Lifecourse-varying structural stigma, minority stress reactions and mental health among sexual minority male migrants

Background

Increasing evidence suggests that structural stigma (e.g. discriminatory laws, policies and population attitudes) can give rise to minority stress reactions (i.e. rejection sensitivity, internalized homophobia and identity concealment) to compromise sexual minorities’ mental health. Yet, many sexual minorities encounter divergent structural stigma climates over the life course, with potential implications for their experience of minority stress reactions and mental health. We take advantage of sexual minority male migrants’ lifecourse-varying exposures to structural stigma contexts to examine this possibility.

Methods

A sample of 247 sexual minority men who had migrated from 71 countries to the low-structural-stigma context of Sweden completed a survey regarding migration experiences, minority stress reactions and mental health. This survey was linked to objective indices of structural stigma present in these men’s countries of origin, diverse in terms of structural stigma.

Results

Country-of-origin structural stigma was significantly associated with poor mental health and this association was mediated by rejection sensitivity and internalized homophobia, but only among those who arrived to Sweden at an older age and more recently.

Conclusions

Prolonged exposure to high levels of structural stigma can give rise to stressful cognitive, affective and behavioural coping patterns to jeopardize sexual minority men’s mental health; yet, these consequences of structural stigma may wane with increased duration of exposure to more supportive structural contexts.

Risk and Protective Factors for Social Anxiety Among Sexual Minority Individuals

Minority stress processes represent clear determinants of social anxiety among sexual minority populations. Yet sources of resilience to social anxiety are less explored as are stressors experienced from within sexual minority communities (i.e., intraminority stress). Based on minority stress theory and the psychological mediation framework, we hypothesized that experiences of discrimination and intraminority stress would predict proximal minority stress processes, including internalized homonegativity, sexual concealment behavior, and rejection sensitivity, as well as two resilience factors-sense of coherence and LGBTQ community connectedness-to explain social anxiety among sexual minority individuals. Self-identified cisgender sexual minority women (n = 245) and men (n = 256) residing in the Republic of Ireland completed an online survey. Results from a structural equation modeling analysis indicated that the data fit the hypothesized model well for both women and men. For both sexual minority women and men, experiences of discrimination and intraminority stress were indirectly associated with social anxiety via two paths (1) increased rejection sensitivity and (2) reduced sense of coherence. Intraminority stress was indirectly associated with social anxiety via increased concealment behavior for sexual minority men only. Experiences of discrimination were indirectly associated with social anxiety via a sequential pathway through increased proximal minority stress (i.e., concealment behavior and internalized homonegativity), and reduced LGBTQ community connectedness solely among sexual minority women. Findings are discussed in terms of implications for future research and clinical practice with sexual minority individuals who suffer from social anxiety.

A pilot cultural adaptation of LGB-affirmative CBT for young Chinese sexual minority men's mental and sexual health

Young men who have sex with men (YMSM) represent one of the most at-risk groups for HIV infection and experience sexual minority stress especially in high-stigma settings, which affects their psychological health and increases likelihood of HIV-risk behaviors. The HIV epidemic in China is increasing rapidly among YMSM. However, no evidence-based intervention has specifically targeted Chinese YMSM's minority stress to improve their mental and sexual health. Adaptation of evidence-based interventions to promote the mental and sexual health of YMSM is one promising way to achieve the global target of HIV epidemic control. The current adaptation study followed the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing model. YMSM (n = 41) and key stakeholders (n = 16) in China provided feedback into the selected intervention, a cognitive-behavioral therapy called Effective Skills to Empower Effective Men, originally developed with efficacy in the United States. An open pilot (n = 8) was also then conducted. Qualitative and quantitative data collected from each adaptation phase were analyzed to form the adapted intervention: "Yi Si Tang ()." Adaptations addressed a cultural context prioritizing family needs, limited support from the health system, as well as YMSM delivery preferences. YMSM and key stakeholders deemed the intervention acceptable and preliminarily feasible for the Chinese context. The pre-post comparison of mental and sexual health outcomes indicated improvement in mental health and sexual health of Chinese YMSM. Outcomes of the small initial pilot suggest future promise for this first-of-its-kind intervention for Chinese YMSM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Has depression surpassed HIV as a burden to gay and bisexual men's health in the United States? A comparative modeling study

BACKGROUND

While advances in HIV prevention and treatment have changed the epidemic for gay and bisexual men, another epidemic faces this population. Gay and bisexual men represent one of the highest risk groups for depression, which potentially poses quality-of-life and public health challenges comparable to those of HIV. The present study seeks to inform comprehensive care for sexual minority men by estimating and comparing the morbidity of HIV and depression for US gay and bisexual men.

