Sexual Identity Mobility and Depressive Symptoms: A Longitudinal Analysis of Moderating Factors Among Sexual Minority Women

Knowledge gaps in existing research exploring sexual fluidity and mental health among young adults

While there is a large body of evidence indicating that sexual minority youth experience inequitably high rates of mental health problems (eg, depression, suicidality), we know little about how temporal changes in sexual attractions, identities and behaviour may impact mental health (and other) outcomes. In this essay, we review existing research regarding sexual fluidity and mental health among young adults in order to identify critical knowledge gaps with respect to an epidemiological understanding of the relationship between these factors. We describe three gaps that in turn inform a larger public health research agenda on this topic. First, there are a number of methodological challenges given that fluidity can occur over short or long periods of time and across multiple dimensions of sexual orientation (eg, attractions, identities and behaviour) with various patterns (eg, directionality of change). Tailored measures that accurately and inclusively reflect diversities of sexual fluidity trajectories are needed. Second, causal relationships between sexual fluidity and mental health remain uncertain and unquantified. Third, little is known about how features of context (eg, gender norms and political climate) influence youth experiences with sexual fluidity and mental health. Finally, we propose a set of recommendations to address these knowledge gaps to improve the quality of epidemiological research involving young people.

Associations of sexual identity change and identity-attraction discordance with symptomatic alcohol and other drug use

PURPOSE

National studies examining alcohol and other drug use by sexual orientation have been primarily cross-sectional. Understanding changes in sexual orientation over time may further elucidate the mechanisms behind sexual orientation differences in alcohol and other drug use. This national longitudinal study examines changes in sexual orientation across four waves (2013-2019), and the associations with symptomatic alcohol and other drug use.

METHODS

Data from Waves 1 through 5 of the Population Assessment of Tobacco and Health (PATH) study were used to examine associations of sexual identity change/stability and sexual identity-attraction discordance/concordance from baseline to follow-up with symptomatic substance use at follow-up. We examined four outcomes: any symptomatic substance use, symptomatic alcohol use, symptomatic other drug use, and symptomatic alcohol + other drug use. Mixed effects logistic regression models were used and all analyses were weighted and stratified by sex.

RESULTS

In models adjusting for potential confounders, greater likelihood of symptomatic alcohol and other drug use outcomes was found among males and females experiencing a change from a heterosexual to sexual minority identity and among females with new or consistent sexual identity-attraction discordance.

CONCLUSION

These findings highlight important sex differences and suggest that the period of transitioning to a sexual minority identity is a particularly vulnerable period for symptomatic alcohol and other drug use. For females, incongruent sexual identity and attraction is also a risk factor. Interventions that assist individuals during this transitional period and during a time when identity and attraction are incongruent, may reduce symptomatic substance use during this period.

A national longitudinal study of sexual orientation discordance, sexual identity fluidity, and alcohol and other drug use disorder symptoms

Background: Many national studies fail to account for discordance between sexual orientation dimensions (e.g. a mismatch between sexual identity and sexual attraction) or sexual identity fluidity (e.g. changes in sexual identity over time).Objective: To examine the longitudinal relationships among sexual identity fluidity/stability, sexual orientation discordance/concordance, and alcohol and other drug use disorder symptoms.Methods: The study used nationally representative longitudinal data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) study of US adolescents and adults (N = 24,591).Results: Substance use disorder symptoms were most prevalent (45.8%) among bisexual-stable females relative to all other sexual identity subgroups. The adjusted odds ratios (AORs) of substance use disorder symptoms were significantly higher among bisexual-stable females vs. heterosexual-stable females in all models (AOR range: 1.94-2.32), while no such associations were found for males. Sexual identity-attraction discordant females had significantly greater AORs (17/20 instances) of substance use disorder symptoms compared to concordant females; this finding was not as consistent for males (6/20 instances).Conclusion: Sexual orientation discordance was significantly associated with substance use disorder symptoms, especially among females discordant in their sexual identity and attraction. Bisexual-stable and discordant females are at highest risk of developing symptomatic substance use; it is vital that they receive screening, no matter where they are in their coming out process. This study highlights pitfalls of relying solely on cross-sectional data using a single sexual orientation dimension to understand the relationship between sexual orientation and substance use disorder.

Sexual Orientation Identity Change, Developmental Trajectories of Depressive Symptoms, and Childhood Abuse From Adolescence to Young Adulthood

PURPOSE

This study tested differences between youths who reported being heterosexual at ages 15.5 and 21, and those who changed from reporting being heterosexual at age 15.5 to nonheterosexual at age 21, in the developmental trajectories of depressive symptoms from age 22-24 years, and whether these longitudinal patterns were explained by childhood and adolescent abuse.

METHODS

The Avon Longitudinal Study of Parents and Children (ALSPAC) was used (849 male youths and 1,455 female youths). Youths' self-reported sexual orientation was measured at ages 15.5 and 21, and depressive symptoms were measured at ages 22, 23, and 24. Childhood and adolescent abuse between birth and 17 years were reported by youths and their mothers.

