Homelessness among youth who identify as LGBTQ+: A systematic review

Health Needs Assessment of Unhoused Youth in Charleston, South Carolina

BACKGROUND

Over 35 000 youth experience homelessness on any given night in the United States (US). Unhoused youth experience unique physical and mental health challenges and face barriers in every social determinant of health (SDoH), which may be amplified in the LGBTQ+ population.

OBJECTIVE

The objective of this study was to define characteristics of the unhoused youth population and their utilization of healthcare to inform programs to meet their needs.

METHODS

Secondary analysis of data from the College of Charleston's YOUth Count survey was conducted, focusing on health-related characteristics, challenges, healthcare utilization, and SDoH of youth aged 18 to 25 experiencing homelessness in Charleston, SC.

RESULTS

Almost three-quarters of respondents (74.6%) reported mental health challenges and 35% reported physical health challenges. A significantly higher proportion of those who engaged in survival sex were LGBTQ+ . More than half (68.4%) visited the emergency department (ED) and 29.3% were admitted to the hospital in the past 12 months. Housing status, safety, food insecurity, sexual orientation, prior foster care, and survival sex were all significantly associated with ED utilization. Housing status and survival sex were significantly associated with hospital admission.

CONCLUSIONS

Addressing SDoH is essential to improving health outcomes and healthcare utilization among unhoused youth, particularly in the LGBTQ+ population.

Are social supports always protective? A seven-city study on heavy drinking among sexual and gender minority young adults experiencing homelessness

PURPOSE

Sexual and gender minority (SGM) young adults are disproportionately impacted by homelessness and heavy drinking (i.e., having five or more drinks of alcohol in a row within a couple of hours). Social support, in general, is protective in reducing individuals' risk of heavy drinking. However, whether and how support from different sources may have different implications on heavy drinking among SGM young adults experiencing homelessness (SGM-YAEH) remains unclear. Informed by the risk amplification and abatement model (RAAM), this study examined the associations between support sources and heavy drinking among SGM-YAEH.

METHODS

A purposive sample of SGM-YAEH (N=425) recruited in homeless service agencies from seven major cities in the U.S. completed a self-administered computer-assisted anonymous survey. This survey covered heavy drinking behaviors and social network properties. Logistic regression models were conducted to identify social support sources associated with SGM-YAEH's heavy drinking.

RESULTS

Over 40 % of SGM-YAEH were involved in heavy drinking in the past 30 days. Receiving support from street-based peers (OR=1.9; 95 % CI=1.1, 3.2) and home-based peers (OR=1.7; 95 % CI=1.0, 2.8) were each positively associated with SGMYAEH heavy drinking risks.

CONCLUSION

This study was not able to identify the protective role social supports may play in reducing SGM-YAEH's heavy drinking. Furthermore, receiving support from network members was correlated with elevated heavy drinking risks among this population. As heavy drinking prevention programs develop interventions: they should use affirming and trauma approaches to promote protective social ties, as research points to its association in reducing alcohol use disparities among SGM-YAEH.

Prevalence, severity and risk factors for mental disorders among sexual and gender minority young people: a systematic review of systematic reviews and meta-analyses

Evidence suggests heightened prevalence and severity of mental disorders among sexual minority (SM) and gender minority (GM) young people. Several risk factors have been associated with these disparities. A systematic review of systematic reviews and meta-analysis was conducted to provide a comprehensive overview of the literature and to determine the field's current position. MEDLINE, PsycInfo, Scopus and Web of Science were searched in March 2022 and updated January 2024. Eligibility criteria were systematic reviews or meta-analyses assessing contemporaneous prevalence, severity and/or risk factors of mental disorders among SM or GM young people aged 25 and under. 42 reviews were included, all of which were low quality. The prevalence of depression among SM was 26% (95% CI 21-32%), and among GM was 46% (95% CI 36-56%). Greater depression severity was found among SM compared to heterosexual young people, with a significant albeit small effect size (Hedges' g = 0.38, 95% CI = 0.25 to 0.50); effect sizes were similar when separating by gender. GM also reported greater symptom severity compared to cisgender young people. Other mental disorders were more prevalent compared to those reported in the general population, and of greater severity compared to heterosexual/cisgender young people. Several proximal and distal risk factors were focused upon within the systematic reviews identified. Past systematic reviews consistently indicate a heightened risk of mental disorders among SM and GM young people. Services need to be aware of these disparities and adapt their care accordingly.

The beliefs and practices used to promote physical and mental health in youth who identify as lesbian, gay, bisexual, transgender, intersex, or queer plus (LGBTIQ+) experiencing housing insecurity: An integrative review

PURPOSE

The purpose of this integrative review was to explore the beliefs and practices used to promote physical and mental health among youth ages 18-25 years, identifying as LGBTIQ+ experiencing housing insecurity.

METHOD

The approach used strategies described by Whittemore and Knafl. Peer-reviewed, published research articles in English were identified using eight electronic databases. Eighteen research reports using qualitative, quantitative, and mixed methods were identified. Articles were evaluated for quality using the American Association of Critical Care Nurses Evidenced-Level Hierarchy evaluation tool. Data were analyzed and synthesized using Braun and Clarke's method.

