The Social Development of Contingent Self-Worth in Sexual Minority Young Men: An Empirical Investigation of the “Best Little Boy in the World” Hypothesis

The Psychosocial Consequences of Sexual Violence Stigma: A Scoping Review

Over the past decade, scholars have explored whether the stigma associated with sexual violence (SV) represents a risk factor for psychopathology and related comorbidities following SV. We conducted a scoping review to summarize and evaluate the state of this burgeoning literature. We included studies from Pubmed, APA PsychInfo, Embase, CINAHL Plus, Social Science Premium, and Web of Science that quantified stigma related to SV. Studies were screened and abstracted in accordance with the PRISMA-SCR guidelines for scoping reviews. Our final sample contained 62 studies. We address two key questions about SV stigma. First, is SV a stigmatized status? Articles (n = 14) provided evidence for SV stigma among potential stigmatizers (e.g., individuals who may perpetuate stigma) across a range of methods (e.g., vignettes) and outcomes (e.g., desire for social distance). Additional work (n = 20) corroborates perceptions of SV stigma among targets (i.e., SV survivors). Second, what are the psychosocial consequences of SV stigma? We reviewed studies (n = 28) demonstrating that SV stigma is correlated with a range of adverse psychosocial outcomes-including anxiety, depression, posttraumatic stress disorder, problematic drinking, and somatic symptoms-among individuals experiencing multiple types of SV (e.g., childhood sexual abuse and sexual assault). Thus, emerging evidence suggests that SV stigma may be a critical determinant of risk and recovery following SV exposure. However, a number of limitations were observed, including that SV stigma has not been consistently measured and that the literature has not fully incorporated stigma constructs, such as concealment and structural stigma. We offer several recommendations to advance this line of work.

Does intergenerational educational mobility vary by sexual identity? A comparative analysis of five OECD countries

Lesbian, gay and bisexual people are disadvantaged in terms of health and socio-economic status compared with heterosexual people, yet findings pertaining to educational outcomes vary depending on the specific identity and gender considered. This study delves into these unexplained findings by applying a social-stratification lens, thereby providing an account of how intergenerational educational mobility varies by sexual identity. To accomplish this, we use representative data from five OECD countries and a regression-based empirical specification relying on coarsened exact matching. We find that gay and lesbian people have higher educational attainment than heterosexual people in all five countries and that these higher levels of education stem from greater rates of upward educational mobility among gay/lesbian people. There were, however, few differences between heterosexual and bisexual people. Variation across countries emerged when analyses were stratified by gender, with higher rates of upward mobility observed for gay men in Australia, Chile, the United Kingdom, and the United States and lesbian women in Australia and Germany. Overall, our results align with previous claims that education can be a strategy for gay/lesbian people to avoid actual or anticipated discrimination. However, variation in these patterns across groups suggests that other mechanisms may also be at play.

Promoting Resilience to Improve Disordered Eating (PRIDE): A case series of an eating disorder treatment for sexual minority individuals

OBJECTIVE

Despite the increased risk for eating disorders (EDs) among sexual minority (SM) individuals, no ED treatments exist specifically for this population. SM stress and appearance-based pressures may initiate and/or maintain ED symptoms in SM individuals; thus, incorporating strategies to reduce SM stressors into existing treatments may help address SM individuals' increased ED risk. This mixed-methods study evaluated the feasibility, acceptability, and preliminary efficacy of Promoting Resilience to Improve Disordered Eating (PRIDE)-a novel ED treatment for SM individuals.

METHODS

N = 14 SM individuals with an ED diagnosis received 14 weekly sessions integrating Enhanced Cognitive Behavioral Therapy for EDs (CBT-E) with techniques and principles of SM-affirmative CBT developed to address SM stressors. Participants completed qualitative interviews and assessments of ED symptoms and SM stress reactions at baseline (pretreatment), posttreatment, and 1-month follow-up.

RESULTS

Supporting feasibility, 12 of the 14 (85.7%) enrolled participants completed treatment, and qualitative and quantitative data supported PRIDE's acceptability (quantitative rating = 3.73/4). By 1-month follow-up, 75% of the sample was fully remitted from an ED diagnosis. Preliminary efficacy results suggested large and significant improvements in ED symptoms, clinical impairment, and body dissatisfaction, significant medium-large improvements in internalized stigma and nonsignificant small-medium effects of sexual orientation concealment.

DISCUSSION

Initial results support the feasibility, acceptability, and initial efficacy of PRIDE, an ED treatment developed to address SM stressors. Future research should evaluate PRIDE in a larger sample, compare it to an active control condition, and explore whether reductions in SM stress reactions explain reductions in ED symptoms.

PUBLIC SIGNIFICANCE

This study evaluated a treatment for SM individuals with EDs that integrated empirically supported ED treatment with SM-affirmative treatment in a case series. Results support that this treatment was well-accepted by participants and was associated with improvements in ED symptoms and minority stress outcomes.

