LGB-Affirming School Climates and Sexual Health Outcomes Among U.S. High School Students 2015-2017: Differences by Sex and Sexual Identity

Structural heteropatriarchy and maternal cardiovascular morbidities

The United States has some of the poorest maternal health outcomes of any developed nation. Existing research on maternal cardiovascular morbidities has focused predominantly on individual- and clinic-level drivers, but we know little about community- and structural-level factors that shape these outcomes. We use a composite measure of "structural heteropatriarchy" which includes measures of structural sexism and structural LGB-stigma to examine the relationship between structural heteropatriarchy and three cardiovascular-related maternal morbidities using the National Longitudinal Study of Adolescent to Adult Health (n = 3928). Results using multivariate regressions show that structural heteropatriarchy is associated with increased risk of reporting maternal morbidities. Our findings provide further evidence that sexuality- and gender-based stigma operate together to shape health disparities, including maternal health.

Structural stigma and LGBTQ+ health: a narrative review of quantitative studies

Health disparities related to sexual orientation and gender identity exist across multiple outcomes. Scholarship has begun to evaluate whether structural stigma-ie, societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing-contributes to health burdens among LGBTQ+ individuals. We conducted a comprehensive review of quantitative studies examining this hypothesis. We found 98 articles that linked objective (ie, non-self-reported) measures of structural stigma to mental (n=57), behavioural (ie, substance use; n=27; HIV/AIDS or sexually transmitted infection; n=20), and physical (n=20) health outcomes. There was generally consistent evidence that structural stigma increases risk of poor health among LGBTQ+ individuals. Several methodological strengths were identified, including the use of multiple measures (eg, laws or policies [59%, 58 of 98]), designs (eg, quasi-experiments [21%, 21 of 98]), and samples (eg, probability-based [56%, 55 of 98]). However, important gaps exist. Just over half of studies included area-level covariates or non-LGBTQ+ comparison groups, which are necessary to address alternative explanations for the observed associations. Additionally, while studies (n=90) have begun to identify candidate mechanisms, only nine (10%) formally tested mediation. We offer suggestions for future research to advance this literature, which has implications not only for the identification of structural determinants of LGBTQ+ health but also for the development of public health interventions that reduce LGBTQ+ health disparities.

High School FLASH Sexual Health Education Curriculum: LGBTQ Inclusivity Strategies Reduce Homophobia and Transphobia

Homophobic and transphobic beliefs that lead to bias-based harassment remain a critical concern for young people in the USA. The aim of the present study was to examine the impact of an inclusive comprehensive sex education program (High School FLASH) on homophobic and transphobic beliefs. Data from this study come from a randomized controlled trial that evaluated the impact of High School FLASH on students' sexual behaviors and related outcomes with 20 schools in two U.S. regions (Midwest and South). Following the baseline survey, the 20 schools were randomly assigned to receive FLASH or a comparison curriculum. Ninth and 10th grade students completed follow-up surveys 3 and 12 months after the instructional period. We examined changes in homophobic beliefs using multilevel linear regression models in the full sample and two sub-groups: straight cisgender young people versus those who identified as not straight or cisgender. Mean scores on the homophobic and transphobic beliefs scale were statistically significantly lower among young people receiving FLASH relative to the comparison at both the 3- and 12-month timepoints (p-values for adjusted mean differences were < 0.01, n = 1357 and 1275, respectively). Specifically, FLASH's positive impact on reducing homophobic and transphobic beliefs was statistically significant for straight and cisgender youth at both survey follow-ups (p < 0.01, n = 1144 and p = 0.05, n = 1078, respectively); the effects for the LGBTQ sub-group reached statistical significance at only the final follow-up (p = 0.01, n = 197). Our results show that carefully designed, inclusive comprehensive sexual health education programs like High School FLASH can play a role in promoting better school climates for all youth by reducing beliefs that may lead to bullying, violence, and victimization.

