Diversity and Inclusion in the American Legal Profession: Discrimination and Bias Reported by Lawyers with Disabilities and Lawyers Who Identify as LGBTQ

PURPOSE

This article is part of an ongoing body of investigation examining the experiences of lawyers with diverse and multiple minority identities, with particular focus on lawyers with disabilities; lawyers who identify as lesbian, gay, bisexual, transgender, and queer ("LGBTQ+" as an overarching term); and lawyers with minority identities associated with race and ethnicity, gender, and age. The focus of this article is on discrimination and bias in their workplaces as reported by the lawyers experiencing it.

METHODS

We employ survey data from the first phase of this investigation, gathered from the survey responses of 3590 lawyers located across all states in the United States and working in most types and sizes of legal venues. The data were collected between 2018 and 2019, before the 2020 pandemic. We estimate differences across three categories of discrimination reported-subtle-only discrimination, overt-only discrimination, and both subtle and overt discrimination. We estimate the nature and magnitude of associations among individual and organizational variables, and we use multinomial logistic regression to illustrate relative risks of reports of discrimination for intersecting identities.

RESULTS

As compared to non-disabled lawyers, lawyers with disabilities show a higher likelihood of reporting both subtle and overt discrimination versus no discrimination. Similarly, lawyers who identify as lesbian, gay, bisexual, and queer ("LGBQ") show a higher likelihood of reporting both subtle and overtdiscrimination, and subtle-only discrimination, as compared to lawyers who identify as straight/heterosexual. Women lawyers and lawyers of color are more likely to report all three types of discrimination. In general, younger lawyers are more likely to report subtle-only discrimination when compared to older lawyers. Lawyers working at a private firm are less likely to report all types of discrimination, while working for a larger organization is associated with a higher relative risk of reporting subtle-only discrimination versus no discrimination.

CONCLUSIONS

The current study represents a next, incremental step for better understanding non-monochromatic and intersectional aspects of individual identity in the legal profession. The findings illustrate that primary individual and multiple minority identities, as identified by disability, sexual orientation, gender, race/ethnicity, and age, are associated with reports of discrimination and bias in the legal workplace.

Perspectives from Young Partnered Gay, Bisexual, and Other Men Who Have Sex with Men on the Adaptation of Couples HIV Testing and Counseling (CHTC)

Young gay, bisexual, and other men who have sex with men (YGBMSM) are a priority population for HIV prevention efforts. Although there has been a growing focus on dyadic HIV prevention interventions for same-gender male couples, the unique needs of partnered YGBMSM have been largely overlooked. In this qualitative study, we explored partnered YGBMSM's perceptions of existing HIV prevention interventions to inform the design of a relationship-focused HIV prevention intervention. Between July and November 2018, we conducted in-depth interviews with 30 young partnered YGBMSM (mean age = 17.8, SD = 1.1). Participants described that interventions were needed to address skills regarding: (1) implicit versus explicit communication about sexual agreements; (2) boundary setting and identifying signs of abusive relationships; and (3) relationship dynamics (e.g., trust). Participants noted the absence of inclusive sexual education for them; thus, findings suggest that the provision of relationship skills training are requisites for HIV prevention interventions with YGBMSM in the US.

State versus trait weight, shape, and eating concerns: Disentangling influence on eating behaviors among sexual minority women

This study examined the relative influence of trait and state weight, shape, and eating concerns on dysregulated eating in the daily lives of sexual minority women with overweight and obesity. This study is a secondary analysis of data from an Ecological Momentary Assessment (EMA) study of 55 sexual minority women with overweight/obesity. Trait shape, weight, and eating concerns were assessed at baseline. For the following five days, participants used a smartphone to report state weight/shape concerns, overeating, and binge eating five times daily. Women who endorsed higher levels of trait weight, shape, and eating concerns at baseline reported more frequent state weight/shape concerns in daily life. Trait eating concerns were associated with higher odds of binge eating during EMA, but trait weight/shape concerns were unrelated to future dysregulated eating. In daily life, state weight/shape concerns was associated with greater risk for over/binge eating at the concurrent EMA prompt, the subsequent EMA prompt, and over the course of a full day, independent of trait concerns. State weight and shape concerns may play an important role in predicting dysregulated eating in daily life among sexual minority women of higher body weight.

Ethnic/racial and gender differences in body image disorders among a diverse sample of sexual minority U.S. adults

This study assessed the occurrence of probable eating disorders (EDs), ED symptoms, probable body dysmorphic disorder (BDD), BDD symptoms, drive for muscularity, and appearance and performance enhancement drug (APED) misuse, in an ethnically/racially diverse sample of 962 cisgender sexual minority (SM) individuals in the United States, aged 18-30 years old. The overall occurrence of probable ED, probable BDD, and APED misuse in the current sample was 32.7 %, 50.9 %, and 30.6 %, respectively. With respect to ethnicity/race, Hispanic SMs reported the highest rates of EDs, BDD, APED misuse, and drive for muscularity, and may therefore be particularly at risk for developing body image disorders (BIDs). With respect to gender, SM men reported significantly greater drive for muscularity and APED misuse compared to SM women, while SM women reported significantly higher occurrence of probable ED and ED symptoms. The occurrence of EDs, BDD, and APED misuse were higher among SMs in this sample compared to previous rates found among heterosexual samples, suggesting that SMs, regardless of gender and ethnicity/race, are vulnerable to experiencing BIDs and APED misuse. Future research is needed to identify the mechanisms that place SMs at (increased) risk for BIDs, which will aid prevention/intervention development.

A review of current strategies to improve HIV prevention and treatment in sexual and gender minority Latinx (SGML) communities

INTRODUCTION

The HIV epidemic continues to disproportionately impact sexual and gender minority Latinxs (SGML). Several syndemic conditions have been linked with HIV acquisition and transmission among SGML including immigration, discrimination, environmental racism, substance use, and mental health.

AREAS COVERED

We provide a summary of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum among SGML. We also discuss intervention approaches and opportunities that respond at the intersection of HIV and COVID-19 prevention and treatment.

EXPERT OPINION

There is a dire need for the combination of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum. Interventions and combination approaches should be driven by community-based participatory action research. The inclusion of community members in all stages of the research process can assure successful implementation of program activities and deliverables, including the provision of culturally and linguistically appropriate services. Given the current COVID-19 pandemic, which is disproportionately impacting individuals living with HIV and other comorbidities, the elderly, and under-resourced communities with a ferocity not seen in other communities, intervention approaches that respond at the intersection of HIV and COVID-19 prevention and treatment are also urgently needed.

Awareness of and willingness to use pre-exposure prophylaxis (PrEP) among people who inject drugs and men who have sex with men in India: Results from a multi-city cross-sectional survey

Introduction

Pre-exposure prophylaxis (PrEP) is effective in reducing HIV transmission among key populations. In India, where PrEP is not currently part of the national HIV program, little is known about PrEP awareness, willingness to use PrEP, and barriers to uptake among people who inject drugs (PWID) and men who have sex with men (MSM).

Methods

We used respondent-driven sampling to accrue PWID and MSM in 22 sites from August 2016 to May 2017. Participants were asked about awareness of PrEP, willingness to use PrEP (following a brief description) and reasons why they might not be willing to use PrEP. Participants were also queried on preferences for PrEP delivery modality (oral vs. injectable). Multi-level logistic regression models were used to determine participant correlates of willingness to use PrEP. Estimates were weighted for the sampling method.