Low self-esteem: a refined cognitive behavioural model

Melanie Fennell's (1997) seminal cognitive approach to low self-esteem was published in Behavioural and Cognitive Psychotherapy. The current paper proposes a refined model, drawing on social theories, and research with people with socially devalued characteristics. This model emphasises how self-esteem relates to perceptions of one's value in the eyes of others. It is proposed that core beliefs typical of low self-esteem relate to one's value in relation to personal adequacy (e.g. having worth or status) and/or to social connection (e.g. being liked, loved, accepted or included). In each of these value domains, beliefs about both the self (e.g. 'I am a failure', 'I am unlovable') and others (e.g. 'Others look down on me', 'Others don't care about me') are considered important. The model suggests that everyone monitors their value but in people with low self-esteem, cognitive biases associated with underlying beliefs occur. In the context of trigger situations, this results in a greater likelihood of negative appraisals of perceived threat to one's value. Such appraisals activate underlying negative beliefs, resulting in negative mood (e.g. low mood, anxiety, shame, disgust) and other responses that maintain low self-esteem. Responses which can be used excessively or in unhelpful ways include (a) corrective behaviours; (b) compensatory strategies; (c) increased value monitoring; (d) safety-seeking behaviours; (e) rumination; (f) unhelpful mood regulation responses. These responses can adversely impact daily functioning or health, having the counterproductive effect of maintaining negative beliefs about one's value. Examples are provided for low self-esteem in lesbian, gay and bisexual individuals.

Examining the Measurement Invariance of the Conformity to Masculine Norms Inventory (CMNI-30) by Sexual Orientation

An abbreviated version of the Conformity to Masculine Norms Inventory, the CMNI-30, was developed with several strengths. However, its measurement invariance across men with different sexual orientations has not been examined in a U.S. sample, so it is unclear whether these different populations understand the items similarly. In addition, no studies have compared conformity to masculinity norms across sexual orientations. This would be important to understand sexual minority men's experience of masculinity and how it differs from heteronormative masculinity. This article explores the measurement invariance of the CMNI-30 among 882 heterosexual, gay, and bisexual+ men using confirmatory factor analysis, and compares their CMNI-30 subscale scores. Results indicated that the CMNI-30 demonstrated residual invariance between men of different sexual orientations, suggesting that men of different sexual orientations interpreted the items similarly. We also found higher levels of conformity to the masculine norms of Winning, Heterosexual self-presentation, and Power over women among heterosexual men relative to gay and bisexual+ men, and higher levels of Pursuit of status among gay men relative to the other groups. Results provide support for the use of the CMNI-30 in research with men of different sexual orientations.

Kept in the Closet: Structural Stigma and the Timing of Sexual Minority Developmental Milestones Across 28 European Countries

Structural stigma's role in lesbian, gay, and bisexual (LGB) people's attainment of identity development milestones remains unknown. In a sample of 111,498 LGB people (ages 15 to 65+) living across 28 European countries, associations were investigated between structural stigma measured using an objective index of discriminatory country-level laws and policies affecting LGB people and the timing and pacing of LGB self-awareness, coming out, and closet duration, and subgroup differences in these associations. On average, self-awareness occurred at age 14.8 years old (SD = 5.1), coming out occurred at 18.5 years old (SD = 5.7), and the closet was 3.9 years long (SD = 4.9); thereby highlighting adolescence as a key period for sexual identity development and disclosure. Greater structural stigma was associated with higher odds of never coming out, later age of coming out, and longer closet duration. Gender identity, transgender identity, and sexual identity moderated associations between structural stigma and these developmental milestones. Reducing structural stigma can plausibly promote sexual identity development among LGB populations, especially during adolescence when identity related milestones are often attained.

A Developmental Model of the Sexual Minority Closet: Structural Sensitization, Psychological Adaptations, and Post-closet Growth

Across the lifespan, most sexual minority individuals experience the closet-a typically prolonged period in which no significant others know their sexual identity. This paper positions the closet as distinct from stigma concealment given its typical duration in years and absolute removal from sources of support for an often-central identity typically during a developmentally sensitive period. The Developmental Model of the Closet proposed here delineates the vicarious learning that takes place before sexual orientation awareness to shape one's eventual experience of the closet; the stressors that take place after one has become aware of their sexual orientation but has not yet disclosed it, which often takes place during adolescence; and potential lifespan-persistent mental health effects of the closet, as moderated by the structural, interpersonal, cultural, and temporal context of disclosure. The paper outlines the ways in which the model both draws upon and is distinct from earlier models of sexual minority identity formation and proposes several testable hypotheses and future research directions, including tests of multilevel interventions.

Why do queer men experience negative body image? A narrative review and testable stigma model

Queer men (i.e., men who are not heterosexual; sexual minority men) are disproportionately affected by negative body image - they experience greater body dissatisfaction are more likely to develop eating disorders than heterosexual men. While existing literature has examined individual-level predictors of negative body image for queer men, less is known about why queer men as a group are disproportionately affected by negative body image. By synthesising existing theoretical frameworks, research, policy, and media reporting, this narrative review moves towards an understanding of systemic-level negative body image for queer men. Through the lens of hegemonic masculinity, we explain how systemic experiences of stigma work to inform unattainable appearance standards for queer men, and how these standards then contribute to pervasive negative body image concerns among this community. Next, we describe how systemic stigma works to exacerbate negative health outcomes for queer men with body image concerns. Finally, we present a synthesized model of the processes outlined in this review, articulate testable predictions for future studies, and describe practical implications that could be widely employed to improve body image for queer men. Our review is the first to propose a comprehensive explanation of systemic negative body image for queer men.