RESULTS

Male and female youths who changed from reporting being heterosexual to nonheterosexual reported significantly more depressive symptoms than their consistently heterosexual counterparts at all 3 ages (except the association for male youths at age 24), with total effects (unstandardized regression coefficients) ranging from 2.00 to 5.27. These associations were weakened but remained statistically significant when childhood and adolescent abuse was controlled for, with direct effects ranging from 1.50 to 4.68. These associations were mediated through childhood and adolescent abuse, with indirect effects ranging from 0.48 to 0.58. Differences between youths who consistently reported being heterosexual and those who changed from reporting being heterosexual to nonheterosexual in depressive symptoms decreased from age 22-24 years, possibly due to the success of identity integration.

DISCUSSION

Childhood and adolescent abuse may partially explain these developmental disparities.

Disparities in Depression and Anxiety That Impact Self-Identified Sexual Minority People Affect a Broader Group of Same-Gender Attracted Young Adults

PURPOSE

Prior work suggests sexual minority (e.g., gay, bisexual) young adults are at greater risk for depression and anxiety. However, the majority of said work focuses exclusively on self-reported sexual minority identity and neglects same-gender attraction. The current study aimed to characterize links between identity- and attraction-based indicators of sexual minority status and depression and anxiety in young adults, and to examine the ongoing significance of caregiver support in mental health during this key developmental period.

METHODS

386 youth (mean age = 19.92 years; SD = 1.39) reported their sexual orientation identity and experiences of attraction toward men and/or women. Participants also reported on anxiety, depression, and caregiver social support.

RESULTS

While less than 16% of participants identified as sexual minority individuals, nearly half reported same-gender attraction. Self-identified sexual minority participants reported significantly higher depression and anxiety than self-identified heterosexual participants. Similarly, same-gender attracted individuals exhibited heightened depression and anxiety compared to exclusively different-gender attracted individuals. Greater caregiver social support predicted lower depression and anxiety.

DISCUSSION

The present findings suggest that not only are self-identified sexual minority individuals at heightened risk for depression and anxiety symptoms, but also that this risk extends to a larger group of young people who experience same-gender attraction. These results demonstrate that better mental health supports may be needed for youth who identify as sexual minority individuals or report same-gender attraction. That higher caregiver social support was associated with lower mental illness risk suggests caregivers may be key to mental health promotion during young adulthood.

Associations of adult roles and minority stressors with trajectories of alcohol dependence symptoms throughout adulthood among sexual minority women

OBJECTIVE

In the present study, we sought to identify trajectories of symptoms of potential alcohol dependence (AD) among adult sexual minority women (SMW). Theoretical correlates were examined in relation to the empirically identified trajectories.

METHOD

Data were collected at three time points between 2000 and 2012 from SMW drinkers (n = 434) enrolled in a longitudinal study (M Age = 37.49 at baseline, SD = 11.55). Using an accelerated-cohort longitudinal design, latent growth curve mixture models identified homogeneous patterns of any past-year symptoms of potential AD. Correlates of trajectories included alcohol-related developmental risk factors, adult roles, and exposure to minority stressors.

RESULTS

Three trajectories were identified that captured risk of symptoms of potential AD over time, reflecting: (a) relatively consistent, low risk over time; (b) deceleration in risk throughout adulthood; (c) relatively persistent, high risk over time. Consistent with prior work, SMW drinkers who reported higher levels of perceived stigma or masculinity showed persistently high risk of reporting at least one past-year symptom of potential AD.

CONCLUSIONS

Most SMW drinkers report deceleration in risk of AD symptoms over time. Findings have implications for prevention and intervention efforts tailored to SMW drinkers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sexual Fluidity and Psychological Distress: What Happens When Young Women's Sexual Identities Change?

The sexual identities of young women today are less binary and more fluid than ever before. Several theoretical perspectives imply that this fluidity could be accompanied by distress. To examine this, we analyzed four waves of data from Australian women born 1989 to 1995 (n = 11,527). We found no evidence of a universal association between sexual identity change and psychological distress. Instead, psychological distress was elevated when women changed their identity away from the heterosexual norm and lowered when they changed their identity toward it. Social stress partly attenuated these associations. In addition, women unsure of their identity at multiple assessment points reported significantly greater psychological distress in the final assessment than women who were never unsure. Our findings suggest that greater support should be offered to women who are questioning their sexual identity or developing a minority identity.

A heavy burden: Associations between sexual minority status, mental health, and BMI in women

BACKGROUND

Sexual minority women (SMW) are at increased risk of elevated body mass index (BMI) compared to heterosexual women, increasing their vulnerability to chronic diseases. Nonmonosexual SMW appear to be at additional risk for elevated BMI, likely due to unique sexual minority stressors.

METHODS

A total of 437 SMW and heterosexual women completed a cross-sectional, online survey including self-report measures of sexual orientation dimensions, weight, psychological distress, and eating behaviors. We investigated relations among these variables to better understand disparities in self-reported BMI based on sexual orientation and sexual orientation discordance (SOD).

RESULTS

SMW self-reported more psychological distress, more binge eating, and higher BMIs than their heterosexual peers, with nonmonosexual groups of SMW often reporting the highest values. SOD was positively associated with psychological distress.