Results

A total of 10,538 PWID and 8,621 MSM who self-reported being HIV-negative were included in the analysis. Only 6.1% (95% confidence interval [CI]: 5.9, 6.3) of PWID and 8.0% of MSM (95% CI: 7.7, 8.4) were aware of PrEP. However, willingness to use PrEP was substantially higher in both groups: 52.4% of PWID and 67.6% of MSM. Participants commonly cited a perceived low risk for acquiring HIV infection, being perceived by others as being HIV-positive, and side effects as reasons why they would be unwilling to use PrEP. Among PWID, sharing needles and hazardous alcohol use were associated with increased willingness to use PrEP. Among MSM, having a main male partner and injection drug use were associated with increased willingness to use PrEP. Preference for daily oral or monthly injectable PrEP was similar among MSM (39.6%% vs. 41.7%,), while PWID were more likely to prefer oral to injectable administration routes (56.3% vs. 31.1%).

Conclusions

As India plans to roll-out of PrEP in the public sector, our multi-city survey of PWID and MSM highlights the need for key population-focused education campaigns about PrEP and self-assessment of risk.

Could Johnny Tremain Be Gay? Reinterpretation as a Subversive Act

Members of sexual minority groups confront a dearth of fictional characters in k-12 curricula with whom they can feel any affinity, particularly in regard to sexual orientation. This is especially problematic for readers who are at odds with themselves and/or society over cultural constructions of normalcy. Queer theory can address this issue by encouraging readers to contest the putative heteronormativity in works of literature. The perennially popular novel Johnny Tremain provides such an opportunity. Though the author, Esther Forbes, depicts the main protagonist as heterosexual, a queer analysis of the novel and comparison to the subsequent film version by Walt Disney suggest that other interpretations are possible. This is significant because healthy identity formation can be fostered by encountering positive portrayals of fictional individuals like oneself. Moreover, promoting self-esteem is consistent with the praxis - the "activist agenda" - that has become an important element of queer criticism.

Heteronormativity in the Lives of Lesbian, Gay, Bisexual, and Queer Young People

Heteronormativity, as defined in queer theory, is the presumption and privileging of heterosexuality. Research on how young people make sense of and narrate heteronormativity in their own lives is needed to inform theories of heteronormativity. Using queer and intersectional frameworks, we conducted semi-structured interviews with 14 sexual and gender minority young people (ages 18 to 24), analyzed using thematic analysis, to examine how young adults make sense of heteronormativity. Participants discussed how gender expression informed both sexuality and sexual attraction. Participants prioritized biological parenthood over other family constructions but rarely discussed marriage. Gender, sexuality, and race contributed important contexts for how participants described heteronormativity in their lives and should be the focus of future research. Finally, binaries of gender, sexuality, and family intersected in participants' lives and their narrative constructions.

The Mediating Role of Attachment Avoidance in the Association between Sexual Orientation and Mental Health

The current study examined whether attachment avoidance mediates the association between being a sexual minority (gay men or lesbian women) and poorer mental health outcomes. For this purpose a community-dwelling sample of 350 gay men and lesbian women (M = 30.39, SD = 6.82) and 445 heterosexual men and women (M = 26.95, SD = 3.11) completed measures of attachment avoidance, depressive symptoms, anxiety symptoms and life satisfaction. Results showed that gay men and lesbians reported poorer mental health. Moreover, attachment avoidance had a mediating effect on the association between being a sexual minority and depressive symptoms, anxiety symptoms and life satisfaction. These findings are some of the first to suggest empirical support for the role of attachment avoidance in accounting for the mental health vulnerability of gay men and lesbians. The results contribute to a better understanding of the minority stress model and should be addressed by practitioners.

Psychological and Interpersonal Factors Associated with Sexualized Drug Use Among Men Who Have Sex with Men: A Mixed-Methods Systematic Review

Chemsex-the use of specific drugs during planned sexual activity to sustain or enhance sexual functioning (Bourne et al., 2015)-is widely reported as a major public health issue among gay, bisexual, and other men who have sex with men (GBM) in Western countries. Considering current evidence surrounding Chemsex, we conducted a mixed-methods systematic review regarding psychological and interpersonal factors associated with Chemsex behaviors among GBM. Publications covering Chemsex and psychological or social variables were eligible. Theoretical papers and studies solely presenting physical health outcomes were excluded. 35 English papers published between January 2008 and June 2019 were identified through PubMed, Scopus, and PsycINFO. We performed a parallel-results convergent synthesis (Hong, Pluye, Bujold, & Wassef, 2017) on results extracted from qualitative and quantitative studies comprising the final corpus. Qualitative data suggest that six mechanisms promote Chemsex-related behaviors: dealing with painful emotions or stressful events; normalization and risk minimization of sexualized drug use; giving into interpersonal pressure or fulfilling desire for community belonging; increasing intimacy or connectedness; enhancing sexual performance and functioning; lessening interpersonal and sexual inhibitions. In quantitative reports, six variable categories emerged: sexual control and self-efficacy; sexual functioning; mental health; attitudes toward substance use; life stressors and internalized stressors; and identification with sexual identities or scenes. This review summarizes key psychological and interpersonal correlates of Chemsex among GBM. Further research is needed to replicate current findings and explore new hypotheses across multiple GBM sociodemographic groups and cultural contexts, following best practices in sampling for hard-to-reach populations.

Understanding How Gay, Bisexual, and Other Men Who Have Sex With Men in China Cope With HIV Care-Related Stressors

Understanding how Chinese gay, bisexual, and other men who have sex with men (GBMSM) cope with HIV care-related stressors could improve their care engagement. Qualitative semistructured interviews were conducted with 30 GBMSM living with HIV recruited through clinics and a community-based organization (CBO) in Chengdu, China. Interviews focused on treatment-related stress, coping strategies, social support, and well-being. Half reported symptoms consistent with mild or moderate depression as measured by the PHQ-9 scale. HIV care-related stressors included side effects, difficulty with adherence, and fear of drug resistance. Challenges to coping include navigating contradictory information about HIV and treatment, experiencing stigma and discrimination within medical and nonmedical settings, and managing financial concerns. CBOs, peer groups, and providers were salient sources of social support benefitting coping. To improve sustained HIV care that meets the needs of Chinese GBMSM living with HIV, tailored interventions that address the above-mentioned stressors and coping challenges are likely needed.

Mental Health and Health Risk Behaviors of Active Duty Sexual Minority and Transgender Service Members in the United States Military

Purpose: The aim of this study was to examine health risk behaviors and mental health outcomes among sexual minority and transgender active duty military service members and their heterosexual and cisgender counterparts. Methods: Participants (N = 544) were recruited by using respondent-driven sampling between August 2017 and March 2018 and completed an online survey by using validated measures of cigarette smoking, alcohol use, anxiety, depression, post-traumatic stress disorder (PTSD), and suicidality. Bayesian random intercept multiple logistic regressions were used to understand differences between sexual minority participants and heterosexual participants as well as between transgender participants and both their cisgender sexual minority and cisgender heterosexual peers. Results: Cisgender sexual minority women service members were more likely to meet criteria for problematic alcohol use (adjusted odds ratio [aOR] = 10.11) and cigarette smoking (aOR = 7.12) than cisgender heterosexual women. Cisgender sexual minority men had greater odds of suicidality (aOR = 4.73) than their cisgender heterosexual counterparts. Transgender service members had greater odds of anxiety, PTSD, depression, and suicidality than their cisgender peers. Conclusion: Military researchers and policymakers who seek to improve the overall health and well-being of sexual minority and transgender service members should consider programs and policies that are tailored to specific health outcomes and unique sexual minority and transgender subgroups.

