Mediating Effects of Social Support and Internalized Homonegativity on the Association Between Population Density and Mental Health Among Gay and Bisexual Men

Internalized Sexual Stigma and Mental Health Outcomes for Gay, Lesbian, and Bisexual Asian Americans: The Moderating Role of Guilt and Shame

The literature unequivocally demonstrates that lesbian, gay, and bisexual (LGB) individuals experience disproportionate mental health and social wellbeing impacts. Here, we respond to recent calls for research in the field of sexual minority health to better understand why various overlapping and intersecting identities can further drive health disparities. In this paper, we focus on the specific intersections of ethnicity and sexuality for Asian LGB individuals and the role of internalized stigma in driving poorer mental health outcomes for this group. We recruited 148 LGB Asian participants residing in the United States (Mage = 22.82 years, SD = 4.88) to participate in our online cross-sectional survey in which we collected data on their internalized stigma, levels of guilt and shame about their sexuality, and measures of depression, anxiety, and distress. Contrary to our predictions, there were no bivariate relationships between internalized sexual stigma and any of the mental health outcomes. However, a parallel mediation analysis revealed that guilt, but not shame, mediates the relationship between internalized sexual stigma and all mental health outcomes (depression, anxiety, and stress) for LGB Asian American individuals. This research highlights the important of exploring additional variables that may exacerbate of protect against poor mental health for individuals with multiple intersecting identities.

A chatbot-delivered intervention for optimizing social media use and reducing perceived isolation among rural-living LGBTQ+ youth: Development, acceptability, usability, satisfaction, and utility

Background

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) youth are at higher risk of isolation and depression than their heterosexual peers. Having access to tailored mental health resources is a documented concern for rural living LGBTQ+ youth. Social media provides access to connections to a broader and like-minded community of peers, but it also is a vehicle for negative interactions. We developed REALbot, an automated, social media-based educational intervention to improve social media efficacy, reduce perceived isolation, and bolster connections for rural living LGBTQ+ youth. This report presents data on the acceptability, feasibility, and utility of REALbot among its target audience of rural living LGBTQ+ youth.

Methods

We conducted a week-long exploratory study with a single non-comparison group of 20 rural-living LGBTQ+ youth aged 14-19 recruited from social media to test our Facebook- and Instagram-delivered chatbot. We assessed pre- and post-test scores of social media self-efficacy, social isolation (4-item Patient-Reported Outcomes Measurement System - PROMIS), and depressive symptoms (Patient Health Questionnaire, Adolescent Version - PHQ-A). At post-test, we assessed acceptability (User Experience Questionnaire - UEQ-S), usability (Chatbot Usability Questionnaire -CUQ and Post-Study Satisfaction and Usability Questionnaire -PSSUQ), and satisfaction with the chatbot (Client Satisfaction Questionnaire - CSQ), along with two open-ended questions on 'likes' and 'dislikes' about the intervention. We compared pre- and post-test scores with standard univariate statistics. Means and standard deviations were calculated for usability, acceptability, and satisfaction. To analyze the responses to post-test open-end questions, we used a content analysis approach.

Results

Acceptability of REALbot was high with UEQ-S 5.3 out of 7 (SD = 1.1) and received high usability scores with CUQ and PSSUQ (mean score (M) = 78.0, SD = 14.5 and M = 86.9, SD = 25.2, respectively), as well as high user satisfaction with CSQ (M = 24.9, SD = 5.4). Themes related to user 'likes' and 'dislikes' were organized in two main categories: usability and content provided. Participants were engaged with the chatbot, sending an average of 49.3 messages (SD = 43.6, median = 30). Pre-/post- changes in scores of perceived isolation, depressive symptoms and social media self-efficacy were not significant (p's > 0.08).

Conclusion

REALbot deployment was found to be feasible and acceptable, with good usability and user satisfaction scores. Participants reported changes from pre- to post-test in most outcomes of interest and effect sizes were small to medium. Additional development and a formal evaluation of feasibility and engagement with behavioral targets is warranted.