Gay and Straight Men Prefer Masculine-Presenting Gay Men for a High-Status Role: Evidence From an Ecologically Valid Experiment

There is increased acceptance of gay men in most Western societies. Nevertheless, evidence suggests that feminine-presenting gay men are still disadvantaged compared to gay men who present in a more traditionally masculine way. Though gay men themselves may be complicit in perpetuating this bias, studies that demonstrate this possibility are scant. Whereas most studies on perceptions of feminine-presenting gay men have manipulated gender nonconformity via written descriptions, research suggests that behavioural cues such as voice and body-language can mitigate or exacerbate prejudice toward a stereotyped individual. In the current study, audio-visual stimuli were created to investigate how masculine versus feminine behaviour would impact status endowment from other gay and heterosexual men. In total, 256 men (Mage = 42.73, SD = 14.48: half gay; half heterosexual) cast, from a selection of six video-taped candidates, one gay man to play a lead role in a purported ad for a tourism campaign. In the videos, the actors delivered a script related to the tourism campaign in a manner where their voice and body-language was manipulated to come across as either masculine or feminine-presenting. Findings indicated that gay and heterosexual participants showed a significant preference for the masculine videoclips. For heterosexual men, the preference for masculine-presenting actors was predicted by greater anti-gay sentiment, whereas internalised anti-gay prejudice did not predict a preference for masculine-presentation among gay men. Implications of the findings for discourse and education on intraminority prejudice and suggestions for future research are offered.

Gay Community Stress Scale with Its Cultural Translation and Adaptions in Taiwan

The present study aimed to adapt the Gay Community Stress Scale (GCSS) into the traditional Chinese version for measuring gay community stress experienced. Additionally, we examined its psychometric propensities among gay and bisexual men (GBM) in Taiwan. In total, 736 GBM participated in this study and completed the 35-item traditional Chinese version of the GCSS (29 items from the original GCSS and six items from the results of the focus group interviews among GBM in Taiwan); the Measure of Internalized Sexual Stigma for Lesbians and Gay Men (MISS-LG); the State-Trait Anxiety Inventory (STAI); and the Center for Epidemiological Studies Depression Scale (CES-D). Exploratory factor analysis results suggest a five-factor structure (i.e., Sex, Status, Competition, Exclusion, and Externals) for the 32-item traditional Chinese version of the GCSS among Taiwanese GBM; three items were deleted due to low factor loadings (i.e., <0.3). The five-factor "Externals" were not observed in the original GCSS. Moreover, the concurrent validity of the traditional Chinese version was supported by the positive correlations with MISS-LG, STAI, and CES-D. In conclusion, the traditional Chinese version of the GCSS showed relatively satisfactory psychometric properties. However, further research is needed to investigate the reasons for the possible etiology account for the different factor structures between the traditional Chinese version and the original GCSS.

Sexual minority young adults' perspectives on how minority stress and other factors negatively affect self-esteem: a qualitative interview study

Sexual minority young adults (lesbian, gay and bisexual), are at increased risk of experiencing mental health problems than their heterosexual peers. On average they also have lower self-esteem which may contribute to the development or maintenance of mental illnesses. Interventions to improve self-esteem could improve well-being and reduce mental ill-health risk in sexual minority young adults. It is important to understand the processes that contribute to lower self-esteem in this population. The present study aimed to explore these processes. Semi-structured qualitative interviews were conducted with a sample of 20 sexual minority young adults (age 16-24 years) with a range of self-esteem levels. Using thematic analysis, three overarching areas were idenitified: 'Negative social evaluations and reduced belonging', 'Striving and failing to meet standards', and 'Negative sexual orientation processes'. These findings have theoretical implications for minority stress models of mental health inequalities, highlighting the potential interaction between minority-specific and more general risk factors for mental health problems. Findings also have clinical implications for the development of tailored interventions to help improve low self-esteem in sexual minority young adults.

Self-esteem in sexual minority young adults: a qualitative interview study exploring protective factors and helpful coping responses

Research on mental health inequalities between sexual minority and heterosexual young adults has historically focussed on the additional stress processes that might explain this disparity. However, more recently there has been a shift towards research focussed on resilience factors that might promote mental health in sexual minority young adults. Self-esteem is one such proposed resilience factor. This study aimed to explore the factors that promote or protect self-esteem itself in sexual minority young adults. A semi-structured interview study was conducted with 20 sexual minority young adults (aged 16-24) to explore their perspectives on the factors, responses and strategies that have helped to protect or promote their self-esteem. Six themes were identified from thematic analysis: helpful responses to minority stress; sexuality acceptance; positive LGBTQ + social connections and representations; positive social relationships and evaluation; successes and positive qualities and general coping strategies for low self-esteem. Findings are discussed in terms of their theoretical implications.

A cognitive behavioural intervention for low self-esteem in young people who have experienced stigma, prejudice, or discrimination: An uncontrolled acceptability and feasibility study

OBJECTIVES

Stigma has been found to be associated with lower self-esteem, which increases the risk of difficulties across life domains including vulnerability to mental health problems. There are no previous studies of interventions for people experiencing low self-esteem in the context of different stigmatized characteristics. This study evaluated feasibility, acceptability, and preliminary outcomes of an intervention targeting low self-esteem in stigmatized people aged 16-24 years.

DESIGN

An uncontrolled study with repeated measures.