CONCLUSIONS

SMW-particularly nonmonosexual SMW-are at increased risk for psychological distress, binge eating, and elevated BMI relative to heterosexual peers. Future research should further elucidate mechanisms for these disparities.

Sexual Orientation Change among Adolescents and Young Adults: A Systematic Review

This article reviews research on changes in self-reported sexual orientation labels and associated health outcomes among adolescents and young adults. Using seven electronic databases and supplementary methods, we identified 30 studies for inclusion in the review, published between 2000 and 2020. This review aimed to summarize the approaches to measuring sexual orientation change; the prevalence, patterns, and directionality of changes in sexual identity; and how changes in sexual orientation relate to health outcomes among adolescents and youth adults. The reviewed studies lacked agreement in operationalization and assessment of sexual orientation changes. Prevalence of change in self-reported sexual orientation differed by birth sex, whereby cisgender female participants were more likely to report a change than male participants. In addition, adolescents and youth identifying with a nonheterosexual orientation or sexual minority at baseline were more likely to report a change in sexual orientation. Few studies reported on the impact of changes in sexual orientation on behavioral health outcomes. Adolescents who reported either nonheterosexual orientation at baseline or a shift toward nonheterosexual orientation had a greater likelihood of reporting depressive symptomology, suicidality, and substance use compared to those who did not report a change or reported consistent heterosexuality. Recommendations for future research and implications for practice are discussed.

Factor structure of the Outness Inventory in a sample of Black and White lesbian and bisexual young adult women

Introduction

The Outness Inventory (OI; Mohr & Fassinger, 2000) is the most commonly used measure for assessing an individual's level of outness, or openness about sexual identity. However, data on the validity of the OI factor structure across diverse populations is limited. The present study aimed to test the factor structure of the OI in a population-based sample of Black and White young adult women.

Method

Participants included 319 lesbian and bisexual women drawn from the Pittsburgh Girls Study (PGS), a large longitudinal study of 5- to 8-year-old girls (53% Black) oversampled from low-income neighborhoods and followed through adulthood. Participants completed the 11-item OI at ages 20-23 years. Confirmatory factor analyses evaluated measurement invariance of the OI across race and suggested significant differences in factor structure between Black and White sexual minority women. Exploratory factor analyses were conducted separately by race.

Results

An EFA revealed three factors for the Black subsample: Family, Straight Friends, and Work/Strangers. Three factors also emerged for the White subsample, representing Familiar Acquaintances, Less Familiar Acquaintances, and Work.

Conclusion

Additional research is needed to investigate potential culturally-based differences in domains of disclosure, which may help to better understand how specific contexts of outness relate to mental health.

Examining the associations of sexual minority stressors and past-year depression with overeating and binge eating in a diverse community sample of sexual minority women

Sexual minority stressors (e.g., stigma consciousness, internalized homophobia, discrimination) are posited to contribute to higher prevalence of overeating and binge eating among sexual minority women (SMW) relative to heterosexual women. Few studies have examined psychosocial mediators of the associations of minority stressors with overeating and binge eating in SMW. Using data from a diverse, community-based sample of SMW, we examined these associations, including the potential mediating effects of past-year depression. We also conducted exploratory analyses to determine if the associations of sexual minority stressors with overeating and binge eating differed by sexual identity or by race and ethnicity. The sample included 607 SMW (38.2% White, 37.1% African American, 24.7% Latina) with a mean age of 39.7 years. Approximately 17% and 9% of SMW reported overeating and binge eating, respectively, in the past 3 months. Greater stigma consciousness was associated with higher odds of overeating (AOR 1.31, 95% CI = 1.03-1.66). We found no significant associations between minority stressors and binge eating. Past-year depression did not mediate associations between minority stressors and overeating or binge eating. Although we found no sexual identity differences, stigma consciousness among Latina SMW was associated with higher odds of overeating relative to White SMW (AOR 1.95, 95% CI = 1.21-3.12) and African American SMW (AOR 1.99, 95% CI = 1.19-3.31). Findings highlight the importance of screening SMW for stigma consciousness as a correlate of overeating and considering racial and ethnic differences in overeating and binge eating in this population.

Alcohol use among sexual minority women: Methods used and lessons learned in the 20-Year Chicago Health and Life Experiences of Women Study

Background

Two decades ago, there was almost no research on alcohol use among sexual minority women (SMW, e.g., lesbian, bisexual). Since then, a growing body of scientific literature documents substantial sexual orientation-related disparities in alcohol use and alcohol-related problems. Research has identified multiple risk factors associated with high-risk/hazardous drinking among SMW. However, this research has almost exclusively used cross-sectional designs, limiting the ability to draw conclusions about processes through which sexual minority status affects alcohol use. Longitudinal designs, although very rare in research on alcohol use among SMW, are important for testing mediational mechanisms and necessary to understanding how changes in social determinants impact alcohol use.

Aim

To describe the processes and lessons learned in conducting a 20-year longitudinal study focused on alcohol use among SMW.