The Effects of Prostate Cancer Treatment on Role-In-Sex in Gay and Bisexual Men: Mixed Methods Results from the Restore-1 and Restore-2 Studies

Gay and bisexual men (GBM) with prostate cancer experience worse sexual and mental health outcomes following prostate cancer treatment than heterosexual men. Emerging evidence suggests that GBM may change their role-in-sex in response to treatment effects. The purpose of this study was to describe the impact of prostate cancer treatment on role-in-sex, to estimate the prevalence of such changes, and to determine the impact on quality of life and mental health. We conducted semi-structured interviews with 30 sexual minority prostate cancer patients. Then, we recruited 401 gay and bisexual prostate cancer patients into a study assessing the effects of rehabilitation. Qualitative data were analyzed using descriptive thematic analysis. Differences in quality of life and mental health outcomes were analyzed using multivariate analyses of variance. Prostate cancer treatment resulted in loss of role-in-sex for many patients. When changes in role-in-sex occurred, the shifts were predominantly from tops to bottoms. Those with a current top role-in-sex had significantly better sexual and mental health outcomes than either versatiles or bottoms. Clinical implications include the need for providers to ask about role-in-sex in order to address disparities in health outcomes by sexual orientation and to provide culturally appropriate care to sexual minority patients.

Sources of Social Support, Self-Esteem and Psychological Distress among Chinese Lesbian, Gay and Bisexual People

Objective

Minority stressors are associated with increased psychological distress, and social support is considered as a significant protective factor to mitigate the psychological distress in LGB individuals. In China, LGB individuals suffer additional pressure from society and family, but only a few studies have explored the effect of social support on the psychological distress of Chinese LGB individuals and the mechanism underlying the association. The current study aimed to examine the mediating role of self-esteem in the relationship between three sources of social support (from family, friends, and others) and psychological distress in Chinese LGB individuals.

Methods

227 LGB individuals (M age = 25.9 years; SD = 5.6) who were voluntarily recruited by a combination of snowballing and targeted sampling strategies. Path analysis was used to test the associations between variables.

Results

Results indicated that 31.3% of LGB individuals had a high level of psychological distress. The results showed that social support from family, friends, and others was associated with higher levels of self-esteem and lower levels of psychological distress. Only the mediating effect of self-esteem was found between friend support and psychological distress.

Conclusions

This study demonstrated that friend support might be a protective factor against psychological distress in Chinese LGB individuals, and more friend support could potentially relieve psychological distress by building higher self-esteem. These results highlight the importance of fostering friend support in the group of Chinese LGB individuals.

Factors influencing the well-being of Asian American LGBT individuals across the lifespan: perspectives from leaders of community-based organizations

BACKGROUND

Lesbian, gay, bisexual, and transgender (LGBT) individuals have documented disparities in mental health that are experienced across the life course. However, limited research has been conducted to identify the factors which contribute to evaluated risk for poor mental health among older Asian Americans who identify as LGBT. The purpose of this study was to determine the perspectives of leaders of community-based organizations about the mental health needs and concerns of their LGBT constituents from diverse Asian backgrounds.

METHODS

Semi-structured qualitative interviews were conducted with leaders of community-based organizations serving the needs of LGBT individuals. A qualitative framework analysis approach was used to identify, analyze and report themes within the data.

RESULTS

11 members of community organizations located in California (54.5%), Chicago (27.2%), and New York (18.1%) were interviewed. Chronic stress was identified as negatively impacting constituents' lives and was attributed to social determinants of health, including inadequate housing, financial insecurity, discrimination, barriers to adequate health care, and immigration status. Ageism, social isolation, language barriers, and limited connections to cultural, religious, or LGBT communities were identified as factors impacting middle-aged and older adults. Participants identified homelessness, violence, and lack of parental acceptance as contributing to distress among youth and younger adults. The most vulnerable community members were identified as gender minorities, undocumented individuals, and individuals with limited English proficiencies. Organizational leaders described strategies to address social determinants.

CONCLUSIONS

Asian Americans who are LGBT are confronted with substantial risks for poor mental health that are linked to modifiable social determinants of health. Organizations serving these populations play a vital role in meeting the needs of a highly underserved population.

Sexual Identity and Birth Cohort Differences in Social Support and Its Link with Well-Being among Sexual Minority Individuals

This study examined sexual identity and birth cohort differences in social support and its association with well-being, using a longitudinal national probability sample of 706 cisgender and non-binary sexual minority individuals from the USA. The data allowed for extensive descriptions of perceived social support and support networks across subgroups. Findings demonstrated that sexual identity and birth cohort differences in overall sizes of support networks and levels of perceived social support were small. Furthermore, fixed effects analyses indicated that changes in the size of respondents' social support networks were not related to well-being, with a one-person change being associated with a .04 SD change in well-being or less, depending on the indicator of well-being being tested. Moreover, changes in perceived social support were only limitedly related to changes in respondents' well-being, a 1-point change in the scale of perceived social support being associated with a .11 SD change in life-satisfaction. Associations were smaller for overall well-being or psychological distress, the other two indicators of well-being used. Together, these findings could imply that cross-sectional research has overestimated the relevance of social support for the well-being of sexual minority individuals, but also that general social support is insufficiently tailored to the support needs of the sexual minority population.