METHOD

People with a range of stigmatized characteristics, who had low self-esteem and associated impaired daily functioning, were recruited from the general population. The individual six-session cognitive behavioural intervention had modules chosen according to participants' formulations. The CBT included compassion-focussed therapy methods and was informed by stigma research. Feasibility was assessed in relation to recruitment, retention, and protocol adherence. Acceptability was assessed through participant feedback. Questionnaires assessing self-esteem, functioning impairments, depression, anxiety, self-criticism, self-compassion, and responses to prejudice and discrimination were administered at baseline, pre-, mid-, post-intervention, and two-month follow-up.

RESULTS

Forty-four people completed screening; 73% were eligible. Of these, 78% consented and 69% (N = 22) started the intervention. Eighteen (82%) participants completed, and four dropped out. Follow-up measures were completed by all treatment completers. Treatment completers reported the intervention was useful, improved their self-esteem and coping, and would recommend it. Ratings of usefulness and frequency of use of intervention components were high at post-treatment and follow-up.

CONCLUSIONS

The intervention was feasible and highly acceptable to treatment completers. This suggests the intervention warrants investigation in a randomized-controlled trial.

PRACTITIONER POINTS

Young people with low self-esteem whom have been negatively affected by stigma may wish to access support and be willing to engage in psychological interventions. Cognitive behavioural therapy may be helpful for young people with low self-esteem who have experienced stigma, prejudice, or discrimination. Cognitive behavioural techniques such as self-compassionate thought records and behavioural experiments were considered acceptable and helpful by young people whose self-esteem has been affected by stigma. Addressing responses to stigma in therapy, such as rumination, avoidance, and perfectionism, appears to be feasible and acceptable.

Project ESTEEM protocol: a randomized controlled trial of an LGBTQ-affirmative treatment for young adult sexual minority men's mental and sexual health

BACKGROUND

Young gay and bisexual men disproportionately experience depression, anxiety, and substance use problems and are among the highest risk group for HIV infection in the U.S. Diverse methods locate the source of these health disparities in young gay and bisexual men's exposure to minority stress. In fact, minority stress, psychiatric morbidity, substance use, and HIV risk fuel each other, forming a synergistic threat to young gay and bisexual men's health. Yet no known intervention addresses minority stress to improve mental health, substance use problems, or their joint impact on HIV risk in this population. This paper describes the design of a study to test the efficacy of such an intervention, called ESTEEM (Effective Skills to Empower Effective Men), a 10-session skills-building intervention designed to reduce young gay and bisexual men's co-occurring health risks by addressing the underlying cognitive, affective, and behavioral pathways through which minority stress impairs health.

METHODS

This study, funded by the National Institute of Mental Health, is a three-arm randomized controlled trial to examine (1) the efficacy of ESTEEM compared to community mental health treatment and HIV counseling and testing and (2) whether ESTEEM works through its hypothesized cognitive, affective, and behavioral minority stress processes. Our primary outcome, measured 8 months after baseline, is condomless anal sex in the absence of PrEP or known undetectable viral load of HIV+ primary partners. Secondary outcomes include depression, anxiety, substance use, sexual compulsivity, and PrEP uptake, also measured 8 months after baseline.

DISCUSSION

Delivering specific stand-alone treatments for specific mental, behavioral, and sexual health problems represents the current state of evidence-based practice. However, dissemination and implementation of this one treatment-one problem approach has not been ideal. A single intervention that reduces young gay and bisexual men's depression, anxiety, substance use, and HIV risk by reducing the common minority stress pathways across these problems would represent an efficient, cost-effective alternative to currently isolated approaches, and holds great promise for reducing sexual orientation health disparities among young men.

TRIAL REGISTRATION

Registered October 10, 2016 to ClinicalTrials.gov Identifier: NCT02929069 .

Minority Stress, Emotion Regulation, and Executive Function: An Experimental Investigation of Gay and Lesbian Adults

Minority stress is associated with emotional, cognitive, and health consequences for sexual minority individuals. Mechanisms remain poorly understood. Theory and preliminary evidence suggests that stress associated with minority identity results in negative emotions and attempts at suppression, which may contribute to depletion of executive function. This study was an experimental investigation of gay and lesbian adults (N = 141). Participants engaged in a stressful interpersonal task with a confederate with anti-gay or pro-gay attitudes. We examined how condition affected executive function, along with potential mediators (state anger, anxiety, expressive suppression). Contrary to hypotheses, participants in the anti-gay condition showed better postmanipulation cognitive performance than the pro-gay condition. This effect was partially mediated by anger. Participants in the anti-gay condition reported greater attempts at suppression, but this variable did not emerge as a mediator. This study was the first to experimentally manipulate exposure to anti-gay attitudes and measure effects on executive function.

Psychotherapy for the Spectrum of Sexual Minority Stress: Application and Technique of the ESTEEM Treatment Model

Converging evidence points to minority stress as a risk factor that predisposes sexual minority individuals to a variety of negative psychosocial health outcomes, particularly depression and anxiety, substance use, and sexual risk-taking. This paper outlines the techniques and theoretical underpinnings for implementing an emerging empirically supported psychotherapy targeting the transdiagnostic mechanisms linking minority stress with these outcomes for sexual minority clients. We outline the essential therapeutic principles, psychoeducation content, as well as session- and homework-based activities that can be adapted for a variety of presenting problems that originate from and are exacerbated by minority stress via these transdiagnostic minority stress processes. As the development and dissemination of this therapeutic model is still within its early stages, we review the intervention's empirical support thus far and outline potential directions for future development and dissemination via individual, clinic-based, and societal channels.