Association Between Sexual Orientation, Mistreatment, and Burnout Among US Medical Students

IMPORTANCE

Medical trainee burnout is associated with poor quality care and attrition. Medical students in sexual minority groups report fear of discrimination and increased mistreatment, but the association between sexual orientation, burnout, and mistreatment is unknown.

OBJECTIVE

To evaluate whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study surveyed US medical students graduating from Association of American Medical Colleges (AAMC)-accredited US allopathic medical schools who responded to the AAMC graduation questionnaire in 2016 and 2017. Statistical analyses were performed from March 15, 2019, to July 2, 2020, and from November 20 to December 9, 2020.

MAIN OUTCOMES AND MEASURES

Burnout was measured using the Oldenburg Burnout Inventory for Medical Students, and sexual orientation was categorized as either heterosexual or lesbian, gay, or bisexual (LGB). Logistic regression models were constructed to evaluate the association between sexual orientation and experiencing burnout (defined as being in the top quartile of exhaustion and disengagement burnout dimensions) and to test the mediating association of mistreatment.

RESULTS

From 2016 to 2017, 30 651 students completed the AAMC Graduation Questionnaire, and 26 123 responses were analyzed. Most respondents were younger than 30 years (82.9%) and White (60.3%). A total of 13 470 respondents (51.6%) were male, and 5.4% identified as LGB. Compared with heterosexual students, a greater proportion of LGB students reported experiencing mistreatment in all categories, including humiliation (27.0% LGB students vs 20.7% heterosexual students; P < .001), mistreatment not specific to identity (17.0% vs 10.3%; P < .001), and mistreatment specific to gender (27.3% vs 17.9%; P < .001), race/ethnicity (11.9% vs 8.6%; P < .001), and sexual orientation (23.3% vs 1.0%; P < .001). Being LGB was associated with increased odds of burnout (adjusted odds ratio, 1.63 [95% CI, 1.41-1.89]); this association persisted but was attenuated after adjusting for mistreatment (odds ratio, 1.36 [95% CI, 1.16-1.60]). The odds of burnout increased in a dose-response manner with mistreatment intensity. Lesbian, gay, or bisexual students reporting higher mistreatment specific to sexual orientation had and 8-fold higher predicted probability of burnout compared with heterosexual students (19.8% [95% CI, 8.3%-31.4%] vs 2.3% [95% CI, 0.2%-4.5%]; P < .001). Mediation analysis showed that mistreatment accounts for 31% of the total association of LGB sexual orientation with overall burnout (P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that LGB medical students are more likely than their heterosexual peers to experience burnout, an association that is partly mediated by mistreatment. Further work is needed to ensure that medical schools offer safe and inclusive learning environments for LGB medical students.

Getting by with a Little Help from Our Friends: The Role of Social Support in Addressing HIV-related Mental Health Disparities among Sexual Minorities in the Lower Rio Grande Valley

This study examines how social support and perceived discrimination influence depressive symptoms of sexual minorities (including, lesbian, gay, bisexual-identifying individuals, and others with same-sex sexual partners) relative to heterosexual peers, while considering the role of HIV-positive status. We surveyed low-income, predominantly Hispanic/Latino/as residents receiving STI-testing and/or HIV/AIDS care in the lower Rio Grande Valley of southernmost Texas. Respondents aged 18+ took a self-administered survey in English or Spanish in a clinic waiting room (N= 273). Based on OLS regression, HIV-positive status (OLS coefficient = 2.54, p< .01) and social support (OLS coefficient = -0.17, p< .001) were significant predictors of depressive symptoms among sexual minorities, but not those who identified as heterosexual. Perceived discrimination was uniquely associated with increased depressive symptoms among sexual minorities (interaction coefficient = 0.21, p< .05). Clinicians treating sexual minority patients for depression should consider developing and applying resources tailored to individuals' level of social support and ongoing experiences of social discrimination.

Narratives of Generativity and Resilience among LGBT Older Adults: Leaving Positive Legacies despite Social Stigma and Collective Trauma

The aim of many adults in middle to old age is to be generative. Generativity is the concern older adults direct toward the wellbeing of future generations. Being generative results in positive well-being during later life and is especially important to lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults who have experienced lifelong discrimination. In this study, we identified stigmatizing social influences that both negatively and positively acted to inform understandings of generativity and the ability to leave a legacy for future generations. Using a narrative analysis methodology, we identified three overarching redemptive narratives from study participants: (1) experiences during the HIV/AIDS pandemic, (2) absence of positive role models, and (3) religious conviction. These life story narratives inform how generative contributions can contribute toward a legacy of resilience, despite social stigma and collective trauma.

Developing and Validating a Computable Phenotype for the Identification of Transgender and Gender Nonconforming Individuals and Subgroups

Transgender and gender nonconforming (TGNC) individuals face significant marginalization, stigma, and discrimination. Under-reporting of TGNC individuals is common since they are often unwilling to self-identify. Meanwhile, the rapid adoption of electronic health record (EHR) systems has made large-scale, longitudinal real-world clinical data available to research and provided a unique opportunity to identify TGNC individuals using their EHRs, contributing to a promising routine health surveillance approach. Built upon existing work, we developed and validated a computable phenotype (CP) algorithm for identifying TGNC individuals and their natal sex (i.e., male-to-female or female-to-male) using both structured EHR data and unstructured clinical notes. Our CP algorithm achieved a 0.955 F1-score on the training data and a perfect F1-score on the independent testing data. Consistent with the literature, we observed an increasing percentage of TGNC individuals and a disproportionate burden of adverse health outcomes, especially sexually transmitted infections and mental health distress, in this population.

A systematic review and meta-analysis of victimisation and mental health prevalence among LGBTQ+ young people with experiences of self-harm and suicide

BACKGROUND

LGBTQ+ youth have higher rates of self-harm and suicide than cisgender, heterosexual peers. Less is known about prevalence of risks within these populations.

OBJECTIVES

The first systematic review and meta-analysis to investigate the prevalence of risks among young people throughout the LGBTQ+ umbrella with experiences across the dimension of self-harm, suicidal ideation and suicide behaviour; and how they may differ between LGBTQ+ umbrella groups.

DATA SOURCES

MEDLINE, Scopus, EMBASE, PsycINFO, and Web of Science searches were run to identify quantitative research papers (database inception to 31st January, 2020).

STUDY ELIGIBILITY CRITERIA

Articles included were empirical quantitative studies, which examined risks associated with self-harm, suicidal ideation or suicidal behaviour in LGBTQ+ young people (12-25 years).

SYNTHESIS METHODS

2457 articles were identified for screening which was completed by two independent reviewers. 104 studies met inclusion criteria of which 40 had data which could be meta-analysed in a meaningful way. This analysis represents victimisation and mental health difficulties as risks among LGBTQ+ youth with self-harm and suicide experiences. Random-effects modelling was used for the main analyses with planned subgroup analyses.

RESULTS

Victimisation and mental health were key risk factors across the dimension self-harm and suicide identified through all analyses. A pooled prevalence of 0.36 was indicated for victimisation and 0.39 for mental health difficulties within LGBTQ+ young people with experiences of self-harm or suicide. Odds ratios were calculated which demonstrated particularly high levels of victimisation (3.74) and mental health difficulties (2.67) when compared to cisgender, heterosexual counterparts who also had these experiences.

CONCLUSIONS

Victimisation and mental health difficulties are highly prevalent among LGBTQ+ youth with experiences of self-harm and suicide. Due to inconsistency of reporting, further risk synthesis is limited. Given the global inclusion of studies, these results can be considered across countries and inform policy and suicide prevention initiatives.

PROSPERO REGISTRATION NUMBER

CRD42019130037.