Methods

The Chicago Health and Life Experiences of Women (CHLEW) study includes five waves of data collection (2000-present) with an age and racially/ethnically diverse sample of 815 SMW (ages 18-83) originally recruited in the Chicago Metropolitan Area in Illinois, a midwestern state in the United States (U.S.). Measures and focus have evolved over the course of the study.

Results

The CHLEW study is the longest-running and most comprehensive study of SMW's drinking in the U.S. or elsewhere. Findings reported in more than 50 published manuscripts have contributed to understanding variations in SMW's risk for hazardous/harmful drinking based on sexual identity, age, race/ethnicity, sex/gender of partner, and many other factors.

Conclusions

By describing the process used in conducting this long-term study, its major findings, and the lessons learned, we hope to encourage and support other researchers in conducting longitudinal research focused on SMW's health. Such research is critically important in understanding and ultimately eliminating sexual orientation-related health disparities.

Knowledge of Chosen Family History and Depressive Symptoms in Sexual Minority Women

Recent work on intergenerational memory has revealed a positive association between family of origin knowledge and wellbeing in adolescents. However, little is known about the generalizability of these data, as significantly less attention has focused on autobiographical memory sharing and wellbeing in historically marginalized communities. Given the high incidence of familial rejection and abandonment within the LGBTQIA + community, close relationships with individuals outside of one’s family of origin, chosen families, often serve as an important source of social support. This study sought to examine the relationship between knowledge of a close non-family member and wellbeing among emerging adult sexual minority women (SMW) according to their gender presentation. A community sample from New York City comprised of heterosexual women (n = 50), masculine-presenting SMW (n = 50), and feminine presenting SMW (n = 50) completed measures associated with their knowledge of their family of origin, knowledge of a close non-family member, as well as self-reported measures of depression, emotion regulation, and socio-demographic questions. Family of origin knowledge was associated with lower levels of depression only among heterosexual women. However, heterosexual and SMW who knew more about their close non-family member reported lower levels of depression. Additionally, emotion regulation (cognitive reappraisals) mediated the relationship between knowing more about one’s chosen family and lower depressive symptom severity among heterosexual women, but this relationship was only significant for SMW who were at least moderately open about their sexuality. These findings extend the literature on the benefits of memory sharing to historically marginalized communities by showing that memory sources outside of one’s family of origin may be particularly important. Additionally, these data begin to shed light on potential mediating factors, such as emotion regulation and openness about one’s sexual identity, that underlie the links between memory sharing and metrics of wellbeing. Taken together, in contexts in which there may not be opportunities to learn about family history from one’s family of origin, it appears that access to stories from someone close outside of one’s family is also associated with lower levels of depression.

Sexual Identity and Birth Outcomes: A Focus on the Moderating Role of Race-ethnicity

Race-ethnic disparities in birth outcomes are well established, and new research suggests that there may also be important sexual identity disparities in birth weight and preterm birth. This study uses the National Longitudinal Study of Adolescent to Adult Health and is the first to examine disparities in birth outcomes at the intersection of race-ethnicity and sexual identity. We use ordinary least sqaures and logistic regression models with live births (n = 10,318) as the unit of analysis clustered on mother ID (n = 5,105), allowing us to adjust for preconception and pregnancy-specific perinatal risk factors as well as neighborhood characteristics. Results show a striking reversal in the effect of lesbian or bisexual identity on birth outcomes across race-ethnicities: For white women, a bisexual or lesbian identity is associated with better birth outcomes than their white heterosexual counterparts, but for Black and Latina women, it is associated with worse birth outcomes than their heterosexual peers.

Changes in Sexual Identity Labels in a Contemporary Cohort of Emerging Adult Women: Patterns, Prevalence and a Typology

Sexual attraction, behavior and identity are subject to change across the life course for some individuals, and certain developmental periods such as emerging adulthood appear particularly conducive to this. However, the evidence documenting these phenomena comes overwhelmingly from data collected 10-20 years ago. In the brief interlude since, the socio-political context has changed markedly and increasing numbers of women are reporting non-heterosexuality. Drawing on contemporary data from the Australian Longitudinal Study on Women's Health (n = 16,870), we provide up to date evidence on changes in sexual identity labels among emerging adult women. We found that 19% of women changed their sexual identity label from one survey wave to the next, and 30.6% changed their identity label at least once across the four waves. Mostly heterosexual and bisexual labels were both more common and more stable in our sample than in previous studies. We propose a new typology of sexual identity sequences and fit this to our data, providing a blueprint for researchers looking to define sexual minority status longitudinally. Findings suggest that the ways women perceive and label their sexual orientation should be treated as dynamic phenomena situated within the nested temporalities of biographical and historical time.

