Longitudinal Associations of Sexual Fluidity and Health in Transgender Men and Cisgender Women and Men

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.

Sexual Fluidity in Identity and Behavior Among Cisgender Youth: Findings from the Longitudinal Growing up with Media Study

OBJECTIVES

To examine fluidity in sexual orientation identity and behavior among cisgender youth.

STUDY DESIGN

Data were analyzed from 5 survey waves of the longitudinal US Growing Up with Media Study (2010-2019). Participants were 989 cisgender youth, aged 13-20 years at baseline, who completed online surveys assessing sexual orientation identity and behavior (gender of sexual partners). Amount of change (mobility) and patterns of change across waves were assessed for identity and behavior.

RESULTS

Consistently heterosexual was the most common sexual orientation identity (89%-97% for boys, 80%-90% for girls), followed by gay (3%) for boys, and bisexual (8%) for girls. Sexual minority identities increased (3%-11% for boys, 10%-20% for girls) over time, same-gender sexual behavior also increased. Girls had more identity mobility than boys; no gender difference was found for behavior mobility. Movement from heterosexual to a sexual minority identity occurred for 9% of girls and 6% of boys; movement from different-gender sexual behavior to same-gender sexual behavior occurred for 2% of girls and boys.

CONCLUSIONS

Findings highlight the need to assess multiple dimensions and patterns of change of youth sexual orientation in research and clinical care. Recognizing and creating space for conversations about changes in sexual identity and behavior over time will help providers accurately and effectively address the health needs of all patients.

Beyond Wokeness: Why We Should All Be Using a More "Sensitive" Measure of Self-Reported Gender Identity

Gender plays a significant role in an individual's experiences and behaviors, as well as their expectations of others. Researchers have long operationalized gender using limited, mutually exclusive categories that fail to capture the rich variability within a gender-diverse population. While open-ended responses or multi-item scales may be a socially progressive approach and necessary for some gender-based research (e.g., Bauer et al., 2017), it may be unsuitable and statistically unfeasible for quantitative researchers in other areas. We analyzed responses from over 700 gender-diverse participants in the U.S. on a series of unipolar scales (i.e., gender identity, expression, and perception by others) that granted participants the flexibility of selecting a comprehensive self-definition while still enabling quantitative analysis of group differences as well as capturing maximum within-group variability. Using a cluster analysis, we found that participants' responses were best represented by five categories: Archetypical Men (n = 169), Archetypical Women (n = 168), Intertypical Men (n = 158), Intertypical Women (n = 126), and Nonconforming (n = 85). We explore the variability of characteristics and beliefs (e.g., gender norms, sexist beliefs) within and between traditional sex and these new gender categories. In this paper, we discuss theoretical considerations for future research and how using this comprehensive operationalization of gender can expand our understanding of "gender differences'' beyond the current scientific assumptions and barriers.

The current state of sexual fluidity research

Sexual fluidity research (i.e., change over time in one or more sexual orientation dimensions) has grown exponentially, with advancements in conceptual models, measurement, and understanding of sexual orientation as a construct and developmental process that accommodates potential for change. Sexual fluidity research has also moved beyond samples of white cisgender women to consider the experiences of individuals with other sociodemographic characteristics and has examined change across multiple dimensions of sexual orientation, mechanisms of change, and associations with health outcomes. This review provides a brief narrative of historical conceptualizations of sexual orientation and fluidity and the current state of research on sexual fluidity. Finally, we identify opportunities for future research, policy, and clinical practice.

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.

Timing of ENDS Uptake by Sexual Orientation among Adolescents and Young Adults in Urban Texas

Introduction

Early-onset of Electronic Nicotine Delivering Systems (ENDS) use puts users at higher risk of developing a regular ENDS use pattern and/or transitioning to combusted tobacco products. Previous studies on ENDS use among adolescents have not considered sexual orientation as a fluid trait that can change over time. Our objective was to evaluate whether ENDS initiation differed by sexual orientation in a longitudinal, population-based cohort of adolescents transitioning into young adulthood in Texas.

Methods

Sample (n = 1712) was drawn from the Texas Adolescent Tobacco and Marketing Surveillance System (waves 5–11) and stratified into three groups, representing sexual orientation: (1) respondents who reported being heterosexuals at each wave (straight), (2) those who consistently self-identified as lesbian, gay or bisexual individuals (LGB), and (3) subjects who reported sexual orientation mobility across waves (mobile). Nonparametric models for interval-censored data were used to estimate the cumulative distribution of age at ENDS initiation by sexual orientation group. Cox models for interval-censored data were used to evaluate whether ENDS initiation varied by sexual orientation group after adjusting for sex assigned at birth, race/ethnicity, cohort, and socioeconomic status.

Results

Compared to Straight adolescents, the risk of earlier-onset of ENDS use was higher among mobile individuals (HR = 1.43, 95% CI: 1.12 to 1.83) and LGB individuals (HR = 1.49, 95% CI: 1.13 to 1.98), respectively, after adjusting for sociodemographic risk factors. Differences between Straight adolescents and LGB/mobile individuals became more pronounced with increasing age.

Conclusion

Analyzing sexual mobility overtime is necessary for understanding the risk associated with youth ENDS initiation and subsequent use.