"Let Us Bless the Twilight": Intersectionality of Traditional Jewish Ritual and Queer Pride in a Reform Congregation in Israel

Kabbalat Shabbat (Welcoming the Sabbath) is a traditional Jewish ritual marking the transition between the profane weekday and the holy Shabbat. Reform Jewish communities maintain this practice with certain ritualistic and textual revisions, in order to include gender and sexual categories previously excluded from mainstream traditional Jewish texts and rituals. This ethnographic article analyzes the particular LGBTQ Kabbalat Shabbat. By creating unique rituals to mark phenomena of both oppression and exclusion, on the one hand, and of love and acceptance, on the other, the Reform congregation emerges as a religious safe space. I argue that those rituals dedicated to and constructed by the LGBTQ community function as a performance of affirmation and empower of gender and sexual identities. This egalitarian performance fosters a shared political discourse for promoting the struggle for equal rights, through a new religious practice.

Association between Discrimination and Depressive Symptoms Among 2,162 Lesbian, Gay, and Bisexual Adults in South Korea: Does Community Connectedness Modify the Association?

This study investigated the association between perceived discrimination and depressive symptoms among Korean lesbian, gay, and bisexual (LGB) individuals and explored the role of community connectedness in that association. We analyzed a nationwide cross-sectional survey of 2,162 LGB adults in Korea. Discrimination based on its types, including sexual orientation, over the past 12 months was classified into four categories: (1) 'never experienced discrimination,' experienced (2) 'only sexual orientation discrimination,' (3) 'any of the other types of discrimination,' and (4) 'both sexual orientation discrimination and any of the other types of discrimination.' Our findings suggest that there was a statistically significant association between 'only sexual orientation discrimination' and depressive symptoms among LGB individuals with a low-level of community connectedness, but not among those with a high-level. In the other two categories of discrimination, which included the other types of discrimination, the associations were statistically significant, regardless of the level of community connectedness.

Non-Heterosexual Medical Students Are Critically Vulnerable to Mental Health Risks: The Need to Account for Sexual Diversity in Wellness Initiatives

Phenomenon: Mental health problems among medical students are a worrisome issue; recent studies have shown that one-third may be suffering major depressive disorder and one out of ten had suicidal ideation. Few studies have evaluated the association of medical students' mental health and their sexual orientation. This study aimed to evaluate differences in mental health indicators among medical students with diverse sexual orientations at a South American medical school. Approach: This study is a secondary analysis of cross-sectional data obtained through an electronic survey. The survey assessed demographics, academic variables, and several mental health scales and indexes, including: World Health Organization Well-being Index, Satisfaction With Life Scale, Family APGAR (Adaptability, Partnership, Growth, Affection, and Resolve), Self-Reporting Questionnaire, Athens Insomnia Scale, Eating Attitudes Test, and Alcohol Use Disorders Identification Test. Sexual orientation was assessed using self-identification and responses dichotomized as heterosexual and non-heterosexual. Findings: 554 students completed the survey (response rate: 70%). Mean age was 20.6 years, and the sample was 58.7% women. Eighty-two participants (14.8%) self-identified as non-heterosexual; this group comprised mostly males, fewer of whom lived with their family, and more of whom used loans or scholarships to pay university tuition fees. After adjustment for sex and tuition fee payment, non-heterosexual orientation was significantly associated (adjusted Odds Ratios [aOR] above 3.00) with rating mental health as bad, self-perceiving a need for mental health evaluation/treatment, and reporting last-year use of psychiatric medication. Lastly, non-heterosexual respondents reported more frequent psychiatric symptoms (depression/anxiety scores, suicidal ideation, eating disorder symptoms and substance use) with an aOR between 2.17 and 2.51. Insights: This study suggests that self-identified non-heterosexual medical students exhibit worse mental health outcomes evaluated through validated self-report scales and subjective perception of mental health status. This report specifically indicates that non-heterosexual medical students report family dysfunction more often and have less social support, which serve as additional risk factors. Future studies must assess social support, clarify the impact of family and peer support in mental health problems, and explore students' views on their sexual identity and the burden imposed by experiences of discrimination.

Freedom and struggling openly in psychotherapy: A qualitative inquiry with LGBQ young adults from religious families

Lesbian, gay, bisexual, and queer (LGBQ) young people from religious families are at increased risk of family rejection, poor mental health outcomes, and are overrepresented in mental health services. This article describes a two-part qualitative study aimed at exploring the experiences of LGBQ young adults from religious families in psychotherapy, identifying positive and negative psychotherapy experiences, and understanding the influence of family and religion on the psychotherapy experience. Data were collected through a web-based survey (n = 77) and interviews (n = 7) with LGBQ young adults (ages 18-25) from religious families. The study followed an interpretative phenomenological approach. Integrated results found often invisible, relational therapy processes, and religious discourses as significant to LGBQ young people who seek psychotherapy. Implications for future research, effective systemic family therapy practices with LGBQ young people from religious families, and a critique on ethical and legal limits of confidentiality with policy implications are outlined.

Relationship between sexual orientation and psychotic experiences in the general population in England

BACKGROUND

Non-heterosexual individuals are at high risk for a variety of factors associated with the emergence of psychotic experiences (PEs) (e.g. common mental disorders, substance use, and stress). However, there is a scarcity of data on the association between sexual orientation and PEs. Therefore, the aim of this study was to examine the sexual orientation-PE relationship, and to identify potential mediators in this relationship.

METHODS

This study used nationally representative cross-sectional data from the 2007 Adult Psychiatric Morbidity Survey. Sexual orientation was dichotomized into heterosexual and non-heterosexual. Past 12-month PE was assessed with the Psychosis Screening Questionnaire. Regression and mediation analyses were conducted to analyze the association between sexual orientation and PEs, and to identify potential mediators involved in this relationship.

RESULTS

The final sample consisted of 7275 individuals aged ⩾16 years. The prevalence of non-heterosexual orientation and any PE was 7.1% and 5.5%, respectively. After adjusting for sex, age, and ethnicity, non-heterosexual orientation was positively associated with any PE (odds ratio 1.99, 95% confidence interval 1.34-2.93). The strongest mediators involved in this relationship were borderline personality disorder (BPD) traits (mediated percentage = 33.5%), loneliness (29.1%), and stressful life events (25.4%).

CONCLUSIONS

These findings suggest that there is a positive relationship between sexual orientation and PEs in the general population in England, and that underlying mechanisms may involve BPD traits, loneliness, and stressful life events. Future studies with a longitudinal design are warranted to shed more light on how these factors are implicated in the association between sexual orientation and PEs.

Out and in Harm's Way: Sexual Minority Students' Psychological and Physical Health after Institutional Betrayal and Sexual Assault

In a large random sample of undergraduate university students, we investigated whether sexual minority individuals (i.e., lesbian, gay, and bisexual individuals) experienced different rates of sexual violence victimization (including sexual assault and rape) and subsequent institutional betrayal compared to their heterosexual counterparts, and whether such differences may account for disparities in the psychological and physical health of sexual minorities compared to heterosexuals. In addition to differences in sexual assault victimization rates by gender and sexual orientation, we found differences in rates of institutional betrayal. When non-heterosexual women experienced sexual assault, they experienced a significantly higher rate of institutional betrayal compared to heterosexual women. Overall, greater institutional betrayal was associated with greater negative psychological and physical health outcomes in sexual minorities compared to heterosexual students. These findings reinforce the need for institutional reforms related to the climate and reporting of sexual violence on college campuses, and also identify sexual minority students as a population of particular risk for additional harm by their institutions when they need them most.