The Survey Measurement of Sexual Orientation: Configurations of Sexual Identity and Attraction and Associations with Mental Health

Purpose: This study aimed to examine how configurations of sexual identity and attraction are associated with mental health outcomes. Methods: Data came from the 2015, 2016, and 2017 waves of the National Survey on Drug Use and Health, one of the few nationally representative surveys to ask about sexual attraction. Sexual identity and attraction were combined into groups that are coincident (heterosexual-opposite gender attraction, gay/lesbian-same gender attraction, or bisexual-any multiple gender attraction) or branched (heterosexual-any same gender attraction, gay/lesbian-any opposite gender attraction, bisexual-only same or opposite gender attraction). The association between these configurations and various measures of mental health and well-being-severe psychological distress, major depressive episode, suicidal ideation, and suicide plan or attempt-was examined. Results: Heterosexual coincidence-being heterosexual and only attracted to the opposite gender-was associated with lower mental health risks than all other configurations of sexual identity and attraction. In addition, bisexual with coincident attraction was often associated with worse mental health outcomes than other configurations of identity and attraction, whereas bisexual with branched attraction did not necessarily follow this pattern. Finally, heterosexual with branched attraction was associated with worse mental health outcomes than heterosexual with coincident attraction, but better mental health outcomes than some of the other sexual identity and attraction configurations. Conclusion: Including one question on sexual attraction and its intersection with sexual identity adds nuance to our understanding of disparities in mental health and well-being among previously identified sexual minority and majority groups.

Changes in Sexual and Gender Identity and Their Associations with Internalized Homophobia Among Black Men Who Have Sex with Men in the HPTN 061 BROTHERS Cohort

Sexual and gender identity have frequently been assessed in public health research as static states. However, a substantial and growing body of evidence indicates that both identities may have greater potential for change over time than once supposed. Despite this evidence, research into adult identity change remains relatively limited. Using longitudinal data from 1553 Black men who have sex with men (BMSM) aged 18-68 years and recruited from study locations in six major cities across the country, we examined changes in sexual and gender identities over a period of 12 months. The results showed that sexual and gender identity did indeed change among adult BMSM. Additionally, we explored internalized homophobia (IH) as a potential driver of identity change and found that IH significantly impacts the degree and direction of change, with individuals who reported higher baseline IH more likely to demonstrate a shift toward a heterosexual/straight identity at 6 and 12 months. The results are discussed in light of what is known and unknown regarding identity change, and potential avenues for future research are explored.

Sexual fluidity and BMI, obesity, and physical activity

Analyzing reported changes in sexual identity over time is necessary for understanding young adult health risks. Utilizing waves 3 and 4 of the National Longitudinal Study of Adolescent to Adult Health, this paper studies the relationships between sexual identity changes and BMI, obesity, and physical activity among young adults in the U.S (N = 11,349). The results show that men who report a change toward a more homosexual identity have a significantly lower BMI and participate in more physical activity, while men who report a change toward a more heterosexual identity participate in less physical activity and have a higher BMI compared to those who did not report a change. For women, a change toward a more homosexual identity is significantly associated with more physical activity and lower odds of being obese compared to no change. The results suggest that specific sexual identity changes may also be linked to improvements in health.

•

Links between sexual fluidity and weight and physical activity are analyzed.

•

Certain sexual identity changes may improve weight and physical activity behavior.

•

The direction of sexual identity change matters more for men than for women.

Sexual Minority Women in Longitudinal Survey Research: Is Attrition a Problem?

As more longitudinal surveys collect information on sexual orientation, evaluating the quality of these data and understanding how sexual minorities engage with the survey process are increasingly important endeavors. This study constitutes the first systematic analysis of sexual orientation as a predictor of attrition from longitudinal surveys. Drawing upon the minority stress model, we developed testable hypotheses about how sexual identity and sexual identity change relate to panel attrition. These hypotheses were subsequently tested using data from two national cohorts of Australian women from the Australian Longitudinal Study on Women's Health (one born 1973-1978, n = 11,262, and one born 1989-1995, n = 16,689). In the older cohort, sexual minority women were more likely to attrit from the survey than exclusively heterosexual women-largely due to noncontact rather than noncooperation. The associations faded once sociodemographic and health-related covariates were included in the models. Further, higher rates of noncontact were observed among women who changed their sexual identity in a more same-sex-oriented direction, compared to women with a stable sexual identity. None of these associations were apparent in the younger cohort. Taken together, our results suggest that sexual minority status may be a risk factor for panel attrition among older but not younger cohorts of women and that improved efforts to locate and contact participants who are generally vulnerable could increase the retention of sexual minorities in longitudinal studies. Effect sizes were nevertheless small, suggesting that existing research on sexual orientation using longitudinal surveys is unlikely to be biased by non-random attrition of non-heterosexual individuals.

Research on alcohol and other drug (AOD) use among sexual minority women: A global scoping review

Until the 1980s, the limited research on alcohol and other drug (AOD) use among sexual minority women (SMW) focused on alcohol and used samples recruited from gay bars, resulting in inflated estimates of hazardous drinking. Over the past several decades the number of AOD studies with SMW has increased dramatically. To characterize this literature, we conducted a scoping review to answer the following questions: What do we know, and what are the gaps in research about AOD use among SMW? We searched multiple electronic databases (Medline [PubMed], CINAHL, PsycInfo, and Web of Science) for peer-reviewed research articles about AOD use among adult SMW published between January 1, 2000 and May 31, 2017. After duplicates were removed the search identified 4,204 articles. We reviewed the titles and abstracts and removed articles that did not meet inclusion criteria. We used full-text review of the remaining 229 articles to make a final determination regarding inclusion and we retained 181 articles for review. Although the quantity of AOD research with SMW has grown substantially, the great majority of studies have been conducted in the United States (US) and most focus on hazardous drinking; relatively little research has focused on other drugs. In addition, although there has been marked improvement in theories and methods used in this research, many gaps and limitations remain. Examples are the lack of longitudinal research; reliance on samples that tend to over-represent white, well-educated, and relatively young women; sparse attention to mechanisms underlying the disproportionately high rates of AOD use among SMW; and the absence of intervention research. In general, more high-quality research on SMW's use of AODs is needed, but gaps and limitations are particularly large in non-western countries. Addressing these research gaps and limitations is essential for providing information that can be used to develop more effective prevention and early intervention strategies, as well as for informing policies that can help to reduce risky drinking and drug misuse among SMW.