How social policies shape the health and well-being of sexual- and gender-minority youth: Pathways of influence, social side effects and implications for life course trajectories

Recent research has documented the harmful health consequences of structural-level stigma that targets sexual and gender minority (SGM) individuals. In the case of sexual and gender minority youth (SGMY), life trajectories are shaped not only by targeted, SGM-focused policies, but also by social policies more broadly which may have unique impacts on SGMY given their social position. However, little work has explored the pathways that connect both targeted and universal social policies and the health and well-being of SGMY. In this study, we conducted 68 qualitative interviews with SGMY in New York City (n = 30) and community stakeholders across the US (n = 38) and used the constant comparative method to identify the pathways through which social policies affect SGMY health and well-being. We propose three pathways that are shaped by specific inter-related social policies in ways that contribute to health inequities among SGMY: 1) access to social inclusion in educational settings; 2) housing-related regulations and subsequent (in)stability; and 3) access to material resources through labor market participation. We also highlight ways that SGMY, and organizations that support them, engage in agency and resistance to promote inclusion and wellbeing. Drawing on ecosocial theory, we demonstrate how policies work across multiple domains and levels to influence cycles of vulnerability and risk for SGMY. We close by discussing the implications of our findings for future research and policy.

The Association of LGBTQ-Supportive School Health Policies and Practices with Sexual Health Outcomes

Purpose: We examined the association of lesbian, gay, bisexual, transgender, and questioning (LGBTQ)-supportive school policies and practices with sexual health outcomes among LGB and heterosexual students. Methods: The 2014 and 2016 School Health Profiles data from principals and lead health educators from 117 high schools in 16 local education agencies across the United States assessed LGBTQ-supportive school policies and practices (e.g., having a gay/straight alliance or similar club). The 2015 and 2017 Youth Risk Behavior Survey data from 75,638 students from the same schools assessed sexual health outcomes (e.g., being currently sexually active). We conducted multilevel cross-sectional logistic regression analyses to examine the associations between school-level LGBTQ-supportive policies and practices with student-level sexual health outcomes, while controlling for sex, grade, race/ethnicity, and school priority status. Results: Several LGBTQ-supportive school policies and practices were significantly associated with lower odds of sexual risk behaviors (e.g., having four or more lifetime sexual partners) and ever being tested for human immunodeficiency virus (HIV) among both LGB and heterosexual students but not with using a condom during last sexual intercourse among sexually active gay, bisexual, or heterosexual male students. Having a greater number of LGBTQ-supportive school policies and practices was significantly associated with lower odds of ever having sex for LGB students and with sexual risk behaviors and ever being tested for HIV for heterosexual students. Conclusion: The study highlights the relationship between multifaceted LGBTQ-supportive school policies and practices and improving sexual health outcomes among both LGB and heterosexual students.

Structural Heteropatriarchy and Birth Outcomes in the United States

Emerging evidence links structural sexism and structural discrimination against lesbian, gay, and bisexual (LGB) populations to poor health outcomes, but studies have yet to examine the combined effects of these mutually reinforcing systems of inequality. Therefore, we developed a composite measure of structural heteropatriarchy-which includes state-level LGB policies, family planning policies, and indicators of structural sexism (e.g., women's political and economic position relative to men)-and examined its relationship to birth outcomes using data from Waves I to V of the National Longitudinal Study of Adolescent to Adult Health. Multivariate regression analyses demonstrated that higher levels of heteropatriarchy were associated with an increased risk of preterm birth and decreased birth weight, net of important covariates. There was no association between clinical low birth weight and heteropatriarchy, or interactions between heteropatriarchy and individuals' race, ethnicity or sexual identity, suggesting a negative effect of heteropatriarchy on birth outcomes for all pregnant people. This study demonstrates the importance of considering gender and sexuality as mutually reinforcing systems of oppression that impact population health. Future research should examine the impact of heteropatriarchy on additional health outcomes and in conjunction with other structural inequalities such as racism and transgender oppression.

Associations between HIV Testing and Consent Policies among Sexually Active Adolescents: Differences by Sexual Behavior

HIV incidence remains high among US youth, especially among sexual minority youth. However, only half of youth with HIV are aware of their status. One potential explanation for low HIV testing rates is that restrictive policies may prevent minors from access HIV testing due to parental consent requirements. Using pooled data from the local Youth Risk Behavior Survey, we assessed whether state HIV testing laws, including age restrictions and explicit inclusion of HIV in STI testing consent laws, were associated with differences in HIV testing rates; differences by sexual behavior were also examined. Among female youth, policies were not associated with HIV testing. However, among male youth, both the presence of age restrictions and explicit inclusion in STI services were significantly associated with increased odds of HIV testing. Results indicate that policy changes may be effective at increasing testing among male youth who have sex with other males.