Internalized homophobia, self-esteem, social support and depressive symptoms among sexual and gender minority women in Taiwan: An online survey

WHAT IS KNOWN ON THE SUBJECT?: Sexual minority individuals are more likely to experience depressive disorders than heterosexual individuals. Factors associated with depressive symptoms among sexual minority individuals have been explored and examined; however, there is a limited evidence to understand the factors among sexual minority women in non-western countries. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To the best our knowledge, this is the first study examining internalized homophobia, self-esteem, social support and depressive symptoms among sexual minority women in Taiwan. Sexual minority women at risk of having depressive symptoms had a higher level of internalized homophobia, lower self-esteem and fewer support from partners, friends, and families. Specifically, being single, being a student and having a higher personal income increased the risk of having depressive symptoms among sexual minority women. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health practitioners and nurses should be aware of and assess sexual minority women's level of internalized homophobia, self-esteem, and received social support to reduce the risk of depressive symptoms and thus help prevent suicidal ideation. LGBT sex education and government involvement are essential to buffer the negative influences of a homophobic society on the mental health of sexual minority women. ABSTRACT: Introduction Sexual minority women are more likely to report depressive symptoms than sexual minority men. However, there is a lack of evidence to understand factors associated with depressive symptoms among sexual minority women in non-western countries. Aim This study examined internalized homophobia, self-esteem, social support and depressive symptoms among Taiwanese sexual minority women. Method A total of 581 Taiwanese sexual minority women (Age range 20-48 years old, Mean 26.96, SD 5.718) completed an online survey. Results Taiwanese sexual minority women at risk of having depressive symptoms had a higher level of internalized homophobia and lower self-esteem. Perceived support from participants' partners, friends and families was related to lower risk of depressive symptoms. Being single, being a student and having a higher personal income were also found to increase the risk of having depressive symptoms among the women. Discussion Mental health interventions are essential for sexual minority women with internalized homophobia and low self-esteem. Implications for Practice Mental health practitioners and nurses should be aware of and assess the concerns that sexual minority women have regarding healthcare services and provide culturally competent care to reduce the risk of depressive symptoms.

Biomedical HIV Prevention among Gay Male Couples: A Qualitative Study of Motivations and Concerns

Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly efficacious biomedical prevention strategies, which significantly reduce the risk of HIV transmission. Yet, partnered sexual minority men (SMM) continue to exhibit poorer uptake rates especially those in a non-monogamous or serodiscordant relationship for whom PrEP is recommended. The purpose of the study was to identify factors that may facilitate or impede the uptake of PrEP or PEP among partnered SMM. This qualitative study conducted semi-structured interviews with 10 sexual minority male couples recruited from the New York City metropolitan area. Thematic analysis identified relationship-specific and structural-level factors, which influence motivation and willingness for biomedical prevention uptake. Specifically, results highlighted the tension between relationship functioning and HIV prevention. In addition, stigma and access to knowledgeable health care providers diminished interest in biomedical prevention. Findings suggest a need for interventions that frame biomedical prevention in ways that minimize social perceptions of mistrust between partners and improve access.

COVID-19 and the Changes in the Sexual Behavior of Men Who Have Sex With Men: Results of an Online Survey

BACKGROUND

Social distancing in the wake of the coronavirus disease 2019 (COVID-19) pandemic may affect the sexual behavior of men who have sex with men (MSM). In early March 2020, Israel imposed travel restrictions and limited social contacts to household members only. The effects of these restrictions on the sexual behavior and mental health of MSM are unknown.

AIM

To assess sexual behaviors and mental health of Israeli MSM during social distancing and to compare sexual behaviors before and during social distancing, due to the COVID-19 pandemic.

METHODS

Data were collected through anonymous web-based questionnaires in a popular geospatial application used by MSM between March and April 2020 during the social-distancing period.

OUTCOMES

The dependent variable was casual sex, in violation of social-distancing regulations. Independent variables were demographic characteristics, sexual behaviors before and during social-distancing restrictions, and mental health.

RESULTS

Of the 2,562 participants, 1,012 (39.5%) continued to meet new casual sex partners during this period. Being of a younger age, single, and with higher levels of mental distress predicted engagement in casual sex during the social-distancing period. MSM reduced their sexual risk and limited sexual repertoire-in particular, kissing with their sexual partners. Participants also spent more time in dating applications than in the pre-social-distancing period and increased their use of sex phone, webcams, and porn consumption. They perceived the threat of severe acute respiratory syndrome coronavirus to be greater than that of HIV: only 3.2% could imagine themselves having sex with a partner who is infected with SARS-CoV-2 compared with 30.1% in case of HIV, P < .01.