METHODS

In 2018, weighted counts of gay and bisexual men living with HIV and depression were derived from the CDC's Medical Monitoring Project and the National Survey on Drug Use and Health, respectively. Years lived with disability for HIV and depression were calculated using the Global Burden of Disease Study's disability weights.

FINDINGS

Among gay and bisexual adult men in the US, the prevalence of past-year major depressive episodes is 14.17%, while the prevalence of HIV is 11.52%. We estimate that in calendar year 2015, major depressive episodes imposed 85,361 (95% CI 58,293-112,212) years lived with disability among US adult gay and bisexual men, whereas HIV posed 42,981 (95% CI 36,221-49,722) years lived with disability.

INTERPRETATION

This analysis shows that depression morbidity currently exceeds that for HIV among US adult gay and bisexual men. While gay and bisexual men are frequently understood to be a high-risk population for HIV, including in guidelines for HIV prevention and treatment, the present analysis suggests that this population should also be considered high-risk for depression.

Country-level structural stigma, identity concealment, and day-to-day discrimination as determinants of transgender people's life satisfaction

PURPOSE

Discriminatory laws, policies, and population attitudes, surrounding transgender people vary greatly across countries, from equal protection under the law and full acceptance to lack of legal recognition and open bias. The consequences of this substantial between-country variation on transgender people's health and well-being is poorly understood. We therefore examined the association between structural stigma and transgender people's life satisfaction across 28 countries.

METHODS

Data from transgender participants (n = 6771) in the 2012 EU-LGBT-survey regarding identity concealment, day-to-day discrimination, and life satisfaction were assessed. Structural stigma was measured using publicly available data regarding each country's discriminatory laws, policies, and population attitudes towards transgender people.

RESULTS

Multilevel models showed that country-level structural stigma was associated with lower life satisfaction, an association largely explained by higher levels of identity concealment in higher-structural-stigma countries. Yet identity concealment was also associated with lower day-to-day discrimination and therefore protected against even lower life satisfaction.

CONCLUSION

The results emphasize the importance of changing discriminatory legislation and negative population attitudes to improve transgender people's life satisfaction, and also highlight targets for intervention at interpersonal and individual levels.

Country-Level Structural Stigma, School-Based and Adulthood Victimization, and Life Satisfaction Among Sexual Minority Adults: A Life Course Approach

Country-level structural stigma, defined as prejudiced population attitudes and discriminatory legislation and policies, has been suggested to compromise the wellbeing of sexual minority adults. This study explores whether and how structural stigma might be associated with sexual minorities' school-based and adulthood experiences of victimization and adulthood life satisfaction. Using a sample of 55,263 sexual minority individuals (22% female; 53% 18-29 years old; 85% lesbian/gay, 15% bisexual) living across 28 European countries and a country-level index of structural stigma, results show that sexual minorities, especially men, reported school bullying in both higher- and lower-stigma countries. Higher rates of school bullying were found among sexual minorities living in higher-stigma countries when open about their identity at school. Past exposure to school bullying was associated with lower adulthood life satisfaction, an association partially explained by an increased risk of adulthood victimization. These findings suggest that sexual minorities living in higher-stigma countries might benefit from not being open about their sexual identity at school, despite previously established mental health costs of identity concealment, because of the reduced risk of school bullying and adverse adulthood experiences. These results provide one of the first indications that structural stigma is associated with sexual minority adults' wellbeing through both contemporaneous and historical experiences of victimization.

Prevalence of Bullying Among Youth Classified as LGBTQ Who Died by Suicide as Reported in the National Violent Death Reporting System, 2003-2017

This cohort study uses data from the National Violent Death Reporting System from 2003-2017 to assess the prevalence of bullying among youth classified as LGBTQ who died by suicide.