Changes in Sexual Identity and Associations With Alcohol Use and Depression Among Young Adult Sexual Minority Women

OBJECTIVE

Sexual minority women report more problematic alcohol use and depression than heterosexual women. Despite evidence that sexual identity can change over time, most studies treat it as a static construct. As a result, little is known about the extent to which changes in sexual identity influence alcohol use and depression. The current study examined (a) changes in sexual identity over 36 months, (b) the associations between the number of changes in sexual identity and measures of alcohol use (typical weekly alcohol consumption, peak drinking, and alcohol-related consequences) and depression at the final assessment, and (c) baseline sexual identity as a moderator of the associations.

METHOD

The analyses used four waves of data from a national U.S. sample of sexual minority women ages 18-25 (n = 1,057).

RESULTS

One third (34%) of participants reported at least one change in sexual identity over the course of the study. The number of changes in sexual identity was positively associated with typical weekly alcohol consumption and depression but was not significantly associated with peak drinking or alcohol-related consequences. None of the associations were moderated by baseline sexual identity.

CONCLUSIONS

These findings provide additional evidence that sexual identity continues to change over time for a sizeable proportion of young adult sexual minority women and these changes are relevant to their health and well-being.

Changes in Sexual Identity and Associations With Alcohol Use and Depression Among Young Adult Sexual Minority Women

OBJECTIVE

Sexual minority women report more problematic alcohol use and depression than heterosexual women. Despite evidence that sexual identity can change over time, most studies treat it as a static construct. As a result, little is known about the extent to which changes in sexual identity influence alcohol use and depression. The current study examined (a) changes in sexual identity over 36 months, (b) the associations between the number of changes in sexual identity and measures of alcohol use (typical weekly alcohol consumption, peak drinking, and alcohol-related consequences) and depression at the final assessment, and (c) baseline sexual identity as a moderator of the associations.

METHOD

The analyses used four waves of data from a national U.S. sample of sexual minority women ages 18-25 (n = 1,057).

RESULTS

One third (34%) of participants reported at least one change in sexual identity over the course of the study. The number of changes in sexual identity was positively associated with typical weekly alcohol consumption and depression but was not significantly associated with peak drinking or alcohol-related consequences. None of the associations were moderated by baseline sexual identity.

CONCLUSIONS

These findings provide additional evidence that sexual identity continues to change over time for a sizeable proportion of young adult sexual minority women and these changes are relevant to their health and well-being.

The Gendered Self of Chinese Lesbians: Self-Esteem as a Mediator Between Gender Roles and Depression

Sexual minority women are at an elevated risk for depression compared to heterosexual women, yet less is known about how gender roles affect the mental health of sexual minority women. Existing studies examining the role of self-esteem in the relationship between gender roles and depression are scarce and have predominantly focused on heterosexual populations. Using a cross-sectional survey of Chinese lesbians in Hong Kong (N = 438), the study tested the direct and indirect effects of different types of gender roles (masculine, feminine, and androgynous) on depression through the mediating factor of self-esteem. We found that masculinity and androgyny were positively associated with self-esteem, while femininity was negatively associated with self-esteem. More importantly, self-esteem fully mediated the inverse relationship between masculinity and depression and that between androgyny and depression. The positive relationship between femininity and depression was also fully mediated by self-esteem. By examining different types of gender roles and incorporating gender roles, self-esteem, and depression into a unified framework, the research highlighted the particularly protective effect of androgyny, which had the strongest positive direct effect on self-esteem and indirect effect on depression through the mediation of self-esteem compared to the effects of other types of gender roles. Our results illuminate the importance of understanding how individual differences in gender roles relate to the mental health of sexual minority women in future research and interventions. Implications for interventions that help Chinese lesbians cope with gender expectations and improve their mental health are discussed.

Elevated Depressive Symptoms Are a Stronger Predictor of Executive Dysfunction in HIV-Infected Women Than in Men

BACKGROUND

HIV-infected (HIV+) women seem to be more vulnerable to neurocognitive impairment (NCI) than HIV+ men, perhaps in part due to mental health factors. We assessed the association between elevated depressive symptoms and NCI among HIV+ and HIV-uninfected (HIV-) women and men.

SETTING

Women's Interagency HIV Study and Multicenter AIDS Cohort Study.