FINDINGS

Four themes related to the purpose were extracted: pervasive experiences of stigma and discrimination, constantly attuned to navigating risks, inconsistent engagement in health information and care, and inner strength developed through personal and community experiences.

DISCUSSION

There are strong implications for future research, public health nursing practice, and health policy. Public health nurses should incorporate social determinants of health (addressing harmful social processes such as homophobia and racism) as well as a strength-based upstream approach in research, education, and health care practices. More research must also be done to assess engagement in physical and mental health information and care.

Keeping young researchers out of harm's way: conducting youth participatory action research with young people experiencing homelessness

Introduction

Youth Participatory Action Research (YPAR) is an approach to conducting research with youth populations in order to effectively engage youth in research that impacts their lives. Young people experiencing homelessness (YEH) are vulnerable to power and social environments in ways that call attention to their experiences in research.

Methods

The context for this paper was a qualitative YPAR project to incorporate youth voice into the operations of a larger research study that hired youth as researchers. Participant-researchers provided feedback and consultation with senior staff in order to improve their access to resources, safety, and stability.

Results

Themes that emerged from thematic analysis of reflections, discussions, and meetings showed the need for consistent access to food, the risk of environmental violence targeting youth researchers, the structural and experiential barriers to professional engagement, and the benefits that young researchers experienced as part of their work in the study.

Discussion

Recommendations and lessons learned are described, notably to ensure that youth are paid and provided food, to construct effective safety plans during fieldwork, and to provide a flexible, inclusive, trauma-responsive approach to supervision of project tasks.

Integrating perspectives of transgender and gender-diverse youth, family members, and professionals to support their health and wellbeing - a mixed-method study protocol

BACKGROUND

The current literature highlights a strong link between the poor health outcomes of transgender and gender diverse (TGD) individuals and their negative experiences in various areas of life. Most of these publications rely on adults' memories, lacking a focus on the current experiences and needs of young transgender and gender-diverse individuals. Furthermore, previous studies on support for these young people often solely consider the perspectives of TGD adults or professionals and rarely involve parents' viewpoints.

METHODS

This study will use a mixed sequential method with a participatory approach. Firstly, the qualitative phase will explore the difficulties and needs of TGD (15-20 years old) and of the families and professionals who support them. Results from this part will be used to develop the questionnaire for the quantitative phase, with the help of a community board. Secondly, based on participatory epidemiological research, the quantitative phase will use an intersectional perspective to measure the impact of individual and structural factors on the quality of life and well-being of transgender and gender-diverse young people. Finally, a co-creation phase will be undertaken to formulate recommendations based on the results of the first two phases.

DISCUSSION

This research aims at better understanding the influence of gender identity on the quality of life and health of TGD young people and their families and to identify protective and risk factors that affect their vulnerabilities.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the Erasme Faculty Hospital (CCB B4062023000140). As this research is participatory and part of a PhD dissertation, we aim to disseminate the results through our partners' networks and structures locally, and internationally through conferences and peer-reviewed journals.

Ethical and methodological challenges conducting participative research with transgender and gender-diverse young people: a systematic review

Introduction

Research with transgender and gender-diverse (TGD) young people is essential to understand their experiences and to be able to propose, implement and adapt 'services' in the broadest sense to meet their needs. However, research outside clinical settings on current experiences and needs of youth under the age of 18 is limited which hinders the development of knowledge on TGD, as well as the development of research informed support practices. Acquiring parental consent for participatory research may present ethical and logistical difficulties, as it could jeopardize the safety, well-being, or confidentiality of adolescent participants. This creates a tension between the adolescent's right to autonomy, privacy, freedom, and all aspects related to the consent of the underage on the one hand, and the parents' right to protect their child on the other hand. This review aims to identify the methodological and ethical challenges associated with participatory research with transgender and gender-diverse young people.

Methods

We systematically searched bibliometric databases for studies published between 2006 and 2022 and included 4 main conceptual groups: transgender and gender non-conforming, adolescence, qualitative research (including participatory research) and consent. This review was registered in PROSPERO (CRD42022368360) in November 2022.

Results

Of the 3,794 articles initially identified, 291 met the inclusion criteria and 48 were examined. The selected studies were analyzed in the light of four main ethical tensions: involving parents or a trusted person in the consent gathering process, ensuring the protection and safety of young people while respecting confidentiality, and ensuring that spaces are created for transgender and gender-diverse young people to express themselves freely as part of an empowering research process. At the same time, several methodological challenges concerning public and stakeholder participation and recruitment, data collection and analysis as well as research integrity emerged from the selected studies.

Conclusion & implications

The existing literature of participatory research involving young transgender and gender-diverse individuals underscores the intricate and conflicting aspects, especially concerning power dynamics, empowerment, and the researcher's role. The relevance of these findings extends across various legal frameworks and is applicable to multiple contexts and countries.

