 2006). However, this is the first peer-reviewed study to systematically ask how important masculinity is to gay men.

Thus, it seems reasonable to ask gay men about traditional gender roles. This may consist of a simple question (e.g., “How important is masculinity to you?”) during an intake session. If it is important, then what does masculinity mean to him and which aspects are important to him? While masculinity is unimportant to some, such a question could open a dialogue regarding one’s view of gender roles and how it relates to his life.

Similarly, the second important finding is that many gay men desire romantic partners who appear masculine. This corresponds with the results from numerous personal advertisement studies that have determined that most gay men desire masculine mates. Our survey enhances those findings because we directly asked gay men if it was important to them rather than inferring that sentiment from the content of posted personal advertisements.

Again exploring this issue with gay men in session may be insightful especially if his presenting concern is related to interpersonal relationships. If a client says that masculinity in a mate is important, then what specific aspect of masculinity is he referring to? Is he referring to one’s outward appearance (e.g., style of dress and mannerisms), sexual proclivities (e.g., sexual adventurism and dominance), or personality (e.g., being competitive and interested in specific activities)? Furthermore, how does such a focus on masculine traits affect his ability to initiate and maintain intimate connections with other gay men? That is, does the exhibition of stereotypical masculinity affect whom he will associate with and does he reject anyone who may violate some aspect of traditional masculinity?

The third important finding is that on average the gay men wished to be more masculine than they perceived themselves to be. Even though they self-rated as being more masculine than feminine, they wanted to be even more masculine. Perhaps this partly explains why many gay men emphasize the outward appearance of masculinity though body art (e.g., piercing and tattoos) and muscularity (Duncan, 2007)—though for specific groups of gay men it may be a way to deflect the sick and weak image associated with HIV (Halkitis et al., 2008).

Therefore, a possible question for gay clients who highly value masculinity is whether they wish to be more masculine than they believe they are. If so, what aspect of masculinity is he referring to? While stereotypically masculine traits are not necessarily problematic, rigidly ascribing to certain traits (e.g., ignoring fear and pain) can undermine psychological well-being.

The fourth important finding is that gay men who place an importance on masculinity, who have trouble being affectionate with other men, and who are immersed in their school/work activities may feel negatively about being gay. Conceptually, it makes sense that if a gay man values traditional masculinity and is concerned about being affectionate with other men that he would feel negatively about being attracted to men. The fact that conflict between work/school and family/leisure life is predictive of negative feelings about being gay may seem unusual. However, perhaps this “workaholic” approach to life is a type of avoidance coping for some gay men. Altogether, professional psychologists should explore negative feelings about being gay with clients who report any of these traits given the clear link between negative feelings about the self and impaired psychological well-being (Johnson et al., 2008; Moradi, van den Berg, & Epting, 2009; Szykmanski & Carr, 2008).

By including an exploration of masculinity with gay men, professional psychologists may find that many presenting concerns (e.g., low self-esteem and problems with dating) are partially rooted in masculine norms. Consequently, part of the therapeutic intervention may be to help the client see the connection between society’s rigid masculine ideals and his internalized conception of masculinity, and how that ideal is affecting his well-being (Haldeman, 2006). This can include recalling the messages he received from significant others (e.g., his parents and peers) regarding gender roles and same-sex attraction, and how these internalized conceptions have impacted his view of his sexual orientation (Kashubeck-West, Szymanski, & Meyer, 2008).

While gaining such insight may be helpful, professional psychologists can also help the client gain skills to counter these rigid conceptions. This can include challenging cognitive distortions (e.g., “Because only heterosexual men are masculine, I’ll never be seen as masculine because I am gay.”) by testing the validity of such beliefs. Furthermore, the client may benefit from group psychotherapy with other gay men where he can form connections and receive supportive interpersonal feedback. This may also facilitate a corrective emotional experience if the client perceives other men as threatening due to a history of rejection and alienation (Haldeman, 2001). Such direct challenges to cognitive distortions by the practitioner and the interpersonal process of group psychotherapy may help reinforce the idea that there is diversity of gender expression across men and that masculinity is not an “all-or-none” trait.

Although the current survey offers valuable information, it is important to recognize that two of the major advantages of online surveys come with unique disadvantages. First, an advantage of this method was that it allowed for a large collection of anonymous data that included people who may not have volunteered in person. However, like other online studies focused on gay men (e.g., Szymanski, 2009; Wester et al., 2005), the sample was largely a White, middle-class, and well-educated group. Furthermore, a self-selection bias likely exists given that gay specific organizations were used to recruit gay men. Consequently, the results from this sample may not generalize to the general population of gay identified men (Meyer & Wilson, 2009). The second major advantage is that online surveys offer participants a greater amount of ease and convenience compared to in-person surveys. However, a cost to this approach is that fairly short measures of key constructs were used to minimize participation time. Consequently, we were not able to obtain more in-depth information or to follow up on the participants’ responses.

Notwithstanding these limitations, this survey provides some insight into the role that masculinity plays in gay men’s lives. Given that research on heterosexual men has shown the many ways in which masculinity undermines their well-being, it is important that research continue to explore how gay men are affected by these dated constructs. This can include whether gay men’s perceptions of their own masculinity are congruent with others’ perception of their masculinity and how they respond when their sense of masculinity is threatened; whether gay men who endorse traditional masculine ideals are higher self-monitors and more self-deprecating of violating gender roles compared to gay men who do not endorses such ideals; and if discomfort with femininity is related to a fear of intimacy and relationship satisfaction. Most importantly, future researchers need to use other modalities to collect data in order to include the experience of racial and ethnic minority gay men given that Internet studies are yielding largely homogenous samples (Moradi, Mohr, Worthington, & Fassinger, 2009).

As research advances our understanding of the effect that traditional masculine ideals have on gay men, our conceptualization of gay men who rigidly endorse these ideals will change. For now, gay men’s focus on masculinity will continue to stir controversy within the gay community—especially as research is starting to support the long held belief articulated by Harvey Fierstein that self-proclaimed “straight-acting” gay men may be “self loathing.” Fortunately, professional psychologists can play a critical role in helping their gay clients understand their focus on masculinity while deconstructing these internalized views, rather than contributing to the criticism of such gay men.

Supplementary Material

Supplemental Material


We thank Timothy Ansley, Sam Cochran, Kathryn Gerken, Benjamin Locke, Rose Medeiros, James O’Neil, Joshua Paul Olson, Robert Schope, Christopher Skidmore, and Yuying Tsong for their assistance on this project. We are also grateful to Beth Daniels, David Frederick, Negin Ghavami, Kelly Gildersleeve, Mark Harris, Justin Lavner, Natalya Maisel, Adriana Manago, Letitia Anne Peplau, Elizabeth Pillsworth, Kathleen Preston, Mariana Preciado, Kelly Turner, and Curtis Yee for their feedback on earlier drafts of this manuscript.


Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at


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