Cultural context matters: Testing the minority stress model among Chinese sexual minority men

Minority stress theory (e.g., Meyer, 2003b), a model for understanding mental health disparities affecting sexual minorities, has primarily been tested in Western samples yet has not been carefully applied to the experiences of sexual minorities in a global context, including in East Asian countries. Combining minority stress theory with considerations of Chinese culture, the current study tested the associations among norm conformity, distal minority stressor (enacted stigma), proximal minority stressors (sexual identity concerns and concealment), lesbian, gay, and bisexual (LGB) family support, and psychological distress among Chinese sexual minority men (n = 748). Structural equation modeling showed that sexual identity concerns mediated the associations of norm conformity, enacted stigma, and lower family support with concealment. Psychological distress was associated with enacted stigma and lower family support, but not with proximal stressors (sexual identity concerns and concealment). Alternative model testing found sexual identity acceptance concerns predicted psychological distress and mediated the associations of norm conformity and LGB family support with distress. Findings provide partial support for the minority stress model in a Chinese context and suggest the importance of incorporating cultural considerations into minority stress conceptualizations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sexual orientation concealment and mental health: A conceptual and meta-analytic review

Identity concealment affects all sexual minority individuals, with potentially complex mental health implications. Concealing a sexual minority identity can simultaneously generate the stress of hiding, protect against the stress of discrimination, and keep one apart from sexual minority communities and their norms and supports. Not surprisingly, existing studies of the association between sexual orientation concealment and mental health problems show contradictory associations-from positive to negative to null. This meta-analysis attempts to resolve these contradictions. Across 193 studies (n = 92,236) we find a small positive association between sexual orientation concealment and internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating; ESr = 0.126; 95% CI [0.102, 0.151]) and a small negative association between concealment and substance use problems (ESr = -0.061; 95% CI [-0.096, -0.026]). The association between concealment and internalizing mental health problems was larger for those studies that assessed concealment as lack of open behavior, those conducted recently, and those with younger samples; it was smaller in exclusively bisexual samples. Year of data collection, study location, and sample gender, education, and racial/ethnic composition did not explain between-study heterogeneity. Results extend existing theories of stigma and sexual minority mental health, suggesting potentially distinct stress processes for internalizing problems versus substance use problems, life course fluctuations in the experience of concealment, distinct experiences of concealment for bisexual individuals, and measurement recommendations for future studies. Small overall effects, heavy reliance on cross-sectional designs, relatively few effects for substance use problems, and the necessarily coarse classification of effect moderators in this meta-analysis suggest future needed methodological advances to further understand the mental health of this still-increasingly visible population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Brief online interventions for LGBTQ young adult mental and behavioral health: A randomized controlled trial in a high-stigma, low-resource context

OBJECTIVE

To identify scalable interventions for improving sexual minority mental health and health-risk behavior, this study tested the efficacy of two self-guided online writing interventions-expressive writing and self-affirmation. To reach sexual minority young adults living in high-stigma, low-resource settings, we developed and tested these interventions in Appalachian Tennessee.

METHOD

In consultation with sexual minority young adults (n = 10) and stakeholders (n = 10) living in Appalachian Tennessee, we adapted these two writing interventions that we then delivered to 108 local sexual minority young adults (Mage = 23.68, SD = 3.11). Participants, representing diverse sexual and gender identities and socioeconomic backgrounds, were randomly assigned to participate in a 3-session expressive writing intervention, self-affirmation intervention, or neutral control. Participants completed mental health and health-risk behavior measures at baseline, postintervention, and 3-month follow-up.

RESULTS

Compared to the neutral control, expressive writing exerted 3-month improvements in depressive symptoms (d = 0.48) and general psychological distress (d = 0.36) whereas self-affirmation exerted improvement in suicidal ideation (d = 0.62) and drug abuse (d = 0.59). Participants who were exposed to greater contextual minority stressors common in rural regions (i.e., discrimination and victimization) experienced significantly greater 3-month reductions in depression from expressive writing and self-affirmation compared to control. Those who experienced greater discrimination also experienced significantly greater 3-month reductions in suicidality from self-affirmation compared to control.