Psychological Symptoms and Service Utilization in Prepubertal and Pubertal Transgender and Gender-Diverse Patients

STUDY OBJECTIVE

To describe the demographic characteristics and psychological symptoms of gender-diverse patients and to compare symptoms between prepubertal and pubertal subgroups METHODS: This was a retrospective chart review of all gender-diverse patients seen by at least 1 provider at the Nemours Gender Wellness Program from March 2015 to December 2020. The extracted data included demographic and psychosocial characteristics at baseline and 1-year follow-up visits. Pubertal status was determined by Tanner staging by a pediatric endocrinologist or gynecologist. Descriptive statistics were used to compare these variables between prepubertal and pubertal subgroups.

RESULTS

Our sample included 177 individuals at baseline and 96 subjects at the 1-year follow-up visit. Most patients were White (83.0%), non-Hispanic (92.0%), transgender male (72.9%), and pubertal (90.4%). Compared with prepubertal patients, at the baseline visit, pubertal patients had significantly higher rates of current (68.1% vs 17.6%, P < .001) and lifetime (80.0% vs 23.5%, P < .001) depressive symptoms, current anxiety symptoms (70.0% vs 41.2%, P = .01), lifetime suicide attempts (12.5% vs 0%, P < .001), and a formal diagnosis of an eating disorder (5.0% vs 0%, P < .001). Symptoms did not change significantly over time from baseline to the 1-year follow-up visit.

CONCLUSION

We found elevated rates of psychological symptoms and diagnoses in gender-diverse youth, with higher rates in pubertal compared with prepubertal patients. By elucidating how the psychosocial characteristics of gender-diverse children and adolescents differ based on pubertal status, these data can be used to improve current outreach and treatment strategies for transgender pediatric patients.

Measuring the prevalence and impact of adverse childhood experiences in the lives of LGBTQ individuals: A much-needed expansion

BACKGROUND

Numerous studies indicate that LGBTQ people have extensive experiences with adverse childhood experiences (ACEs), more so than their heterosexual and cisgender counterparts. Research also shows that LGBTQ youth endure traumatic experiences with victimization, including bullying, harassment, and violence, based on their non-hetero-cis-normative genders and/or sexual identities. Yet, most ACE measurement strategies fail to: (1) explicitly link the risk of ACE exposure to the discrimination and stigmatization of LGBTQ people, and (2) account for the breadth of potential ACE exposure in LGBTQ populations.

OBJECTIVE

In the current article, we develop and present a more comprehensive ACE measurement strategy for understanding the cumulative and deleterious impacts of ACEs in the lives of LGBTQ individuals.

METHODS

Here, we offer three expansions to the current ACE framework: (1) the inclusion of an LGBTQ-specific ACE in addition to the standard ACE measures, (2) the addition of LGBTQ qualifiers for current ACE items (when applicable), and (3) the expansion of ACE measures to capture the unique ACE experiences of LGBTQ individuals in family life, schools, and faith communities.

CONCLUSIONS

The implementation of a more comprehensive ACE measurement strategy will assist scholars and policymakers in better understanding the impacts of ACEs in the lives of LGBTQ individuals. In all, ACE measurement strategies that capture the breath of exposure of ACEs in the lives of LGBTQ individuals will assist in ACE screening, public health policy, and clinical intervention efforts.

Exploring the Association Between Indicators of Socioeconomic Instability, Survival Sex, and Methamphetamine Use Among Young Adult Black Gay, Bisexual, and Other Men Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

Methamphetamine (Meth) use is a contributor to poor health outcomes among young Black American gay, bisexual, and other men who have sex with men (YB-GBMSM). Emerging research indicates that socioeconomic instability may be a salient antecedent of meth use as men may be encouraged to engage in health-eroding activities, such as survival sex, to care for themselves, and then cope with instability-related stress via use of substances. We examined the degree to which indicators of socioeconomic instability, including homelessness and food insecurity, would directly, and indirectly, predict increases in meth use, via survival sex engagement. Hypotheses were tested using mediated path analysis with data from 100 YB-GBMSM in Atlanta, Georgia. Preliminary analysis results demonstrated positive associations between engaging in survival sex, food insecurity, homelessness, and living with HIV. Findings demonstrated that homelessness and food insecurity were directly associated with increased survival sex engagement but were not directly associated with meth use. Homelessness and food insecurity were indirectly associated with increased severity of meth use, via increased engagement in survival sex. Socioeconomic instability and survival sex engagement may be important intervention targets for future meth use intervention/prevention programming. Integrating programmatic components that address homelessness and food insecurity may decrease YB-GBMSM's need to rely on survival sex to meet their needs and decrease their likelihood of using meth as a result.

Substance Use Disorders and Psychiatric Illness Among Transitional Age Youth Experiencing Homelessness

Objective

Transitional age youth experiencing homelessness (TAY-EH) bear a high burden of substance use disorders (SUDs) and psychopathology. However, limited data exist on the co-occurrence and interactions between these diagnoses in this marginalized group. This study sought to identify rates of single and co-occurring SUDs and psychiatric diagnoses among a sample of TAY-EH and to investigate associations between psychopathology and prevalence and severity of SUDs in this group.