Gay and Bisexual Men in the US Lack Basic Information About Anal Cancer

OBJECTIVE

The purpose of this study was to assess knowledge of human papillomavirus (HPV) as a cause of anal cancer among at-risk gay, bisexual, and other men who have sex with men (GBM).

MATERIALS AND METHODS

Secondary analysis was conducted of cross-sectional data from 3 cycles of the Health Information National Trends Survey (2017, 2018, 2019). Results were reported for the subset of adults who identified as GBM (N = 212). Knowledge that HPV can cause anal cancer was the main outcome. Differences in knowledge were evaluated (using χ2 and multiple logistic regression) by demographic, health information factors, and access to care.

RESULTS

Sixty-eight percent of GBM were aware of HPV. Knowledge that HPV causes anal cancer was low (<20%) in the overall sample and sample of GBM (17.9%; 95% CI = 11.0-24.7). Gay, bisexual, and other men who have sex with men were no more knowledgeable that HPV causes anal cancer than heterosexual men (14.8%; 95% CI = 12.9-16.9; p = .376). College-educated GBM had higher odds (adjusted odds ratio = 3.50; 95% CI = 1.02-11.97) of knowing HPV causes anal cancer than GBM with no college degree. No other factors were associated with knowledge.

CONCLUSIONS

Gay, bisexual, and other men who have sex with men are largely unaware that HPV can cause anal cancer, despite high awareness of HPV itself. This is concerning given that GBM are at increased risk of HPV-associated anal cancer than the general population. Our findings suggest that information about anal cancer and health information about the benefits of HPV vaccination for anal cancer prevention are only reaching a small subset of college-educated GBM. Targeted anal cancer education programs are needed.

Association of sexual minority status, gender nonconformity with childhood victimization and adulthood depressive symptoms: A path analysis

BACKGROUND

Sexual minority status and childhood gender nonconformity have been associated with elevated risks of childhood adversities and poorer mental health.

OBJECTIVE

To explore how abuse and bullying explain the disparities in the associations of sexual minority status and childhood gender nonconformity with adulthood depressive symptoms in men.

PARTICIPANTS AND SETTING

We conducted a cross-sectional study using a self-report questionnaire among Chinese adult men (18-35 years) who were identified as heterosexual (n = 873) and sexual minority (n = 858) in Guangzhou from 2017 to 2019.

METHODS

Structural equation modeling (SEM) were conducted for path analysis.

RESULTS

The levels of exposure to childhood maltreatment were higher in sexual minorities than in straight men, and sexual minority status predicted an increased risk of depressive symptoms via childhood maltreatment (indirect effect: β = 0.026, p = 0.004). Meanwhile, childhood gender nonconformity predicted higher depressive symptoms via both family (indirect effect: β = 0.042, p < 0.001) and school (indirect effect: β = 0.028, p < 0.001) victimization, and there was a direct effect (β = 0.154, p < 0.001) of gender nonconformity on depressive symptoms.

CONCLUSION

Sexual minority status and gender nonconformity are indicators of men's increased risk of childhood victimization and adulthood depressive symptoms. As a result, intervention based on both family and school dimensions needs to be developed.

Differences in Health-Related Quality of Life and Health Behaviors Among Lesbian, Bisexual, and Heterosexual Women Surviving Cancer from the 2013 to 2018 National Health Interview Survey

Purpose: Health-related quality of life (HRQoL) and health behaviors contribute to cancer morbidity and mortality, which are elevated in lesbian and bisexual women (LBW). The purpose of this study was to assess differences in HRQoL and health behaviors between heterosexual and lesbian women and heterosexual and bisexual women cancer survivors. Methods: We pooled 2013-2018 National Health Interview Survey data. HRQoL comprised physical, mental, financial, and social health domains. Health behaviors included tobacco and alcohol use, physical activity, and preventive health care. Weighted, multivariable logistic regression models estimated odds ratios (ORs) with 95% confidence intervals (CIs). Results: The sample included 10,830 heterosexual, 141 lesbian, and 95 bisexual cancer survivors. Lesbian women reported higher odds of fair/poor self-rated health (OR: 1.68, 95% CI 1.02-2.78), chronic obstructive pulmonary disease (OR: 1.98, 95% CI 1.09-3.56), and heart conditions (OR: 1.90, 95% CI 1.16-3.12) than heterosexual women. Bisexual women reported higher odds of severe psychological distress (OR: 3.03, 95% CI 1.36-6.76), heart conditions (OR: 1.98, 95% CI 1.12-3.53), and food insecurity (OR: 2.89, 95% CI 1.29-6.50) than heterosexual women. For health behaviors, lesbian women reported greater odds of current (OR: 2.34, 95% CI 1.26-4.34) and former tobacco use (OR: 1.89, 95% CI 1.21-2.96), and bisexual women had lower odds of a recent mammogram (OR: 0.42, 95% CI 0.23-0.78) than heterosexual women. Conclusions: LBW cancer survivors reported disparities in HRQoL and health behaviors. In cancer care settings, identification of LBW patients requiring physical and mental health promotion, financial services, and supported tobacco cessation may improve health and survival.

Longitudinal trends in PrEP familiarity, attitudes, use and discontinuation among a national probability sample of gay and bisexual men, 2016-2018

This study explored familiarity with, attitudes toward, uptake and discontinuation of PrEP (Pre-exposure prophylaxis) among a national probability sample of gay and bisexual men. PrEP is one of the most effective biomedical HIV prevention strategies; however, use among gay and bisexual men remains low within the United States. This study used a national probability sample of gay and bisexual men from three age cohorts of men (18-25, 34-41, and 52-59 years at wave 1) who completed three annual surveys between March 2016 and March 2018 (N at wave 1 = 624). Recruitment occurred through a Gallup dual-frame sampling procedure; results for this study came from eligible individuals who consented to be part of the self-administered online or mailed survey questionnaire. We used descriptive data with sampling weights to understand trends in PrEP familiarity, PrEP attitudes and PrEP use across all three time points. Next, PrEP uptake and discontinuation were assessed among men completing all three surveys and who remained eligible for PrEP at all three time points (N = 181). PrEP familiarity increased considerably between 2016 and 2018 among those eligible for PrEP (from 59.8% from wave 1 to 92.0% at wave 3). Favorable attitudes toward PrEP increased more modestly (from 68.3% at wave 1 to 72.7% at wave 3). While PrEP use increased by 90% between the two time points (from 4.1% in 2016 to 7.8% in 2018), this represented a small percentage of overall uptake among eligible participants across time (6.6%). Among respondents who reported PrEP use at wave 1 or wave 2, 33.3% subsequently discontinued PrEP use at a later wave. Findings indicate modest increases in PrEP use between 2016 and 2018 in a national probability sample of sexually-active gay and bisexual men. PrEP discontinuation was high and suggests the need for further research into gay and bisexual men's PrEP discontinuation and persistence.

Myths, misconceptions, othering and stigmatizing responses to Covid-19 in South Africa: A rapid qualitative assessment

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.