CONCLUSION

Brief writing interventions exert significant impact on the mental health of young adult sexual minorities, especially those exposed to minority stress. Future research can consider strategies for population-level implementation, especially in high-stigma, low-resource settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study

OBJECTIVE

Despite professional recommendations to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence, the long-term effect of such interventions on mental health is largely unknown. The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population.

METHODS

This study used the Swedish Total Population Register (N=9,747,324), linked to the National Patient Register and the Prescribed Drug Register. Among individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015 (N=2,679), mental health treatment in 2015 was examined as a function of length of time since gender-affirming hormone and surgical treatment. Outcome measures were mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt.

RESULTS

Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).

CONCLUSIONS

In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.

A transdiagnostic minority stress intervention for gender diverse sexual minority women's depression, anxiety, and unhealthy alcohol use: A randomized controlled trial

OBJECTIVE

To remedy the notable gap in evidence-based treatments for sexual minority women, this study tested the efficacy of a minority-stress-focused cognitive-behavioral treatment intended to improve this population's mental and behavioral health.

METHOD

The intervention, EQuIP (Empowering Queer Identities in Psychotherapy), was adapted from a transdiagnostic cognitive-behavioral treatment as also recently adapted for sexual minority men. Sexual minority women at risk of mental and behavioral health problems (n = 19) and expert providers with this population (n = 12) shaped the treatment's development, including by supporting its primary focus on universal and minority-stress-focused processes underlying this population's disproportionately poor mental and behavioral health. The resulting treatment was then delivered to young adult sexual minority women (n = 60; M age = 25.58; 41.67% racial/ethnic minority; 43.33% transgender/nonbinary) experiencing depression/anxiety and past 90-day heavy alcohol use.

RESULTS

Compared to waitlist (n = 30), participants randomized to immediately receive EQuIP (n = 30) experienced significantly reduced depression and anxiety (d = 0.85, 0.86, respectively); effects for alcohol use problems were smaller (d = 0.29) and marginally significant. In pre- to post-intervention pooled analyses, effect sizes for minority stress processes (mean d = .25) and universal risk factors (mean d = .48), through which the treatment was expected to work, were small and moderate, respectively, and in the expected direction.

CONCLUSIONS

This study provides initial support for a minority-stress-focused transdiagnostic cognitive-behavioral treatment for sexual minority women. These first results can launch exploration of other mechanisms and modalities through which to equip this population with evidence-based support. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Parent versus child report of children's sexual orientation: associations with psychiatric morbidity in the Adolescent Brain Cognitive Development study

PURPOSE

We sought to document the association between parent's report and their child's report of the child's sexual orientation and associations between this agreement/disagreement and the child's psychiatric morbidity.

METHODS

Data were drawn from 11,565 parent-child dyads who completed the baseline assessment of the Adolescent Brain Cognitive Development study (2016-2018; children ages 9-10 years). Whether the child was "gay or bisexual" was asked separately of parent and child. We created four categories: (1) Concordant No; (2) Discordant: Parent Yes/Maybe, Child No/Unclear; (3) Discordant: Parent No, Child Yes/Maybe; (4) Concordant Yes/Maybe. Parents reported their child's lifetime psychiatric morbidity (i.e., depression, anxiety, ADHD, ODD, OCD, PTSD, eating disorder, and conduct disorder).

RESULTS

Of parent-child dyads, 960 (7.9%) disagreed about the child's sexual orientation; the Concordant No dyads reported the lowest psychiatric morbidity compared with the other three dyad groups. Child psychiatric morbidity among the Discordant: Parent Yes/Maybe dyads compared with the Concordant No dyads was elevated across all disorders except PTSD (e.g., depression [adjusted odds ratio (aOR) = 2.20, 95% confidence interval (95% CI): 1.51-3.21], anxiety [aOR = 1.63, 95% CI: 1.38-1.92], and eating disorder [aOR = 2.63, 95% CI: 1.39-4.68]).

CONCLUSIONS

The sexual orientation disparity in psychiatric morbidity begins in childhood. Parent-child agreement/disagreement of children's sexual orientation represents a potential marker of this early vulnerability.