Method

TAY-EH accessing a low-threshold social service agency in a large metropolitan area completed psychosocial and diagnostic interviews to assess for SUDs and psychopathology. Analyses examined rates of single and co-occurring disorders and associations between burden of psychopathology and presence and severity of SUDs.

Results

The assessment was completed by 140 TAY-EH; the majority were youth of color (54% Black/African American, 16% Latinx), and 57% identified as male. Rates of single and co-occurring psychiatric disorders and specific SUDs (cannabis use disorder [CUD] and alcohol use disorder [AUD]) were notably high. An increasing number of psychiatric diagnoses was significantly associated with elevated CUD/AUD prevalence and severity. Mood, anxiety, attention-deficit/hyperactivity, and antisocial personality disorders were significantly associated with elevated CUD/AUD prevalence and severity, as was suicidality (all p < .05).

Conclusion

This study reveals a complex overlay of SUDs and psychopathology facing TAY-EH, with a significant association between co-occurring psychopathology and severity of CUD/AUD. To the authors' knowledge, this is the first study to examine associations between specific psychopathology and severity of SUDs among TAY-EH. Further research into the mechanistic and temporal links between these conditions is needed to inform tailored treatment interventions.

Nursing pre-licensure and graduate education for LGBTQ health: A systematic review

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) people experience discrimination and health disparities compared to heterosexual cisgender people. Clinicians report discomfort and insufficient preparation for providing care to LGBTQ people and nursing has been slow to integrate LGBTQ health into curricula.

PURPOSE

Conduct a systematic review to examine and critically appraise peer-reviewed literature on nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health and the development/evaluation of LGBTQ health content in nursing curricula.

METHODS

A systematic review was conducted (N = 1275 articles from PubMed, LGBT Health, CINAHL, ERIC, and Health Source-Nursing/Academic Edition).

FINDINGS

Twenty articles met inclusion criteria. Twelve studies described curricular interventions; however, there were few validated tools to evaluate content coverage or KSAs. Four themes emerged specific to LGBTQ health content inclusion.

DISCUSSION

While an emerging science of LGBTQ nursing education has been identified, more work is needed to build and evaluate a comprehensive curricular approach for full programmatic integration of LGBTQ health.

CONCLUSION

As nursing programs build LGBTQ content into nursing curricula, care must be taken to integrate this content fully with the depth of curricular content in population health, social determinants of health, social justice, intersectionality, cultural competence, and political advocacy.

TWEETABLE ABSTRACT

Greater integration of LGBTQ health content into nursing education should be a priority for nursing education.

Lesbian, Gay, and Bisexual Students Experiencing Homelessness and Substance Use in the School Context: A Statewide Study

PURPOSE

This study explored differences between lesbian, gay, and bisexual (LGB)-housed and homeless students regarding substance use patterns on and off school grounds and the unique contribution of homelessness to substance use in school.

METHODS

Data were from the 2013-2015 California Healthy Kids Survey, a statewide survey of school protective factors and risk behaviors. A representative sample of 9th- and 11th-grade students (N = 20,337) was used. Comparisons between housed (n = 19,456) and homeless (doubled up: n = 715; acute homeless: n = 166) LGB students were conducted. We used chi-square tests to compare rates of lifetime, past-30-day, and in-school substance use and conducted multivariate logistic regression models for each substance use variables.

RESULTS

Chi-square test results indicated significant differences in rates of substance use among students experiencing homelessness (both categories) and housed LGB students. Lesbian, gay, and bisexual students experiencing homelessness were more likely to report substance use off and on school grounds. Results from logistic regression analyses indicated that LGB students who experience homelessness were significantly more likely to report recent and in-school substance use. For example, students experiencing acute homelessness were about 3 times as likely to report heavy episodic drinking (adjusted odds ratio [AOR] = 3.13; 95% confidence interval [CI] = 2.13, 4.26) and more than 5 times as likely to smoke marijuana in school (AOR = 5.38; 95% CI = 3.46, 8.36), compared to housed LGB students.

CONCLUSIONS

LGB students who experience homelessness are at higher risk than housed LGB students of substance use on and off school grounds. Findings highlight the need to provide support in the school context for this subpopulation.

Mental healthcare for young and adolescent LGBTQ+ individuals in the Indian subcontinent

The coronavirus disease (COVID-19) pandemic has led to a significant change in the way healthcare is dispensed. During the pandemic, healthcare inequities were experienced by various sections of society, based on gender, ethnicity, and socioeconomic status. The LGBTQ individuals were also affected by this inequity. There is a lack of information on this topic especially in the developing countries. Hence this issue requires further exploration and understanding. Previous literature briefly explored the mental, physical, and emotional turmoil faced by the LGBTQ community on a regular basis. They feared rejection by family and friends, bullying, physical assault, and religious biases. These issues prevented them from publicly speaking about their sexual orientation thereby making it difficult to collect reliable data. Although they require medical and psychological treatment, they are afraid to ask for help and access healthcare and mental health services. Being mindful of these difficulties, this article explores the various underlying causes of the mental health problems faced by LGBTQ individuals, especially, in the Indian subcontinent. The article also examines the status of healthcare services available to Indian sexual minorities and provides recommendations about possible remedial measures to ensure the well-being of LGBTQ individuals.