Sexual Distress Mediates the Associations Between Sexual Contingent Self-Worth and Well-Being in Women With Genitopelvic Pain: A Dyadic Daily Experience Study

Provoked vestibulodynia (PVD), a common cause of women's genitopelvic pain, is associated with poorer psychological and sexual well-being in affected couples. Greater sexual contingent self-worth (CSW)-defined as self-esteem that is dependent on the perceived success or failure of a sexual relationship-has been linked to poorer well-being in a cross-sectional study of couples coping with PVD. This study aimed to examine whether daily sexual distress mediated the associations between greater sexual CSW and lower sexual satisfaction and greater anxiety, depressed mood, and women's pain in affected couples. Women (N = 125) diagnosed with PVD and their partners completed the Sexual CSW Scale and then online daily surveys for eight weeks measuring sexual distress, sexual satisfaction, anxiety, depressed mood, and women's pain during intercourse. Multilevel analyses were based on the actor-partner interdependence model (APIM). For women who had higher sexual CSW (compared to lower sexual CSW), on sexual activity days when their sexual distress was higher, they reported lower sexual satisfaction and greater anxiety, depressed mood, and pain (compared to their average level across all sexual activity days). Findings suggest that daily sexual distress may be one pathway between greater sexual CSW and poorer day-to-day well-being in women with PVD.

Satisfaction and Health Within Four Sexual Identity Relationship Options

Using a sample of 1,782 same-sex attracted (SSA) and lesbian, gay, and bisexual (LGB) identified participants, this study examined similarities and differences among those who are (a) single and celibate (SC); (b) single and not celibate (SNC); (c) in a heterosexual, mixed-orientation relationship (MOR); and (d) in a same-sex relationship (SSR). To reduce bias and increase generalizability, an ideologically diverse research team was formed. Participants in SSRs reported higher levels of some amount of satisfaction with their status (95%) compared to those in MORs (80%), those who are SC (42%) and those who are SNC (40%). The SSR group had the least depression and anxiety and the most life satisfaction and physical health, followed by the MOR group, followed by the two single groups. Results from a stepwise regression predicting satisfaction from important aspects of life and relationships identified that meeting needs for connection, intimacy, and mutual understanding was the strongest predictor of satisfaction across all options. Other significant variables included participant-defined authentic sexual expression, resolving conflicts with religion, and reducing depression and anxiety. Results may inform SSA/LGB individuals who are questioning which option fits best for them and help guide therapists who work with these individuals.

Body Image Disturbances as Predictors of Reduced Mental Health Among Australian Gay Men: Being in a Relationship Does Not Serve as a Protective Factor

Past studies have demonstrated associations between gay men's body image disturbances and poorer mental health. However, little research has considered whether relationship status, or sexual agreements within relationships, moderates these associations. The present study was designed to address this gap. Results from a survey involving 796 Australian gay men between the ages of 18-39 showed that various measures of body image disturbance significantly and independently predicted satisfaction with life, self-esteem, positive well-being, and psychological distress. However, neither relationship status nor sexual agreement type (monogamous vs. non-monogamous) moderated these associations. These findings suggest that, although gay men may experience appearance-related pressure in order to attract sexual or relationship partners, simply being in a relationship does not reduce the detrimental associations of body image disturbance with mental health. Future research could examine specific aspects of relationship quality and dynamics that may serve as risk or protective factors in this context.

Sexual orientation and sex differences in socioeconomic status: a population-based investigation in the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Socioeconomic status (SES) is a fundamental contributor to health; however, limited research has examined sexual orientation differences in SES.

METHODS

2008-2009 data from 14 051 participants (ages 24-32 years) in the US-based, representative, National Longitudinal Study of Adolescent to Adult Health were analysed using multivariable regressions that adjusted for age, race-ethnicity, childhood SES, urbanicity and Census region, separately for females and males. Modification by racial minority status (black or Latino vs white, non-Hispanic) was also explored.

RESULTS

Among females, sexual minorities (SM) (10.5% of females) were less likely to graduate college, and were more likely to be unemployed, poor/near poor, to receive public assistance and to report economic hardship and lower social status than heterosexuals. Adjusting for education attenuated many of these differences. Among males, SM (4.2% of males) were more likely than heterosexuals to be college graduates; however, they also had lower personal incomes. Lower rates of homeownership were observed among SM, particularly racial minority SM females. For males, household poverty patterns differed by race-ethnicity: among racial minority males, SM were more likely than heterosexuals to be living at >400% federal poverty level), whereas the pattern was reversed among whites.

CONCLUSIONS

Sexual minorities, especially females, are of lower SES than their heterosexual counterparts. SES should be considered a potential mediator of SM stigma on health. Studies of public policies that may produce, as well as mitigate, observed SES inequities, are warranted.