CLINICAL IMPLICATIONS

MSM reduced their risk behaviors during social distancing because of the threat of COVID-19. Casual sex during social distancing was associated with negative feelings of mental distress. Future public health response in the future waves of COVID-19 morbidity should strike a balance between containment measures and the need for social distancing with its possible mental and social burdens.

STRENGTHS AND LIMITATIONS

This is the first study in Israel and one of the few in the world to examine sexual behaviors among MSM during the COVID-19 social distancing period. It involved a relatively large sample, through convenience sampling, which limits causality. Findings should be interpreted cautiously, specifically because COVID-19-related behaviors and circumstances may change rapidly.

CONCLUSION

The negative feelings of distress due to social distancing should be considered as a potential barrier to adherence among vulnerable populations, such as MSM. Future public health response should strike a balance between containment measures and its possible mental, social, and financial burdens. Shilo G, Mor Z. COVID-19 and the Changes in the Sexual Behavior of Men Who Have Sex With Men: Results of an Online Survey. J Sex Med 2020;17:1827-1834.

Gay-Specific and General Stressors Predict Gay Men's Psychological Functioning Over Time

Gay men experience various stressors, including gay-specific stressors such as discrimination and internalized homonegativity as well as general stressors such as occupational and financial strain. While a robust literature has examined how gay-specific stressors are associated with negative mental health outcomes among gay men, less attention has been paid to the association between general stress and gay men's psychological functioning or to how different types of stressors may interact to affect functioning. The current study sought to address this gap by examining the unique and combined associations between gay-specific external stress (discrimination), gay-specific internal stress (rejection sensitivity, internalized homonegativity, sexual identity concealment), and general stressors (e.g., academic difficulties) and negative affect and alcohol use over time. A total of 147 self-identified gay men living in the greater New York City area participated in a baseline assessment and a 7-week diary study. Univariate and multivariate results revealed that gay-specific external stress, gay-specific internal stress, and general stress were each positively and uniquely associated with higher mean levels of and greater fluctuations in negative affect over time, and general stress was positively associated with greater fluctuations in alcohol use over time. Multiplicative analyses indicated that individuals reporting high levels of stress in multiple domains experienced particularly high mean levels of negative affect. These findings highlight the unique contribution of general stress to gay men's functioning over time and underscore the importance of considering multiple forms of stress (i.e., gay-specific and general stress) and their interactions to better understand gay men's psychological functioning.

The Disparities in Mental Health between Gay and Bisexual Men Following Positive HIV Diagnosis in China: A One-Year Follow-Up Study

This study aimed to determine the change in mental health (depression and anxiety) among HIV-positive gay and bisexual men (GBM) one year after diagnosis and the disparities in trajectories of mental health between them. The potential factors contributing to the disparities were also investigated. This was a one-year follow-up study focusing on the mental health of newly diagnosed HIV-positive individuals. Participants rated their depression, anxiety, stress, and social support levels at baseline and one year later. Information on the utilization of mental healthcare and the initiation of antiretroviral therapy (ART) after diagnosis was collected at one-year follow-up. A total of 171 and 87 HIV-positive gay and bisexual men, respectively, completed two-time points surveys in this study. The depressive and anxiety symptoms experienced by HIV-positive GBM improvement one year after diagnosis. These improvements tended to be smaller in gay participants. Other factors including mental health care utilization and ART status during the one-year follow-up period, changes in social stress scores and objective social support scores were also associated with the changes in depression and anxiety, and all these factors, except for change in objective support, were found to be statistically different between HIV-positive GBM. Special attention should be given to the mental health of HIV-positive gay men. Promoting HIV-positive gay men to assess to mental health services and ART may be important for these populations to improve mental health. Enhancing social support and reducing stress levels may also be necessary for the vulnerable HIV-positive sexual minority groups.