Gender Minority Youth Experiencing Homelessness and Corresponding Health Disparities

PURPOSE

Pediatricians and youth service providers frequently interface with vulnerable populations, including gender minority youth (e.g., transgender, nonbinary, gender questioning, and other gender diverse individuals) and youth experiencing homelessness. The purposes of this study are to estimate the prevalence of homelessness and types of homelessness experienced among gender minority youth and their corresponding health outcomes.

METHODS

Data for this study came from gender minority (n = 3,194) and cisgender (n = 93,337) high school students who answered questions on transgender status and homelessness status in the 2017 and 2019 Youth Risk Behavior Survey (YRBS). We compared the prevalence of homelessness between gender minority and cisgender youth and assessed where youth experiencing homelessness had slept in the prior month: shelters, nonparental homes, streets, hotel, or other locations. Finally, logistic regression models and marginal effects (ME) were used to examine health outcomes at the intersection of gender minority status and homelessness.

RESULTS

22% of gender minority youth reported homelessness during the prior month. Cisgender youth were significantly less likely to report being homeless (3%). Transgender youth experiencing homelessness were significantly more likely to live on the streets than cisgender youth experiencing homelessness (ME = 0.20; 95% CI = 0.10-0.30; p < .001). Gender minority youth experiencing homelessness reported elevated health-risk behaviors in excess of nonhomeless gender minority youth and cisgender youth experiencing homelessness.

DISCUSSION

Public health campaigns, housing interventions, and youth service providers should consider and create tailored programs to secure housing and to promote the health of gender minority youth experiencing homelessness.

Social resource patterns and health outcomes among Canadian LGBTQ2+ adults: A latent class analysis

BACKGROUND

Decades of research have shown a strong association between wellbeing, health, and social resources. LGBTQ2+ communities are among those who historically have been excluded from accessing quality social resources. However, little is known about how access to different types of resources influences mental health and wellbeing.

METHOD

Data were drawn from an online sample of 3890 LGBTQ2+ people aged 18 years and older in Quebec, Canada. We identified key social resource patterns (from family of origin, friends, partner, neighbourhood, and LGBTQ2+ community) and investigated differences in socio-demographic and health outcomes across classes.

RESULTS

A five-class solution best fitted the data, highlighting distinctive patterns in access to five key social resources: moderate friend support access (42.14%), overall high support access (23.51%), high friend support access (18.06%), only close ties support access (10.90%) and overall low support access (5.39%). Marginalized groups (trans and non-binary people, racialized or disabled people, immigrants) were less likely to access diverse, high-quality social resources. Accessing diverse social resources, particularly close ties (e.g., family of origin), was associated with better health outcomes. In the absence of close ties, having at least one other social resource was associated with better health outcomes compared to having limited access to all resources.

CONCLUSIONS

We found a major imbalance in social resource access among LGBTQ2+ people. Creating safe spaces for LGBTQ2+ people and ensuring access to high-quality social resources is important in sustaining their health and wellbeing.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system

PURPOSE

Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination.

METHODS

We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality.

RESULTS

A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68).

CONCLUSION

The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

Critical Consciousness for Connectivity: Decoding Social Isolation Experienced by Latinx and LGBTQ+ Youth Using a Multi-Stakeholder Approach to Health Equity

Systemic oppression creates a context in which Latinx LGBTQ+ youth experience social isolation. Social isolation has been associated with mental and physical health disparities, including disproportionate levels of depression, substance use, self-harm, and attempted suicide. These disparities are often magnified in rural and suburban areas with fewer identity-affirming spaces. This community-engaged study reports on the formative process of developing a Latinx LGBTQ+ telenovela (soap opera) allyship intervention based on critical consciousness theory. We conducted eight focus groups with community advisory boards, which included Latinx LGBTQ+ youth (n = 12), health and social service providers serving LGBTQ+ youth (n = 10), 4-H Latinx alumni youth (n = 12), and 4-H Latinx parents (n = 8). We interviewed nine Latinx LGBTQ+ youth enrolled in a film-making workshop. As a result of our multi-stakeholder approach, we: (1) described how stakeholders reflected on and decoded intersectional isolation on the individual, community, and structural levels; and (2) identified ways that stakeholders suggested taking action by improving access to resources to address social isolation, provide culturally competent healthcare, and co-create an enabling social environment. Our study indicated the importance of tapping into core values and intersectional identities to build solidarity among and within marginalized groups to dismantle oppressive systems.