Striving for Prestige in Samoa: A Comparison of Men, Women, and Fa'afafine

In numerous non-Western cultures around the world, a small but meaningful proportion of individuals occupy alternative gender categories beyond the man/woman binary. A substantial body of past research has shown that feminine, same-sex attracted males in Samoa-a nonbinary gender known as fa'afafine-are more altruistic toward their nieces and nephews than are Samoan men and women. The present study examined the degree to which these kin-directed altruistic tendencies of fa'afafine are motivated by striving for prestige, and hence demonstrating value, within their family. Results showed that cisgender men and women do not differ in the degree to which they seek familial recognition of their altruistic behavior toward nieces and nephews. However, compared to men, fa'afafine sought significantly more acknowledgment of this altruism. These results illustrate one proximate cognitive mechanism for the elevated kin-directed altruism of fa'afafine and highlight the importance of the sociocultural context in which these motivations develop.

Evidence of Multiple Mediating Pathways in Associations Between Constructs of Stigma and Self-Reported Suicide Attempts in a Cross-Sectional Study of Gay and Bisexual Men

Gay and bisexual men (GBM) are more likely to attempt suicide than heterosexual men. This disparity is commonly interpreted using minority stress theory; however, specific pathways from antigay stigma to suicidal behavior are poorly understood. We aimed to estimate associations between multiple constructs of stigma and suicide attempts among adult GBM, and to measure the proportion of these associations mediated by distinct suicide risk factors, thus identifying proximal points of intervention. Data were drawn from a Canadian community-based survey of adult GBM. Structural equation modeling was used to compare associations between three latent constructs-enacted stigma (e.g., discrimination, harassment), anticipated prejudice (worry about encountering antigay/bisexual prejudice), and sexuality concealment-and self-reported suicide attempts (last 12 months). Coefficients were estimated for direct, indirect, and total pathways and evaluated based on magnitude and statistical significance. The proportion of associations mediated by depression, drug/alcohol use, and social isolation was calculated using indirect paths. Among 7872 respondents, 3.4% reported a suicide attempt in the past 12 months. The largest total association was observed for enacted stigma, and this association was partially mediated by depression and drug/alcohol use. The total association of anticipated prejudice was relatively smaller and mediated by depression and social isolation. Concealment had an inverse association with suicide attempts as mediated by depression but was also positively associated with suicide attempts when mediated through social isolation. Multiple constructs of antigay stigma were associated with suicide attempts; however, mediating pathways differed by construct, suggesting that a combination of strategies is required to prevent suicide in adult GBM.

State Authenticity as Fit to Environment: The Implications of Social Identity for Fit, Authenticity, and Self-Segregation

People seek out situations that "fit," but the concept of fit is not well understood. We introduce State Authenticity as Fit to the Environment (SAFE), a conceptual framework for understanding how social identities motivate the situations that people approach or avoid. Drawing from but expanding the authenticity literature, we first outline three types of person-environment fit: self-concept fit, goal fit, and social fit. Each type of fit, we argue, facilitates cognitive fluency, motivational fluency, and social fluency that promote state authenticity and drive approach or avoidance behaviors. Using this model, we assert that contexts subtly signal social identities in ways that implicate each type of fit, eliciting state authenticity for advantaged groups but state inauthenticity for disadvantaged groups. Given that people strive to be authentic, these processes cascade down to self-segregation among social groups, reinforcing social inequalities. We conclude by mapping out directions for research on relevant mechanisms and boundary conditions.

The Mental Health Impact of Physical Appearance Concerns in the Context of Other Life Domains Among Australian Gay Men

Previous studies have identified gay men as a high-risk population for body image disturbances. However, little research has examined the mental health impact of gay men's physical appearance concerns in the context of other major life domains. The present study addressed this gap by investigating how mental health outcomes (satisfaction with life, self-esteem, positive well-being, and psychological distress) were associated with satisfaction with and importance of physical appearance, work, family relationships, friendships, health and fitness, and sex life among Australian gay men aged 18-39. The possible moderating role of intimate relationship status was also examined. Results from an online survey revealed that greater satisfaction with physical appearance, work, family, and friendships all had similar positive associations with mental health. However, more importance placed on physical appearance was more consistently associated with poorer mental health compared with the subjective importance of other domains. Findings also indicated the associations between physical appearance satisfaction and life satisfaction, and between physical appearance importance and positive well-being, were weaker for those in relationships. Thus, physical appearance matters in gay men's lives, but was only one factor when considered in the broader context of other life areas that contributed to overall well-being. These findings suggest the need for a nuanced and contextualized understanding of how physical appearance concerns fit into gay men's lives.

School victimization and substance use among lesbian, gay, bisexual, and transgender adolescents

Lesbian, gay, bisexual, and transgender (LGBT) adolescents are at increased risk for substance use, relative to their heterosexual counterparts. Although previous research has demonstrated that experiences of anti-LGBT harassment, discrimination, and victimization may explain some of this disparity, little is known about the mechanisms whereby such mistreatment leads to substance abuse. This study aimed to examine whether mechanisms suggested by the Social Development Model might explain the links between school-based victimization and substance use in this population. Five hundred and four ethnically diverse LGBT adolescents ages 14-19 reported their experiences with school victimization, substance abuse, school bonding, and deviant peer group affiliation. Anti-LGBT victimization in school was associated with substance abuse, and although causality cannot be established, structural equation modeling confirmed that the data are consistent with a theoretical model in which this association was mediated by increased affiliation with deviant peers. Preventive interventions for LGBT adolescents must not only attempt to make schools safer for these youth, but also help keep them engaged in healthy peer groups when they are confronted with mistreatment in school.