Differences by Sexual Orientation in Perceptions of Neighborhood Cohesion: Implications for Health

A large body of research documents the relationship between health and place, including the positive association between neighborhood cohesion and health. However, very little research has examined neighborhood cohesion by sexual orientation. This paper addresses that gap by examining differences in perceived neighborhood cohesion by sexual orientation. We use data from the 2016 National Health Interview Survey (n = 28,164 respondents aged 18 years and older) to examine bivariate differences by sexual orientation in four measures of neighborhood cohesion. We then use ordered logistic regression models to assess the relationship between sexual orientation and a scaled measure of neighborhood cohesion, adjusting for socio-demographic characteristics, living arrangements, health status, region, and neighborhood tenure. We find that lesbian, gay, and bisexual (LGB) adults are less likely to say that they live in a close-knit neighborhood (54.6 vs. 65.6%, p < 0.001), they can count on their neighbors (74.7 vs. 83.1%, p < 0.001), they trust their neighbors (75.5 vs. 83.7%, p < 0.001), or people in their neighborhood help each other out (72.9 vs. 83.1%, p < 0.001), compared to heterosexual adults. Even after controlling for socio-demographic factors, neighborhood cohesion scores are lower for LGB adults compared to heterosexual adults (odds ratio of better perceived neighborhood cohesion for sexual minorities: 0.70, p < 0.001). Overall, LGB adults report worse neighborhood cohesion across multiple measures, even after adjusting for individual characteristics and neighborhood tenure. Because living in a cohesive neighborhood is associated with better health outcomes, future research, community-level initiatives, and public policy efforts should focus on creating welcoming neighborhood environments for sexual minorities.

Psychosocial and Behavioral Correlates of Internalized Homonegativity in Midlife and Older Gay and Bisexual Men

This study investigated psychosocial and demographic variables that might influence internalized homonegativity (IH) in midlife and older gay and bisexual men (GBM). Data were collected from 802 community-dwelling GBM aged 40 to 94 years ( M = 54.8) through an anonymous questionnaire that assessed levels of IH, coping self-efficacy, self-silencing, and other characteristics. Multivariate logistic regression analysis successfully explained 22% of the variance in predicting IH, which was significantly related to coping self-efficacy, self-silencing, gay community volunteering, partnership status, and race, F = 59.74, p < .001. IH scores were highest in participants who were single, had lower education levels, were non-White, were less involved in gay community volunteering, experienced less coping self-efficacy, and reported higher levels of self-silencing behaviors. These data underscore the need for more tailored programming approaches for midlife and older GBM, focusing on underlying factors contributing to IH that include skill-building to increase coping self-efficacy, community involvement, and decrease self-silencing behaviors in this overlooked population.

The Prevalence and Correlates of Sexual Arrangements in a National Cohort of HIV-Negative Gay and Bisexual Men in the United States

Sexual agreements have received considerable attention as an aspect of dyadic functioning associated with HIV risk. To date, this research has primarily utilized convenience samples which overrepresented men from large urban areas and with higher HIV risk. The current study utilized a national cohort of 1061 HIV-negative gay and bisexual men recruited to be geographically diverse within the U.S. The sample included 531 (50.0%) men who identified as single. Of the 530 partnered men, 240 (45.3%) were monogamous; 238 (44.9%) were in open relationships (where sex with outside partners was permitted); and 52 (9.8%) were in monogamish relationships (where sex with outside partners was limited to instances where both primary partners were present). Regardless of urban (vs. non-urban) residence, men in monogamous relationships engaged in less anal sex generally and condomless anal sex (CAS) specifically with casual partners. Single men reported significantly more frequent anal sex with casual partners compared to open and monogamish men; however, there were no significant differences among these three groups with respect to CAS with casual partners. In multivariable models, monogamish men reported significantly more frequent marijuana use and alcohol consumption compared to all other groups. Urban (vs. non-urban) residence moderated associations between sexual arrangements and depression as well as the use of illicit drugs other than marijuana. These findings point to the need to better examine the potentially unique mechanisms which confer risk and resilience for gay male couples in urban versus non-urban settings. The observed association between sexual arrangements and substance use suggests interventions which facilitate the negotiation of sexual agreements may present an opportunity to engage in dyadic substance use intervention.

Social Determinants of Mental Health: Where We Are and Where We Need to Go

PURPOSE OF REVIEW

The present review synthesizes recent literature on social determinants and mental health outcomes and provides recommendations for how to advance the field. We summarize current studies related to changes in the conceptualization of social determinants, how social determinants impact mental health, what we have learned from social determinant interventions, and new methods to collect, use, and analyze social determinant data.

RECENT FINDINGS

Recent research has increasingly focused on interactions between multiple social determinants, interventions to address upstream causes of mental health challenges, and use of simulation models to represent complex systems. However, methodological challenges and inconsistent findings prevent a definitive understanding of which social determinants should be addressed to improve mental health, and within what populations these interventions may be most effective. Recent advances in strategies to collect, evaluate, and analyze social determinants suggest the potential to better appraise their impact and to implement relevant interventions.