A Peer-Led, Artificial Intelligence-Augmented Social Network Intervention to Prevent HIV Among Youth Experiencing Homelessness

BACKGROUND

Youth experiencing homelessness (YEH) are at elevated risk of HIV/AIDS and disproportionately identify as racial, ethnic, sexual, and gender minorities. We developed a new peer change agent (PCA) HIV prevention intervention with 3 arms: (1) an arm using an artificial intelligence (AI) planning algorithm to select PCAs; (2) a popularity arm, the standard PCA approach, operationalized as highest degree centrality (DC); and (3) an observation-only comparison group.

SETTING

A total of 713 YEH were recruited from 3 drop-in centers in Los Angeles, CA.

METHODS

Youth consented and completed a baseline survey that collected self-reported data on HIV knowledge, condom use, and social network information. A quasi-experimental pretest/posttest design was used; 472 youth (66.5% retention at 1 month postbaseline) and 415 youth (58.5% retention at 3 months postbaseline) completed follow-up. In each intervention arm (AI and DC), 20% of youth was selected as PCAs and attended a 4-hour initial training, followed by 7 weeks of half-hour follow-up sessions. Youth disseminated messages promoting HIV knowledge and condom use.

RESULTS

Using generalized estimating equation models, there was a significant reduction over time (P < 0.001) and a significant time by AI arm interaction (P < 0.001) for condomless anal sex act. There was a significant increase in HIV knowledge over time among PCAs in DC and AI arms.

CONCLUSIONS

PCA models that promote HIV knowledge and condom use are efficacious for YEH. Youth are able to serve as a bridge between interventionists and their community. Interventionists should consider working with computer scientists to solve implementation problems.

Victimization Typologies Among a Large National Sample of Sexual and Gender Minority Adolescents

Purpose: The overall objective of this study was to examine the hypothesis that victimization exposure among sexual and gender minority (SGM) youth would result in different latent classes and that victimization exposure class membership would relate to demographic, SGM-specific risk and protective factors, and health variables. Methods: Between April 2017 and December 2017, SGM youth (N = 17,112) aged 13-17 years completed self-report online surveys as part of the LGBTQ National Teen Survey. Data were analyzed between August 2020 and November 2020. Results: Three classes emerged: (1) no victimization exposure, (2) sexual harassment and bullying, and (3) poly-victimization (sexual victimization, sexual harassment, SGM-based bullying, and non-SGM bullying). The results demonstrated that victimization experiences co-occur disproportionately in vulnerable subpopulations of SGM youth, including those who identify as transgender or other gender minority, who are experiencing stigma-related stress and family rejection, and who had disclosed their sexual orientation to family members/parents. SGM youth who reported a diversity of strengths seemed to be protected against victimization. Finally, SGM youth in the sexual harassment and bullying class and the poly-victimization class were more likely to report depressive symptoms, self-perceived stress, and substance use than were SGM youth in the no victimization class, regardless of sex assigned at birth. Conclusion: These findings underscore the urgency with which affirmative prevention and intervention initiatives are needed for SGM youth to reduce risk factors for and correlates of victimization experiences. The data also underscore the importance of addressing SGM-specific risk and protective factors as part of comprehensive violence-related initiatives.

Towards an integrative self: a digital photo elicitation study of resilience among key marginalized populations of sexual and gender minority youth

Purpose: Sexual and gender minority youth (SGMY) experience unique challenges related to identity and disclosure, and cope in vibrant ways. Qualitative research has not yet fulsomely explored the risk, resilience, and identity intersections that impact vulnerable SGMY wellbeing. Methods: This digital photo-elicitation study (QueerView) recruited thirty SGMY (aged 14–29) from priority populations that had one or more of the following experiences:  trans and gender diverse, homelessness, child welfare, and immigration. From submission of fifteen photos representing resilience and a semi-structured interview via web conferencing, constructivist grounded theory was utilized for multimodal analysis of photos, interview video, and interview transcript. Triangulation, an audit trail, and member checking were employed to support trustworthiness. Results: A visual model emerged showing how participants work towards an integrative self, with themes of reflecting and knowing, discrimination and intersectional challenges, connecting, performing, curating, coping, (re)defining and (re)creating, growing and being. Sub-themes of the impact of family dynamic and values, mental health and trauma, and the cathartic benefit from advocacy and leadership offered insight. Participant images were captured in a digital gallery. Conclusions: QueerView animates the complex lives of multiply marginalized SGMY and their intersectional strengths and challenges while demonstrating the utility of a digital multimodal approach.

The LGBTQ+ communities and the COVID-19 pandemic: a call to break the cycle of structural barriers

The COVID-19 pandemic has disproportionately impacted LGBTQ+ communities. Many disparities mirror those of the HIV/AIDS epidemic. These health inequities have repeated throughout history due to the structural oppression of LGBTQ+ people. We aim to demonstrate that the familiar patterns of LGBTQ+ health disparities reflect a perpetuating, deeply rooted cycle of injustice imposed on LGBTQ+ people. Here, we contextualize COVID-19 inequities through the history of the HIV/AIDS crisis, describe manifestations of LGBTQ+ structural oppression exacerbated by the pandemic, and provide recommendations for medical professionals and institutions seeking to reduce health inequities.