Daily minority stress and affect among gay and bisexual men: A 30-day diary study

BACKGROUND

This study examined the time-variant association between daily minority stress and daily affect among gay and bisexual men. Tests of time-lagged associations allow for a stronger causal examination of minority stress-affect associations compared with static assessments. Multilevel modeling allows for comparison of associations between minority stress and daily affect when minority stress is modeled as a between-person factor and a within-person time-fluctuating state.

METHODS

371 gay and bisexual men in New York City completed a 30-day daily diary, recording daily experiences of minority stress and positive affect (PA), negative affect (NA), and anxious affect (AA). Multilevel analyses examined associations between minority stress and affect in both same-day and time-lagged analyses, with minority stress assessed as both a between-person factor and a within-person state.

RESULTS

Daily minority stress, modeled as both a between-person and within-person construct, significantly predicted lower PA and higher NA and AA. Daily minority stress also predicted lower subsequent-day PA and higher subsequent-day NA and AA.

LIMITATIONS

Self-report assessments and the unique sample may limit generalizability of this study.

CONCLUSIONS

The time-variant association between sexual minority stress and affect found here substantiates the basic tenet of minority stress theory with a fine-grained analysis of gay and bisexual men's daily experience. Time-lagged effects suggest a potentially causal pathway between minority stress as a social determinant of mood and anxiety disorder symptoms among gay and bisexual men. When modeled as both a between-person factor and within-person state, minority stress demonstrated expected patterns with affect.

A transdiagnostic minority stress treatment approach for gay and bisexual men's syndemic health conditions

Developing and deploying separate treatments for separate conditions seems ill-suited to intervening upon the co-occurring, and possibly functionally similar, psychosocial conditions facing gay and bisexual men. This article argues for the need to create transdiagnostic interventions that reduce multiple syndemic conditions facing gay and bisexual men at the level of their shared source in minority stress pathways. This article first reviews psychosocial syndemic conditions affecting gay and bisexual men, then suggests pathways that might link minority stress to psychosocial syndemics based on recent advancements in emotion science, psychiatric nosology, and cognitive-affective neuroscience, and finally suggests cross-cutting psychosocial treatment principles to reduce minority stress-syndemic pathways among gay and bisexual men. Because minority stress serves as a common basis of all psychosocial syndemic conditions reviewed here, locating the pathways through which minority stress generates psychosocial syndemics and employing overarching treatment principles capable of simultaneously alleviating these pathways will ultimately create a transdiagnostic approach to improving gay and bisexual men's health. Clinical research and training approaches are suggested to further validate the pathways suggested here, establish the efficacy of treatment approaches tied to those pathways, and generate effective methods for disseminating a transdiagnostic minority stress treatment approach for gay and bisexual men's psychosocial syndemic health.

Typologies of sexually explicit media use among MSM: An application of latent class analysis

The viewing of sexually explicit media (SEM) is widespread, especially among men, and research linking SEM viewing and sexual behavior has shown a variety of results, some positive (e.g., sexuality education) and some negative (e.g., poorer body image). These results might be due to limitations in measuring SEM consumption, particularly around typology. The goal of the current study was to examine potential patterns of SEM viewing activities. Using data from an online survey of men who have sex with men (MSM), we conducted latent class analyses of 15 SEM activities. Results suggested a three-class solution. The most prevalent class included over 60% of men and was characterized by viewing primarily safer-sex or conventional behaviors. The second class included 32% of men and had a similar albeit amplified pattern of viewing. The final class included just 7% of men and was marked by high levels of viewing of all activities, including fetish and kink. Compared to the conventional or safer-sex class, the other classes had lower internalized homonegativity, lower condom use self-efficacy, and higher SEM consumption or dose. Implications for HIV prevention, sexuality research and the SEM industry are discussed.

Future directions in research on sexual minority adolescent mental, behavioral, and sexual health

This article describes current knowledge on sexual, mental, and behavioral health of sexual minority (SM) youth and identifies gaps that would benefit from future research. A translational sciences framework is used to conceptualize the article, discussing findings and gaps along the spectrum from basic research on prevalence and mechanisms, to intervention development and testing, to implementation. Relative to adults, there has been much less research on adolescents and very few studies that had longitudinal follow-up beyond 1 year. Due to historical changes in the social acceptance of the SM community, new cohorts are needed to represent contemporary life experiences and associated health consequences. Important theoretical developments have occurred in conceptualizing mechanisms that drive SM health disparities and mechanistic research is underway, including studies that identify individual and structural risk/protective factors. Research opportunities exist in the utilization of sibling-comparison designs, inclusion of parents, and studying romantic relationships. Methodological innovation is needed in sampling SM populations. There has been less intervention research and approaches should consider natural resiliencies, life-course frameworks, prevention science, multiple levels of influence, and the importance of implementation. Regulatory obstacles are created when ethics boards elect to require parental permission and ethics research is needed. There has been inconsistent inclusion of SM populations in the definition of "health disparity population," which impacts funding and training opportunities. There are incredible opportunities for scholars to make substantial and foundational contributions to help address the health of SM youth, and new funding opportunities to do so.