Suicide Attempt Rates and Associations with Discrimination Are Greatest in Early Adulthood for Sexual Minority Adults Across Diverse Racial and Ethnic Groups

Purpose: The study purpose was to investigate differences in past 5-year suicide attempts among racially/ethnically diverse sexual minority (SM) and heterosexual adults across the life course and examine the association of discrimination with past 5-year suicide attempts among SM adults. Methods: Using nationally representative data collected from 2012 to 2013, we assessed differences in age-varying prevalence of past 5-year suicide attempts among Black, Hispanic, and White SM and heterosexual adults (ages 18-60). We tested whether the association between discrimination and suicide attempts differed by race/ethnicity among SM adults. All secondary data analyses were approved by the Institutional Review Boards of The Pennsylvania State University and University of Maryland. Results: Compared with heterosexual adults of any race/ethnicity, SM adults exhibited elevated suicide attempt rates until the late twenties when prevalence for Black and Hispanic SM adults declined. Disparities persisted into the mid-40s for White SM adults. Among SM adults of all races/ethnicities, the relationship between SM discrimination and suicide attempts was strongest between ages 18 and 25. For SM adults reporting SM discrimination, odds of suicide attempts were 3.6 times higher for White SM adults and 4.5 times higher for Black and Hispanic SM adults, relative to same-race/ethnicity SM adults who did not report SM discrimination. The effect of SM discrimination was robust among Black and Hispanic SM young adults even when accounting for racial/ethnic discrimination. Conclusions: SM adults of all racial/ethnic groups demonstrated disparities when contrasted with heterosexual adults of any race/ethnicity, although ages characterized by heightened prevalence rates of suicide attempts differed by race/ethnicity. Early adulthood is a critical period for intervention seeking to disrupt the association between SM discrimination and suicide attempts.

Single Bisexual Men's and Women's Perceptions of Acceptance in the LGBTQ Community

In recent years, sociocultural shifts in the U.S. have cast a positive light on the LGBTQ community, presumably providing benefits to sexual and gender minorities. Using a sample of single lesbian, gay, and bisexual men and women (N= 924) collected from a 2016 survey in the U.S., we assess bisexual people's attitudes about the "LGBTQ community", as well as how others in the community - gay men and lesbian women - view bisexuals. We also examine contexts in which bisexual people feel they are unable to share their sexual identities. Descriptive analyses revealed that while many bisexual people feel they need to hide their sexual identity in most contexts, the majority of bisexual men and women feel "mostly" to "near total acceptance" in the LGBTQ community. Thus, while bisexual people do experience stigma-related stress, findings suggest a promising shift for bisexual people's lives in terms of drawing resources and support from the larger LGBTQ community.

Clergy Attitudes About Ways to Support the Mental Health of Sexual and Gender Minorities

This pilot study explored clergy members' attitudes about ways to support the mental health needs of sexual and gender minorities (SGM; e.g., lesbian, gay, bisexual, and transgender people). Participants (N = 86, 46% female, 26% SGMs) were US clergy members from a variety of religious faiths but mostly were leaders in Christian faith communities in the greater Chicago area. Clergy participants completed quantitative and qualitative items asking what types of resources (e.g., workshops, websites, consultations, or testimonies) and delivery format (online or in-person) they perceived as most helpful in supporting the mental health of SGM members in their faith communities. The results demonstrated that clergy members found all listed resources to be helpful to varying degrees, although suicide and homelessness prevention were prioritized above other resources. Clergy members also prioritized resources related to supporting gender minorities to be more informative, relative to resources for supporting sexual minorities. Finally, clergy member preferred information to be delivered in-person instead of online. The degree of openness to LGBTQ health promotion resources did not vary by clergy religious denomination.

Evaluation of Suicide Mortality Among Sexual Minority US Veterans From 2000 to 2017

IMPORTANCE

Identification of subgroups at greatest risk for suicide mortality is essential for prevention efforts and targeting interventions. Sexual minority individuals may have an increased risk for suicide compared with heterosexual individuals, but a lack of sufficiently powered studies with rigorous methods for determining sexual orientation has limited the knowledge on this potential health disparity.

OBJECTIVE

To investigate suicide mortality among sexual minority veterans using Veterans Health Administration (VHA) electronic health record data.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study used data on 8.1 million US veterans enrolled in the VHA after fiscal year 1999 that were obtained from VHA electronic health records from October 1, 1999 to September 30, 2017. Data analysis was carried out from March 1, 2020 to October 31, 2020.

EXPOSURE

Veterans with documentation of a minority sexual orientation. Documentation of sexual minority status was obtained through natural language processing of clinical notes and extraction of structured administrative data for sexual orientation in VHA electronic health records.

MAIN OUTCOMES AND MEASURES

Suicide mortality rate using data on the underlying cause of death obtained from the National Death Index. Crude and age-adjusted mortality rates were calculated for all-cause death and death from suicide among sexual minority veterans compared with the general US population and the general population of veterans.

RESULTS

Among the 96 893 veterans with at least 1 sexual minority documentation in the electronic health record, the mean (SD) age was 46 (16) years, 68% were male, and 70% were White. Of the 12 591 total deaths, 3.5% were from suicide. Veterans had a significantly higher rate of mortality from suicide (standardized mortality ratio, 4.50; 95% CI, 4.13-4.99) compared with the general US population. Suicide was the fifth leading cause of death in 2017 among sexual minority veterans (3.8% of deaths) and the tenth leading cause of death in the general US population (1.7% of deaths). The crude suicide rate among sexual minority veterans (82.5 per 100 000 person-years) was higher than the rate in the general veteran population (37.7 per 100 000 person-years).

CONCLUSIONS AND RELEVANCE

The results of this population-based cohort study suggest that sexual minority veterans have a greater risk for suicide than the general US population and the general veteran population. Further research is needed to determine whether and how suicide prevention efforts reach sexual minority veterans.

An Assessment of Lesbian, Gay, Bisexual, and Transgender Health Competencies Among Bachelors-Prepared Registered Nurses in Graduate-Level Study

PURPOSE

To assess graduate nursing students' lesbian, gay, bisexual, and transgender (LGBT)-specific health competencies.

METHOD

Using a cross-sectional design, a 13-item multiple response survey, derived from The Joint Commission guidelines and LGBT health competencies proposed by the Association of American Medical Colleges, was administered online to 116 registered nurses enrolled in graduate study. Survey items assessed nurses' knowledge of LGBT health, professionalism, provision of patient care, communication skills, care environment, gaps in learning, and systems-based practice. Descriptive analyses were used to summarize frequencies and proportions of study variables.

RESULTS

Respondent nurses' knowledge about health, prevalent conditions, and social factors that influence LGBT health was somewhat limited. Respondents did not rate their knowledge about LGBT health high (µ = 3.11 [1.1], median = 3) and did not feel qualified to educate other colleagues about LGBT health issues (µ = 2.43 [1.26], median = 2). But 58% (n = 65) indicated that they felt comfortable performing prostate exams on transgender female patients (born with male genitalia); 62% (n = 70) felt comfortable doing pap smears for transgender male patients (born with female genitalia). Sixty nurses (52%) stated that they would advocate reforms within existing health care institutions to improve the care of LGBT patients. Cultural competency training was offered in some health care settings and environmental indications of inclusivity were inconsistent.

CONCLUSIONS

LGBT health competence among graduate nursing students was limited. There is a need to reevaluate LGBT health-related content in nursing curricula as well as robust assessment of competence in LGBT health.

The Role of Sexual Orientation in the Associations Between Religiousness and Hypertension

This study assessed the cross-sectional associations between organizational religious activity (ORA), intrinsic religiosity (IR), and hypertension in a US nationally representative sample. Data were from Wave IV of the National Longitudinal Study of Adolescent to Adult Health, collected in 2008. The sample (N = 5115, M_age = 28.96 years, 54% female) was divided into three sexual orientation categories: heterosexual, mostly heterosexual, and sexual minority. Dependent variables were systolic and diastolic blood pressure and binary cut-scores of clinical hypertension. ORA and IR were independent variables, with sexual orientation as the moderator. Multivariable analyses revealed greater ORA was associated with increased blood pressure (BP)/hypertension for the sexual minority group. There was a trend in the heterosexual group where ORA was associated with decreased BP. Generally, ORA was not associated with BP/hypertension in the mostly heterosexual group. There were no significant effects for IR. Future research should continue to examine the complex ways ORA and IR are associated with health based on sexual orientation and use longitudinal methodology to examine how ORA may impact BP/hypertension across the lifespan.