The Annual Examination for Lesbian, Gay, and Bisexual Patients

The annual examination is a comprehensive evaluation of patients in which all aspects of health and well-being are considered, including proper screening, appropriate preventive care, and recommendations and resources for healthy living. Clinicians commonly avoid certain topics with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients because they may be unprepared to address their health needs. Therefore, clinicians should learn how to conduct an LGBTQ-friendly annual examination in order to provide high-quality care. This article focuses on both the general and unique health needs of lesbian, gay, bisexual, and queer patients; care for transgender and gender-diverse patients is considered elsewhere.

Perceived Impacts, Acceptability, and Recommendations for Ecological Momentary Assessment Among Youth Experiencing Homelessness: Qualitative Study

BACKGROUND

The use of ecological momentary assessment (EMA) to study youth experiencing homelessness (YEH) behaviors is an emerging area of research. Despite high rates of participation and potential clinical utility, few studies have investigated the acceptability and recommendations for EMA from the YEH perspective.

OBJECTIVE

This study aimed to describe the perceived benefits, usability, acceptability, and barriers to the use of EMA from the homeless youth perspective.

METHODS

YEH were recruited from a larger EMA study. Semistructured exit interviews were performed using an interview guide that focused on the YEH experience with the EMA app, and included perceived barriers and recommendations for future studies. Data analyses used an inductive approach with thematic analysis to identify major themes and subthemes.

RESULTS

A total of 18 YEH aged 19-24 years participated in individual and group exit interviews. The EMA was highly acceptable to YEH and they found the app and EMA surveys easy to navigate. Perceived benefits included increased behavioral and emotional awareness with some YEH reporting a decrease in their high-risk behaviors as a result of participation. Another significant perceived benefit was the ability to use the phones for social support and make connections to family, friends, and potential employers. Barriers were primarily survey and technology related. Survey-related barriers included the redundancy of questions, the lack of customizable responses, and the timing of survey prompts. Technology-related barriers included the "freezing" of the app, battery charge, and connectivity issues. Recommendations for future studies included the need to provide real-time mental health support for symptomatic youth, to create individually customized questions, and to test the use of personalized motivational messages that respond to the EMA data in real time.

CONCLUSIONS

YEH are highly receptive to the use of EMA in studies. Further studies are warranted to understand the impact of EMA on YEH behaviors. Incorporating the YEH perspective into the design and implementation of EMA studies may help minimize barriers, increase acceptability, and improve participation rates in this hard-to-reach, disconnected population.

Older lesbian, gay, bisexual, transgender, queer and intersex peoples' experiences and perceptions of receiving home care services in the community: A systematic review

BACKGROUND

Numbers of older lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) people are increasing worldwide in line with the ageing populations of many countries. Most LGBTQI+ people want to remain in their own homes as they age, making it important to understand their experiences and perceptions of receiving home care. This systematic review aimed to examine older (over 60 years) LGBTQI+ people's perceptions and experiences of using formal home care services in the community.

METHODS

The following six electronic databases were searched from the date of their first records until the first week of March 2020: MEDLINE; PsycINFO; Social Policy and Practice; CINAHL; SSCI; and ASSIA. Hand searches of the reference lists of the included studies and relevant reviews were also conducted. Only peer reviewed research published in English was included. There were no restrictions on study design. Findings were analysed using narrative synthesis. The PROSPERO protocol registration identification number is: CRD42020168443.

RESULTS

Seven studies involving 169 participants were included in the synthesis. All were qualitative. Most participants were either lesbian women or gay men, with no studies investigating home care for transgender, queer, intersex or other sexual minorities. Fear of accessing home care services due to the perceived threat of homophobia and past negative experiences of discrimination were common. Some concealed any LGBTQI+ materials in their homes to try and hide their sexuality from home care workers. Despite fear of discrimination, lesbian women and gay men reported wanting and expecting the same level of care, dignity and respect as their heterosexual counterparts. Mandatory LGBTQI+ sensitivity training for home care workers was identified for reducing homophobia and increasing the inclusivity of service providers.

CONCLUSION

Older lesbian women and gay men fear or experience discrimination from home care workers, with some choosing to hide their sexuality causing stress and anxiety. Sensitivity training in the needs of older LGBTQI+ people should be considered by home care service providers as a way of reducing homophobic attitudes which may exist among some home care workers. Due to the paucity of studies and their focus on older lesbian women and gay men, more research is needed to explore the experiences of other sexual minorities receiving home care services who are represented by the LGBTQI+ umbrella term.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

Disclosure of Sexual Identities Across Social-Relational Contexts: Findings from a National Sample of Black Sexual Minority Men