METHODS

Eight hundred fifty-eight HIV+ (429 women; 429 men) and 562 HIV- (281 women; 281 men) completed the Center for Epidemiologic Studies Depression (16 cutoff) Scale and measures of psychomotor speed/attention, executive, and motor function over multiple visits (or time points). Women's Interagency HIV Study and Multicenter AIDS Cohort Study participants were matched according to HIV status, age, race/ethnicity, and education. Generalized linear mixed models were used to examine interactions between biological sex, HIV serostatus, and depression on impairment (T-scores <40) after covariate adjustment.

RESULTS

Despite a higher frequency of depression among men, the association between depression and executive function differed by sex and HIV serostatus. HIV+ women with depression had 5 times the odds of impairment on a measure of executive control and inhibition versus HIV- depressed women and 3 times the odds of impairment on that measure versus HIV+ depressed men. Regardless of group status, depression was associated with greater impairment on processing speed, executive (mental flexibility), and motor function (P's < 0.05).

CONCLUSIONS

Depression contributes to NCI across a broad range of cognitive domains in HIV+ and HIV- individuals, but HIV+ depressed women show greater vulnerabilities in executive function. Treating depression may help to improve cognition in patients with HIV infection.

Sexual Orientation Disparities in Pregnancy and Infant Outcomes

Objectives Little is known about maternal and infant health among sexual minority women (SMW), despite the large body of research documenting their multiple preconception risk factors. This study used data from the 2006-2015 National Survey of Family Growth (NSFG) to investigate sexual orientation inequities in pregnancy and birth outcomes, including miscarriage, stillbirth, preterm birth, and birth weight. Methods Women reported 19,955 study eligible pregnancies and 15,996 singleton live births. Sexual orientation was measured using self-reported identity and histories of same-sex sexual experiences (heterosexual-WSM [women who only report sex with men]; heterosexual-WSW [women who report sex with women]; bisexual, and lesbian). Logistic regression models were used that adjusted for several maternal characteristics. Results Compared to heterosexual-WSM, heterosexual-WSW (OR 1.25, 95% CI 1.00-1.58) and bisexual and lesbian women (OR 1.77, 95% CI 1.34-2.35) were more likely to report miscarriage, and bisexual and lesbian women were more likely to report a pregnancy ending in stillbirth (OR 2.85, 95% CI 1.40-5.83). Lesbian women were more likely to report low birth weight infants (OR 2.64, 95% CI 1.38-5.07) and bisexual and lesbian women were more likely to report very preterm births (OR 1.84, 95% CI 1.11-3.04) compared to heterosexual-WSM. Conclusions for Practice This study documents significant sexual orientation inequities in pregnancy and birth outcomes. More research is needed to understand the mechanisms that underlie disparate outcomes and to develop interventions to improve sexual minority women's maternal and infant health.

Sexuality and Sexual Identity Across the First Year of Parenthood Among Male-Partnered Plurisexual Women

Women who (a) hold plurisexual identities (e.g., bisexual, pansexual) and (b) are male-partnered are understudied. Of interest is how these women construct their sexual identities across the transition to parenthood-a period associated with intensified heteronormative expectations, and changes in women's roles and identities. This longitudinal study of 28 plurisexual, male-partnered women examined women's sexual identity construction across the first year of parenthood, using four waves of data. Most women were White, bisexual-identified, and first-time parents. The majority of women described decreases in the salience or centrality of their sexuality more generally. Almost all women continued to hold plurisexual identities across the first year of parenthood, although many described these as private identities amidst public assumptions of heterosexuality. Some, though, sought to maintain a connection to their plurisexual identities through sexual identity disclosure, same-gender fantasies, and involvement in consensual nonmonogamy. Although only one woman articulated a shift in sexual identity label (from bicurious to heterosexual), others increasingly distanced themselves from their same-gender behaviors and desires. Our findings illustrate how women engage in an active process of sexual identity construction amidst heteronormative pressures, and how they navigate tensions amongst their partnership and parenthood statuses and their private identities and past behaviors.

Do Sexual Minorities Receive Appropriate Sexual and Reproductive Health Care and Counseling?

CONTEXT

Sexual minority women (SMW) are less likely to use sexual and reproductive health care services and receive contraceptive counseling than their heterosexual peers. The role of recent sexual partners and the type of information provided when SMW access health services are unclear.

METHODS

The National Survey of Family Growth 2006-2015 was used to document sexual orientation disparities in the use of sexual and reproductive health services and counseling in clinical settings among 20,703 women. We incorporate data on sexual partners in the past 12 months to investigate whether recent sex with men was associated with health care seeking behavior and reproductive counseling.

RESULTS

Eight-seven percent of the sample reported a male partner in the past 12 months, including 83% of bisexual women and 17% of lesbian women. In clinical settings, 48% of women reported birth control counseling at pregnancy or Pap tests, 49% reported a condom consult at an sexually transmitted diseases (STD) screening, and 9% reported emergency contraception counseling at a Pap test. Logistic regression models show that lesbian women were less likely than heterosexual women to have been given a contraceptive prescription or received contraceptive counseling, but were more likely to have received an STD test. In clinical settings, lesbian women were less likely to receive contraceptive counseling at pregnancy tests, and lesbian women without male partners were less likely to have a counseling about condom use at STD-related visits compared with heterosexual women.