Uncovering Clinical Principles and Techniques to Address Minority Stress, Mental Health, and Related Health Risks Among Gay and Bisexual Men

Gay and bisexual men disproportionately experience depression, anxiety, and related health risks at least partially because of their exposure to sexual minority stress. This paper describes the adaptation of an evidence-based intervention capable of targeting the psychosocial pathways through which minority stress operates. Interviews with key stakeholders, including gay and bisexual men with depression and anxiety and expert providers, suggested intervention principles and techniques for improving minority stress coping. These principles and techniques are consistent with general cognitive behavioral therapy approaches, the empirical tenets of minority stress theory, and professional guidelines for LGB-affirmative mental health practice. If found to be efficacious, the psychosocial intervention described here would be one of the first to improve the mental health of gay and bisexual men by targeting minority stress.

Sexual orientation disparities in mental health: the moderating role of educational attainment

PURPOSE

Mental health disparities between sexual minorities and heterosexuals remain inadequately understood, especially across levels of educational attainment. The purpose of the present study was to test whether education modifies the association between sexual orientation and mental disorder.

METHODS

We compared the odds of past 12-month and lifetime psychiatric disorder prevalence (any Axis-I, any mood, any anxiety, any substance use, and comorbidity) between lesbian, gay, and bisexual (LGB) and heterosexual individuals by educational attainment (those with and without a bachelor's degree), adjusting for covariates, and tested for interaction between sexual orientation and educational attainment. Data are drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative survey of non-institutionalized US adults (N = 34,653; 577 LGB).

RESULTS

Sexual orientation disparities in mental health are smaller among those with a college education. Specifically, the disparity in those with versus those without a bachelor's degree was attenuated by 100 % for any current mood disorder, 82 % for any current Axis-I disorder, 76 % for any current anxiety disorder, and 67 % for both any current substance use disorder and any current comorbidity. Further, the interaction between sexual orientation and education was statistically significant for any current Axis-I disorder, any current mood disorder, and any current anxiety disorder. Our findings for lifetime outcomes were similar.

CONCLUSIONS

The attenuated mental health disparity at higher education levels underscores the particular risk for disorder among LGBs with less education. Future studies should consider selection versus causal factors to explain the attenuated disparity we found at higher education levels.

Diaries for observation or intervention of health behaviors: factors that predict reactivity in a sexual diary study of men who have sex with men

BACKGROUND

Behavioral diaries for observation of health-related behaviors assume absence of reactivity (i.e., change in behavior resulting from observation), while self-monitoring diaries maximize reactivity for behavior change. Little is known about when and for whom behavioral diary studies become self-monitoring interventions.

PURPOSE

This study evaluated the moderating effects of social cognitive variables on reactivity in sexual risk behavior and risk appraisals in a diary study of men who have sex with men (MSM).

METHODS

One hundred forty-three MSM completed weekly online sexual diaries for 3 months. Analyses were conducted with hierarchical linear modeling.

RESULTS

There was no evidence of reactivity for the sample as a whole. Social cognitive variables (e.g., risk reduction motivation, condom use intentions, and social norms) moderated reactivity in study outcomes. For example, more highly motivated MSM experienced declines in serodiscordant unprotected anal intercourse over time.

CONCLUSIONS

Effectiveness of behavioral self-monitoring strategies may vary depending on social cognitive domains.

The role of maladaptive cognitions in hypersexuality among highly sexually active gay and bisexual men

Cognitive appraisals about sex may represent an important component of the maintenance and treatment of hypersexuality, but they are not currently represented in conceptual models of hypersexuality. Therefore, we validated a measure of maladaptive cognitions about sex and examined its unique ability to predict hypersexuality. Qualitative interviews with a pilot sample of 60 highly sexually active gay and bisexual men and expert review of items yielded a pool of 17 items regarding maladaptive cognitions about sex. A separate sample of 202 highly sexually active gay and bisexual men completed measures of sexual inhibition and excitation, impulsivity, emotional dysregulation, depression and anxiety, sexual compulsivity, and a measure of problematic hypersexuality. Factor analysis confirmed the presence of three subscales: perceived sexual needs, sexual costs, and sexual control efficacy. Structural equation modeling results were consistent with a cognitive model of hypersexuality whereby magnifying the necessity of sex and disqualifying the benefits of sex partially predicted minimized self-efficacy for controlling one's sexual behavior, all of which predicted problematic hypersexuality. In multivariate logistic regression, disqualifying the benefits of sex predicted unique variance in hypersexuality, even after adjusting for the role of core constructs of existing research on hypersexuality, AOR = 1.78, 95 % CI 1.02, 3.10. Results suggest the utility of a cognitive approach for better understanding hypersexuality and the importance of developing treatment approaches that encourage adaptive appraisals regarding the outcomes of sex and one's ability to control his sexual behavior.

Envisioning an America without sexual orientation inequities in adolescent health

This article explicates a vision for social change throughout multiple levels of society necessary to eliminate sexual orientation health disparities in youths. We utilized the framework of Bronfenbrenner's ecological theory of development, a multisystemic model of development that considers direct and indirect influences of multiple levels of the environment. Within this multisystem model we discuss societal and political influences, educational systems, neighborhoods and communities, romantic relationships, families, and individuals. We stress that continued change toward equity in the treatment of lesbian, gay, and bisexual youths across these levels will break down the barriers for these youths to achieve healthy development on par with their heterosexual peers.