Implications

Future research should use more accurate sexual orientation assessments to explore further the relationship between sexual orientation mobility and early-onset Electronic Nicotine Delivering Systems (ENDS) use. Understanding the implications of sexual orientation mobility on ENDS initiation will be critical for developing inclusive public health programs aimed at preventing or delaying ENDS use and for providing practical recommendations at state and local levels.

Prevalence and associated characteristics of youth who trade sex in a representative sample of high school students

INTRODUCTION

Our understanding of youths' sex trading predominantly stems from non-representative studies with high-risk populations (e.g. homeless/runaway youth). The purpose of this study is to identify the prevalence and associated characteristics of youth who report sex trading (compared to those who do not) in a representative sample of high school students.

METHODS

Data comes from the 2018 Youth Assessment, a cross-sectional survey administered to 9th through 12th graders across 24 high schools in Dane County, a predominantly urban area in Wisconsin, U.S.A. All youth who answered the question, "have you ever had sexual contact in order to stay safe or to get something like a place to stay, money, gifts, alcohol or drugs?" were included for secondary data analysis (n = 13,714). Participants were 70% White, 50% female/47% male, and 90% minors. Chi-square tests and logistic regression analyses were conducted.

RESULTS

2.47% of youth reported sex trading, of whom 91% were minors. Bivariate analysis revealed significant differences across demographics, economic instability, behavioral health and substance use, delinquency, and romantic/sexual behaviors. Multivariate results suggested that students who reported substance use, cutting class, 3 or more out-of-school suspensions, knowing a friend involved in a gang, dating violence, foster care involvement, or identifying as LGBTQ+ were more likely to report sex trading.

CONCLUSIONS

Although the causal order of characteristics analyzed in relation to the sex trading is not known, these findings have important implications for sex trading prevention, assessments, and intervention, particularly among youth with marginalized identities and adverse experiences.

The New Genetic Evidence on Same-Gender Sexuality: Implications for Sexual Fluidity and Multiple Forms of Sexual Diversity

In September of 2019, the largest-ever (N = 477,522) genome-wide-association study of same-gender sexuality was published in Science. The primary finding was that multiple genes are significantly associated with ever engaging in same-gender sexual behavior, accounting for between 8-25% of variance in this outcome. Yet an additional finding of this study, which received less attention, has more potential to transform our current understanding of same-gender sexuality: Specifically, the genes associated with ever engaging in same-gender sexual behavior differed from the genes associated with one's relative proportion of same-gender to other-gender behavior. I review recent research on sexual orientation and sexual fluidity to illustrate how these findings speak to longstanding questions regarding distinctions among subtypes of same-gender sexuality (such as mostly-heterosexuality, bisexuality, and exclusive same-gender experience). I conclude by outlining directions for future research on the multiple causes and correlates of same-gender expression.

Gender Affirmation through Correct Pronoun Usage: Development and Validation of the Transgender Women's Importance of Pronouns (TW-IP) Scale

Social interactions where a person is addressed by their correct name and pronouns, consistent with their gender identity, are widely recognized as a basic and yet critical aspect of gender affirmation for transgender people. Informed by the Model of Gender Affirmation, we developed a self-report measure of the importance of social gender affirmation, the Transgender Women's Importance of Pronouns (TW-IP) scale, which measures gender affirmation through the usage of correct pronoun by others. Data were from self-administered surveys in two independent samples of transgender women living with HIV in the US (N1 = 278; N2 = 369). Using exploratory factor analysis with data from Study 1 and confirmatory factor analysis with data from Study 2, we obtained a four-item scale with a single-factor structure and strong reliability (α = 0.95). We present evidence of TW-IP's convergent and discriminant validity through its correlations with select mental health and HIV-related measures. Further, scores on TW-IP were linked in expected directions to several hypothesized mental health and HIV care outcomes, demonstrating its predictive validity. The resulting brief measure of importance of pronouns among transgender women shows strong psychometric properties. Validation evidence offers highly promising opportunities for use of the measure in clinical and research settings.

Sexual orientation and mental health over the life course in a birth cohort

BACKGROUND

Sexual minority individuals consistently report higher rates of mental disorder than heterosexuals. However, much of the research has methodological limitations related to the classification of sexuality, the use of cross-sectional data and problematic sampling procedures such as using convenience samples.

METHODS

We used longitudinal data from a birth cohort enrolled in the Christchurch Health and Development Study (n = 1040). Latent class analysis was used to classify participants sexuality based on self-report data of sexual behaviour, attraction, identity and fantasy, gathered over five assessments between the ages of 18 and 35 years. Mental health and substance use outcome data were gathered at four assessments between the ages of 21 and 35 years. Potential covariate variables were collected during childhood.

RESULTS

The latent class analysis identified four groups interpreted as: 'heterosexual' 82%, 'mostly heterosexual' 12.6%, 'bisexual' 3.5% and 'gay/lesbian' 1.9%. In the sexual minority groups, women outnumbered men by at least 2:1. Pooled rates for mental health disorders of depression, anxiety disorders, suicidal ideation, cannabis abuse and total disorders, after adjustment for childhood covariate variables, were significantly higher in the sexual minority groups (p < 0.01). The strength of association between sexuality group and mental health outcomes did not differ according to sex. Fluidity in sexuality reports appeared unrelated to risk of mental health outcomes.

CONCLUSIONS

Over the life course, membership of a sexual minority group is clearly associated with mental health problems of depression, anxiety and suicidal ideation regardless of the age when same-sex attraction, behaviour, identity or fantasy is expressed.