CONCLUSIONS

At least some women and providers adjust health care seeking behaviors and information provided to women based upon recent sexual behavior histories. More work is needed to understand why disparities in reproductive health services and contraceptive use persist among SMW who engage in sex with men.

Religion and Sexual Identity Fluidity in a National Three-Wave Panel of U.S. Adults

Research has shown that cross-sectional estimates of sexual identities overlook fluidity in those identities. Research has also shown that social factors, such as competing identities, can influence sexual identity fluidity. We contributed to this literature in two ways. First, we utilized a representative panel of US adults (N = 1034) surveyed in 2010, 2012, and 2014 by the General Social Survey. The addition of a third observation allowed us to examine more complexity in sexual identity fluidity. We found that 2.40% of US adults reported at least one change in sexual identity across the 4 years, with 1.59% reporting one change and 0.81% reporting two changes. Our second contribution came from examining the role of religion, as past research has suggested that religion can destabilize and prolong sexual identity development. We found that lesbian or gay individuals (N = 17), bisexuals (N = 15), and females (N = 585) showed more sexual identity fluidity compared to heterosexuals (N = 1003) and males (N = 450), respectively. Marital status, age, race, and education did not have significant associations with sexual identity fluidity. Regarding the role of religion, we found that participants identifying as more religious in Wave 1 showed more fluidity in sexual identity across later observations. Further analysis showed that higher levels of religiosity make it more likely that lesbian or gay individuals will be fluid in sexual identity, but this is not the case for heterosexual individuals. This finding reinforces past qualitative research that has suggested that religion can extend or complicate sexual minorities' identity development.

Longitudinal Examination of a Bisexual-Specific Minority Stress Process Among Bisexual Cisgender Women

Bisexual individuals experience increased risk of mental health disorders compared to lesbian, gay, and heterosexual populations. This increased risk is theorized to arise from the stigmatization of bisexuality (i.e., anti-bisexual stigma). Research has linked anti-bisexual experiences with higher internalized binegativity (i.e., internalized anti-bisexual stigma), sexual identity uncertainty, and anxiety and depression. However, researchers have almost exclusively used cross-sectional designs, limiting our ability to draw conclusions about processes through which anti-bisexual stigma affects mental health. In the current study, we longitudinally examined a proposed bisexual-specific minority stress process in a sample of predominately White (92.2%), self-identified bisexual, cisgender women. Results provide support for the proposed process, indicating that experiencing more frequent anti-bisexual stigma predicted subsequent increases in internalized binegativity and sexual identity uncertainty. In turn, these increases in internalized binegativity were associated with concurrent decreases in strength of identification as bisexual, increases in strength of identification with monosexual identity labels (i.e., heterosexual, lesbian), and changes in visibility management strategies. These changes in identification were associated with concurrent increases in symptoms of anxiety and depression, and changes in visibility management were associated with increases in anxiety. Clinicians should consider this process when treating bisexual clients who present with psychological distress arising from anti-bisexual stigma.

Self-Reported Changes in Attractions and Social Determinants of Mental Health in Transgender Adults

This study examined associations between changes in self-reported attractions and mental health in a community-based sample of self-identified transgender adults. Participants were purposively recruited in 2013 using bimodal sampling methods and completed a one-time survey. Multivariable logistic regression models estimated adjusted risk ratios and 95 % confidence intervals to examine associations between changes in attractions and mental health outcomes (lifetime self-harm, suicide attempts, depression diagnosis; past-week clinically significant depressive distress assessed via CES-D 10) among the entire sample (N = 452; 285 female-to-male spectrum, 167 male-to-female spectrum) and after gender transition among those who had socially transitioned (n = 205; 156 female-to-male spectrum, 49 male-to-female spectrum). Models were adjusted for known population social determinants (age, race/ethnicity, gender identity, socioeconomic status, sexual orientation identity), transgender-specific determinants (age of transgender realization, social transition, medical transition, visual gender nonconformity, non-binary gender identification), and survey mode (online vs. in-person sampling). Lifetime changes in attractions were significantly associated with increased probability of all mental health outcomes; individuals reporting any change in attractions were more likely than individuals not reporting changes to indicate lifetime self-harm, suicide attempts, depression diagnosis, and current depressive distress (all ps < .05). Changes in attractions post-social transition were not significantly associated with mental health outcomes. Many, but not all, population and transgender-specific social determinants were significantly associated with mental health in the full sample and among those who had socially transitioned. Clinical implications of findings about changes in attractions and mental health are discussed for transgender individuals.

Addressing Health Care Disparities Among Sexual Minorities

There is evidence of health disparities between sexual minority and heterosexual populations. Although the focus of lesbian, gay, bisexual, and transgender health research has been human immunodeficiency virus/acquired immunodeficiency syndrome and sexually transmitted infection among men who have sex with men, there are health disparities among sexual minority women. Using the minority stress framework, these disparities may in part be caused by individual prejudice, social stigma, and discrimination. To ensure equitable health for all, there is urgent need for targeted culturally sensitive health promotion, cultural sensitivity training for health care providers, and intervention-focused research.