Sexual risk behaviors in the internet age: the case of Chinese men who have sex with men

This cross-sectional study examined a sample of sexually active Chinese MSM recruited online (N = 403) to determine the associations of MSM social life (both online and in-person) and sexual identity stigma with three types of sexual risk behaviors in the past 12 months, including condom use %, number of anal intercourse partners, and number of partners engaged in condomless anal intercourse (CAI). Hierarchical regression analyses were conducted. More frequent use of social media was associated with higher numbers of anal intercourse partners as well as more condom use in past 12 months, but not number of CAI partners. More active in-person MSM social life was associated with higher numbers of partners in anal intercourse as well as CAI. Both perceived and enacted sexual identity stigma associated with higher numbers of CAI partners; perceived stigma was also linked to less condom use. In conclusion, social life and minority stress are relevant factors of sexual risk among MSM in China in the uptrend of internet use. The internet may be an important and promising platform for HIV prevention, and intervention efforts should consider online-based designs to promote safe sex and reduce sexual minority stigma.

Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China

PURPOSE OF REVIEW

Men who have sex with men (MSM) in China experience elevated risks of mental health issues in comparison to the general population in China, which contribute to vulnerability to HIV/STI risks and can comprise the effectiveness of HIV prevention efforts. A conceptual framework for understanding this mental health disparity is minority stress theory, which posits that experiences of external prejudice events (i.e., distal stressors) and internal stress processes such as internalized homophobia and concealment (i.e., proximal stressors) contribute to sexual minorities' elevated risk of psychological distress. To deepen the understanding of mental health among Chinese MSM and explore the potential utility of minority stress theory in this population, this paper synthesizes research evidence regarding prevalent mental health issues as well as how minority stress may be linked to psychological health in Chinese MSM.

RECENT FINDINGS

Results indicate that Chinese MSM experience a high prevalence of several mental health issues including depression, anxiety, suicidal behaviors, and alcohol dependence. This review further reveals minority stress to be an important determinant of psychological distress among Chinese MSM, though evidence is mixed regarding the relationship between proximal minority stress and psychological health. Nonetheless, there is a lack of mental health services and interventions focusing on MSM in China. Culturally relevant, competent, and LGBT-affirmative mental health interventions are needed for Chinese MSM. To guide future intervention research, we provide considerations for reducing minority stress and promoting psychological health among Chinese MSM.

"It Truly Does Get Better:" Young Sexual Minority Men's Resilient Responses to Sexual Minority Stress

Due to minority stress, sexual minority men experience mental health disparities. Sexual minority men who engaged in cognitive-behavioral therapy to address the minority stress underlying their distress completed an exercise eliciting their own resilience. This exercise involved writing an advice letter to a hypothetical peer about coping with minority stress. Qualitative analysis of these letters yielded 18 codes grouped into three categories reflecting resilience to minority stress. Categories included (1) cultivating internal affirmation strategies, (2) building supportive relationships and community, and (3) using cognitive and behavioral skills to cope with minority stress. Findings highlight this population's resilience and suggest building resilience through treatment.

Sex, status, competition, and exclusion: Intraminority stress from within the gay community and gay and bisexual men's mental health

Gay and bisexual men might face unique, status-based competitive pressures given that their social and sexual relationships often occur with other men, who are known to compete for social and sexual gain. In a multistage study, we delineated intraminority gay community stress theory-that status-focused elements of the gay community challenge the mental health of gay and bisexual men. We first created a measure of gay community stress with items derived from qualitative interviewing (n = 49); calculated its psychometric properties, including 1-year temporal stability (n = 937); and confirmed its structural stability in distinct samples (n = 96; n = 1,413). Being stressed by perceiving the gay community's focus on sex, focus on status, focus on competition, and exclusion of diversity predicted gay and bisexual men's mental health over-and-above a comprehensive battery of traditional minority stressors (β = .17, p < .01) and mediated the association between one's gay community status and mental health. To examine the impact of individual differences in status concerns (i.e., about masculinity, attractiveness, and wealth) on gay and bisexual men's feelings of within-community exclusion, a series of experiments manipulated (a) the sexual orientation (gay vs. heterosexual) of rejecters (n = 103), (b) the social status of gay rejecters (n = 83), and (c) whether rejection from gay and bisexual rejecters was status-based or nonstatus-based (n = 252). Overall, these experiments provide partial support for the possibility that gay and bisexual men's status concerns underlie their experience of gay community stress. Together, these studies advance psychological and sociological accounts of gay and bisexual men's mental health beyond minority stress theory, with implications for intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Untethered lives: barriers to societal integration as predictors of the sexual orientation disparity in suicidality