Security in a safety pin

A narrative about realizations as a young, gay, cis-gender man going through the medical system then through medical training. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Comparison of Trends in Rates of Sexually Transmitted Infections Before vs After Initiation of HIV Preexposure Prophylaxis Among Men Who Have Sex With Men

IMPORTANCE

There have been concerns that HIV preexposure prophylaxis (PrEP) may be associated with increases in sexually transmitted infections (STIs) because of subsequent reductions in condom use and/or increases in sexual partners.

OBJECTIVE

To determine trends in STI test positivity among high-risk men who have sex with men (MSM) before and after the start of HIV PrEP.

DESIGN, SETTING, AND PARTICIPANTS

A before-after analysis was conducted using a subcohort of a single-group PrEP implementation study cohort in New South Wales, Australia (Expanded PreEP Implementation in Communities in New South Wales [EPIC-NSW]), from up to 1 year before enrollment if after January 1, 2015, and up to 2 years after enrollment and before December 31, 2018. STI testing data were extracted from a network of 54 sexual health clinics and 6 primary health care clinics Australia-wide, using software to deidentify, encrypt, and anonymously link participants between clinics. A cohort of MSM dispensed PrEP for the first time during the study, with 2 or more STI tests in the prior year and who tested during follow-up, were included from the EPIC-NSW cohort of HIV-negative participants with high-risk sexual behavior. Data analysis was performed from June to December 2019.

EXPOSURES

Participants were dispensed coformulated tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP.

MAIN OUTCOMES AND MEASURES

The main outcome was STI, measured using test positivity, defined as the proportion of participants testing positive for an STI at least once per quarter of follow-up. Outcomes were calculated for Chlamydia trachomatis and Neisseria gonorrhoea by site of infection (anorectal, pharyngeal, urethral, or any) and for syphilis.

RESULTS

Of the EPIC-NSW cohort of 9709 MSM, 2404 were included in the before-after analysis. The mean (SD) age of the participants was 36 (10.4) years, and 1192 (50%) were Australia-born. STI positivity was 52% in the year after PrEP (23.3% per quarter; 95% CI, 22.5%-24.2% per quarter) with no significant trend (mean rate ratio [RR] increase of 1.01 per quarter [95% CI, 0.99-1.02]; P = .29), compared with 50% positivity in the year prior to PrEP (20.0% per quarter [95% CI, 19.04%-20.95% per quarter]; RR for overall STI positivity, 1.17 [95% CI, 1.10-1.24]; P < .001), with an increase in quarterly STI positivity (mean RR of 1.08 per quarter, or an 8% increase per quarter [95% CI, 1.05-1.11]; P < .001; RR, 0.93 [95% CI, 0.90-0.96]; P < .001). Findings were similar when stratified by specific STIs and anatomical site.

CONCLUSIONS AND RELEVANCE

STI rates were high but stable among high-risk MSM while taking PrEP, compared with a high but increasing trend in STI positivity before commencing PrEP. These findings suggest the importance of considering trends in STIs when describing how PrEP use may be associated with STI incidence.

"Moving from one environment to another, it doesn't automatically change everything". Exploring the transnational experience of Asian-born gay and bisexual men who have sex with men newly arrived in Australia

Asian-born gay, bisexual and other men who have sex with men (gbMSM) who are newly arrived in Australia are at a higher risk of acquiring HIV than Australian-born gbMSM. We used a social constructionist framework to explore HIV knowledge and prevention strategies used by newly-arrived Asian-born gbMSM. Twenty four Asian-born gbMSM, aged 20–34 years, attending Melbourne Sexual Health Centre, who arrived in Australia in the preceding five years, participated in semi-structured, face-to-face interviews. Interviews were recorded, transcribed verbatim and analysed thematically. Participants described hiding their sexual identities in their country of origin, particularly from family members, due to fear of judgement and discrimination resulting from exposure to sexual identity and HIV related stigma in their countries of origin, although some were open to friends. Despite feeling more sexual freedom and acceptance in Australia, many were still not forthcoming with their sexual identity due to internalised feelings of stigma and shame. Exposure to stigma in their country of origin led many to report anxiety around HIV testing in Australia due to a fear of testing positive. Some described experiencing racism and lack of acceptance in the gay community in Australia, particularly on dating apps. Fear of discrimination and judgement about their sexual identity can have a significant impact on Asian-born gbMSM living in Australia, particularly in terms of social connectedness. Additionally, HIV-related stigma can contribute to anxieties around HIV testing. Our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asian-born gbMSM.

Impacts of Public Debates on Legalizing the Same-Sex Relationships on People's Daily Lives and Their Related Factors in Taiwan

This study examined the proportion of the individuals who experienced negative impacts on daily lives resulted from public debates on the legalization of same-sex relationships and related factors in Taiwan. Data provided by 1370 participants recruited through a Facebook advertisement were analyzed. Participants completed an online questionnaire assessing negative impact of public debates on daily lives, gender, age, sexual orientation, the number of lesbian, gay and bisexual (LGB) friends, and perceived population's acceptance of homosexuality. The results showed that 39.5% of participants reported the negative impacts on their occupational or academic performance; 34.2% reported the negative impact on friendship; 37.7% reported the negative impact on family relationship; and 57.4% reported the negative impact on mood or sleep quality. Non-heterosexual participants were more likely to report negative impacts of public debates on all domains of daily lives than heterosexual ones. The number of LGB friends was positively associated with negative impacts of public debates on all domains of daily lives. Participants who were 20-29 years old were more likely to report negative impacts of public debates on the domains of family relationship and mood/sleep quality than those who were 40 or older. Participants who were 30-39 years old were more likely to report negative impacts of public debates on the domain of mood/sleep quality than those who were 40 or older. Males were less likely to report the negative impact on their mood/sleep quality than females. Perceiving population's acceptance for homosexuality were negatively associated with negative impacts of public debates on the domains of occupational/academic performance, family relationship and mood/sleep quality.

How norms concerning maternity, femininity and cisgender increase stress among lesbians, bisexual women and transgender people with a fear of childbirth

OBJECTIVE

To explore and describe norms concerning maternity, femininity and cisgender in lesbian and bisexual women and transgender people (LBT) assigned female at birth, with an expressed fear of childbirth (FOC).

DESIGN

Semi-structured interviews were conducted with self-identified LBT people with an expressed FOC.

PARTICIPANTS

17 self-identified LBT people participated. 15 had an expressed FOC, and two were non-afraid partners.

FINDINGS

Participants described how their FOC was related to ideals of "the primal woman", including ideals of a natural birth. They also described stress in relation to expectations of gaining a feminine-coded body during pregnancy and of being related to as feminine women.

KEY CONCLUSIONS

Maternity ideals, and the ideal of the "natural" birth, can be particularly stressful on those who fear childbirth. Norms concerning femininity and cisgender can contribute to FOC among those who do not comfortably conform with feminine body ideals or feminine gender expressions.

IMPLICATION FOR PRACTICE

Treatments of FOC must be designed to acknowledge whether and how norms concerning maternity, femininity and cisgender affect the individual's FOC.

Factors Associated with Condom Use among a Sample of Men Who Have Sex with Men (MSM) Residing in Rural Oklahoma

Public health literature often neglects populations from rural communities, particularly with men who have sex with men (MSM). Although HIV/STI infections are decreasing slightly, there is an increase within rural MSM, thus opening the door for further research on condom use behavior in a rural context. In-depth interviews were conducted with 40 MSM in rural Oklahoma regarding their condom use and sexual behaviors. A qualitative analysis revealed five themes with respect to condom usage: physical discomfort of condoms, relationship trust, usage based on the type of sexual act, substance use, and knowledge of a partner's HIV/STI status. A sixth theme within the context of rural Oklahoma revealed participants' fear of physical/verbal abuse, hesitations seeking medical help due to confidentially issues, and general acknowledgment of the lack of education and resources available. Implications include increasing mobile testing locations and a push for marketing greater confidentially within health service providers.

A Picture is Worth 1000 Messages: Investigating Face and Body Photos on Mobile Dating Apps for Men Who Have Sex with Men

The present study investigated the way men visually self-present on MSM-specific mobile dating app profiles, as well as the connection between visual self-presentation strategies, demographic variables, and psychosocial attitudes about masculinity and the body. In particular, emphasis was placed on two aspects of men's visual self-presentation: face-disclosure and body-disclosure. Using a selective self-presentation framework, findings indicated that the majority of men presented their face in their profile photo and that nearly one in five presented their unclothed torso. Face-disclosure was connected to higher levels of app usage, longer-term app usage, and levels of outness. The use of shirtless photos was related to age, a higher drive for muscularity, more self-perceived masculinity, and stronger anti-effeminacy attitudes. The findings are discussed in relation to both strategic self-presentation, and the distinct meanings of face and body photos within MSM online culture.

Sex-Ed without the Stigma: What Gay and Bisexual Men Would like Offered in School Based Sex Education

This study highlights the experiences of gay and bisexual men who live in Oklahoma with formalized sex education. Open-ended prompts were provided to individuals (N= 112) who completed an online questionnaire assessing their experience with sex education and what they would like to see offered. The majority of participants did not receive a formalized sex education and they want to see a comprehensive sex education program provided in public schools. A need exists for a more comprehensive and inclusive formalized sex education program to be provided in socio-politically conservative areas like Oklahoma.

Contingency management for the treatment of methamphetamine use disorder: A systematic review

Methamphetamine use continues to be an important public health problem. Contingency management is among the most effective interventions for reducing methamphetamine use. It has been more than ten years since the last systematic review of contingency management for methamphetamine use disorder. Since then, an additional ten randomized controlled trials and a variety of other studies have been completed. The present systematic review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome. However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to implementation in community programs, and in studies of the general population of methamphetamine users conducted in research treatment programs. There appear to be broad benefits of contingency management intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine use disorder should prioritize adoption and implementation of contingency management intervention.

Older Lesbians' experiences of ageing in place in rural Tasmania, Australia: An exploratory qualitative investigation

While there is increasing awareness of the specific health and aged care needs of older lesbian and gay people, little is known about their needs and experiences of ageing in rural communities. In Australia, older people are over-represented in regional and rural areas, however, rural communities face particular challenges to age friendliness, including infrastructure and transport limitations, reduced health and social services. In this context, few studies explore older lesbians' gendered experiences of ageing in place. To address this gap in the literature, this article draws on qualitative interviews with 13 rural Tasmanian lesbians over the age of 55, exploring their perceived barriers and enablers for 'healthy ageing' in their communities. Findings reveal that geographical isolation was a literal barrier to accessing specialist healthcare and lesbian-inclusive services, which may be absent in rural areas. The women perceived community health initiatives and social activities aimed at 'healthy ageing' in rural towns as heteronormative and unappealing for lesbians. In some cases women reported experiencing homophobic discrimination in these social groups. In contrast, rural communities were positively associated with a good quality of life derived from closeness to nature and feelings of reciprocity with rural neighbours and communities. These findings suggest that specific approaches to lesbian-inclusive rural health and social care are required. Rural communities are well-placed to build on community strengths to ensure higher quality of place-based health and social care for isolated older people, including those of diverse genders and sexualities.

Emerging trends in eating disorders among sexual and gender minorities

PURPOSE OF REVIEW

To review the recent literature on eating disorders, disordered eating behaviors (DEB), and body image dissatisfaction among sexual and gender minority populations, including, but not limited to, gay, lesbian, bisexual, and transgender people.

RECENT FINDINGS

Overall, eating disorders, DEB, and body dissatisfaction are common among sexual and gender minority populations. Lifetime prevalence for anorexia nervosa (1.7%), bulimia nervosa (1.3%), and binge-eating disorder (2.2%) diagnoses are higher among sexual minority adults compared with cisgender heterosexual adults in the United States. Lifetime prevalence of eating disorders by self-report of a healthcare provider's diagnosis are 10.5% for transgender men and 8.1% for transgender women in the United States, including anorexia nervosa (4.2 and 4.1%) and bulimia nervosa (3.2 and 2.9%), respectively. DEB may be perpetuated by minority stress and discrimination experienced by these individuals. Body dissatisfaction may be a core stressor experienced by transgender people; gender dysphoria treatment has been shown to increase body satisfaction. A particular clinical challenge in caring for transgender youth with eating disorders is the standard use of growth charts based on sex.

SUMMARY

Novel research demonstrates that sexual and gender minorities with eating disorders have unique concerns with regards to disordered eating and body image.

Sexual Assault and Co-Occurrence of Mental Health Outcomes Among Cisgender Female, Cisgender Male, and Gender Minority U.S. College Students

PURPOSE

The aim of this study was to examine the co-occurrence of mental health (depression, anxiety, nonsuicidal self-injury, and suicide ideation) and substance use outcomes among cisgender female, cisgender male, and gender minority college students exposed to sexual assault (SA).

METHODS

Data were drawn from a 2018 U.S. national survey of college student well-being (N = 50,438). Inverse propensity-weighted three-step latent class analysis was used to examine co-occurrence of outcomes while adjusting for 31 potential confounders of the relation between SA and outcome classes.

RESULTS

Four latent classes were identified for cisgender female and male participants and two for gender minority participants, reflecting a range from low to high risk of co-occurring outcomes. SA was associated with significantly and substantially increased odds (odds ratio: 2.03-3.64) of membership to the highest-risk outcome class compared with the lowest-risk class across gender identity subgroups.

CONCLUSIONS

SA in the college setting is associated with substantially increased odds of co-occurring depression, anxiety, nonsuicidal self-injury, and suicide ideation, regardless of gender identity.

Future Directions in Understanding and Addressing Mental Health among LGBTQ Youth

Today's LGBTQ youth come of age at a time of dynamic social and political change with regard to LGBTQ rights and visibility, yet remain vulnerable to compromised mental health. Despite advances in individual-level treatment strategies, school-based programs, and state-level policies that address LGBTQ mental health, there remains a critical gap in large-scale evidence-based prevention and intervention programs designed to support the positive development and mental health of LGBTQ youth. To spur advances in research and translation, I pose six considerations for future scholarship and practice. I begin by framing LGBTQ (mental) health disparities in a life course perspective and discuss how research focused on the timing of events could offer insight into the optimum targets and timing of prevention and intervention strategies. Next, I argue the importance of expanding notions of "mental health" to include perspectives of wellbeing, positive youth development, and resilience. I then consider how research might attend to the complexity of LGBTQ youths' lived experience within and across the various contexts they traverse in their day-to-day lives. Similarly, I discuss the importance of exploring heterogeneity in LGBTQ youth experiences and mental health. I also offer suggestions for how community partnerships may be a key resource for developing and evaluating evidence-informed programs and tools designed to foster the positive development and mental health of LGBTQ youth. Finally, I acknowledge the potentials of team science for advancing research and practice for LGBTQ youth health and wellbeing. Throughout, these future directions center the urgent needs of LGBTQ youth.