PURPOSE

Despite increasing legal protections and supportive attitudes toward sexual minorities (e.g., those who identify as lesbian, gay, and bisexual [LGB]) in recent decades, suicidality remains more common among this population than among heterosexuals. While barriers to societal integration-or a lack of meaning, purpose, and belonging as derived from societal norms, goals, and attachment-have been widely theorized as determinants of suicidality for the general population, they have not been comprehensively explored to explain the sexual orientation disparity in suicidality. The aim of this study was to examine differences in suicidal ideation and attempts between LGB and heterosexual individuals in a nationally representative sample, and to examine barriers to societal integration as a potential explanation for any observed disparities over-and-above the influence of established contributors to sexual orientation disparity in suicidality.

METHODS

Data come from the cross-sectional Swedish National Public Health Survey, which collected data from unrestricted random samples of individuals (16-84 years of age) living in Sweden, annually from 2010 to 2015 (n = 57,840 individuals [response rates: 48.1-51.3%]; 1281 (2.2%) self-identified as LGB). Analyses examined sexual orientation differences in suicidality (i.e., past-12-month ideation and attempts), and explored the role of barriers to societal integration (i.e., not living with a partner or children, unemployment, and lack of societal trust) in explaining this disparity over-and-above more commonly explored psychological (e.g., depression, substance use) and interpersonal (e.g., discrimination, victimization, lack of social support) suicidality risk factors.

RESULTS

Compared to heterosexuals, suicidal ideation and attempts were more common among both gay men/lesbians (adjusted odds ratio [AOR] for suicide ideation: 2.69; 95% confidence intervals [CI]: 2.09, 3.47; AOR for suicide attempts: 5.50; 95% CI: 3.42, 8.83), and bisexuals (AOR for suicide ideation: 3.83; 95% CI: 3.26, 4.51; AOR suicide attempts: 6.78; 95% CI: 4.97, 9.24). Barriers to societal integration mediated the association between sexual orientation and suicidality even in models adjusting for established risk factors for suicidality.

CONCLUSION

Our results suggest that previously under-examined factors, namely the disproportionate barriers to societal integration that LGB individuals experience, are important contributors to the substantially elevated risk of suicidality among sexual minorities. Preventive interventions should consider innovative ways to foster societal integration within sexual minority populations and to adjust hetero-centric social institutions to better include sexual minority individuals.

Sexual violence as a mediator of sexual orientation disparities in alcohol use, suicidality, and sexual-risk behaviour among female youth

Sexual violence exposure represents a serious public health issue among female youth given its association with female youths' engagement in health-risk behaviours. Sexual minority female youth are particularly vulnerable to sexual violence exposure, alcohol use, suicidality, and sexual-risk behaviour. Using the population-based 2017 Youth Risk Behaviour Survey, we examined sexual violence as a mediator of sexual orientation disparities in health-risk behaviours among female youth. This study included 7,532 female students in grades 9 through 12 across the US. Participants identified their sexual orientation as heterosexual (73.5%); bisexual (12.2%); and, gay or lesbian (2.2%). Compared to heterosexual female youth, sexual violence exposure, alcohol use, binge drinking, and multiple sex partners were more common among bisexual female youth. The elevated risk of suicidality was most notable among gay or lesbian female youth relative to heterosexual female youth and bisexual female youth relative to heterosexual female youth. Mediation analyses showed that sexual violence exposure partially explained the sexual orientation disparity in these co-occurring health-risk behaviours between bisexual female youth and heterosexual female youth. Our findings highlight the need for clinical attention to be paid to assessing and treating the health effects of sexual violence, especially among bisexual female youth.