Black sexual minority men (BSMM) in the USA navigate a range of factors that may influence the extent to which they disclose or conceal their sexual identity in various social contexts. To date, few studies have investigated the correlates of sexual identity disclosure or concealment among BSMM across multiple life domains. Guided by a minority stress perspective and intersectionality, we analyzed data from N = 809 BSMM who participated in the Social Justice Sexuality Survey. We conducted ordinary least squares regression to examine the relative weight of perceptions of homophobia, religiosity, LGBT community connectedness, racial identity salience, and sexual identity salience on disclosure of sexual identity in six social-relational contexts: (1) family, (2) friends, (3) neighbors, (4) religious community, (5) work, and (6) online. Findings indicate that BSMM disclosed their sexual identity unevenly across social-relational contexts. Notably, LGBTQ community connectedness and sexual identity importance were consistent predictors of sexual identity disclosure across contexts. In contrast, perceptions of homophobia were not related to sexual identity disclosure, suggesting that other factors may be more salient for BSMM when deciding to disclose their sexual identity. Finally, bisexual men consistently reported lower levels of sexual identity disclosure relative to gay men in all six contexts. Study findings have important implications for future research on sexual identity disclosure with diverse samples of BSMM.

Clinical psychology PhD students' admission experiences: Implications for recruiting racial/ethnic minority and LGBTQ students

AIM

The purpose of this study was to explore differences in the clinical psychology PhD program admissions experience (i.e., interviewing and decision-making) by race/ethnicity and lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity.

METHODS

Participants were 803 students (24% racial/ethnic minority; 19% LGBTQ) enrolled in US clinical psychology PhD programs. Two-group comparisons tested for differences in admission experiences by race/ethnicity and LGBTQ identity.

RESULTS

Racial/ethnic minority and LGBTQ students considered a programmatic commitment to diversity as more important in application decisions compared to non-Hispanic White and cisgender heterosexual students, respectively. LGBTQ students were more likely to be advised to not discuss personal information (e.g., sexual orientation) than cisgender heterosexual students. Racial/ethnic minority and LGBTQ students identified financial considerations and program outcomes as more important in their decision-making compared with non-Hispanic White and cisgender heterosexual students, respectively.

CONCLUSION

Increasing funding and fostering authentic training environments should be prioritized in institutional conversations around recruiting racial/ethnic minority and LGBTQ trainees.

Homelessness and people with intellectual disabilities: A systematic review of the international research evidence

BACKGROUND

People with intellectual disabilities can experience homelessness, and some of the reasons differ from the general homeless population. Specific policy and practice responses are required.

METHOD

A systematic review of studies examining homelessness among people with intellectual disabilities utilizing CINAHL, MEDLINE, PsycINFO and Sociological Abstracts databases from inception to November 2019.

RESULTS

The search produced 259 papers, and following screening, a total of 13 papers were included in the review. The themes identified were (i) pathways into homelessness, (ii) experiencing homelessness and (iii) routes out of homelessness.

CONCLUSIONS

People with ID become homeless due to multifactorial issues. The identification of people within homeless services and their care and support concerns remains challenging, impacting upon the provision of assessments, interventions, care and supports. Psychosocial assessments, interventions and supports are necessary to assist people with ID to leave homelessness.

The needs of LGBTI+ people within student nurse education programmes: A new conceptualisation

There is a growing body of international research evidence highlighting concerns around social exclusion and discrimination, significant health inequalities and health needs, and barriers to accessing effective healthcare for LGBTI + people. However, ways in which the healthcare needs of LGBTI + people can be addressed in student nurse education programmes have yet to be fully explored. The aim of this discussion paper is to present the evidence to support the inclusion of LGBTI + health throughout the nursing curriculum. A new conceptualisation of the full and effective integration of LGBTI + health content across and within the nursing curriculum is proposed. This can be achieved by further developing theory, skills simulation and practice learning opportunities. There is a need to ensure that nursing students are positioned and adequately prepared to effectively address concerns of social justice, reducing health inequalities, and providing responsive person-centred care for LGBTI + health service users.

The Confluence of Housing Instability and Psychosocial, Mental, and Physical Health in Sexual Minority Young Adults: The P18 Cohort Study

Sexual and gender minority (SGM) youth experience housing instability, including homelessness, at higher rates than heterosexuals. Few studies have examined differences within SGM populations and intersections of housing and health. Data were drawn from a study of SGM young adults who were assigned male at birth. Nearly one-quarter of the sample reported homelessness, unstable housing, or both in the six months prior to assessment. Housing instability was higher among those of lower income and educational attainment. Additionally, those who experienced any housing instability reported higher levels of depression, poorer self-rated health, and greater gay-related stigma; in multivariable models, only self-rated health was related to housing status. Stigma and discrimination may lead to poorer mental health; housing instability and homelessness may be a manifestation of stigma perpetuated by social conditions and mental health burdens directed by familial rejection. Findings indicate the importance of a biopsychosocial perspective in addressing housing instability in SGM youth.

Homelessness experiences and gender identity in a population-based sample of adolescents

This paper examines the prevalence of homelessness among transgender/gender diverse (TGD) youth in a population-based sample of adolescents. We used data from a statewide sample of 9th and 11th grade adolescents in Minnesota who responded to a school-based survey during 2016 (N = 80,929). Survey questions assessed adolescents' gender identity and experiences of homelessness (either with adult family members or unaccompanied) in the past 12 months. We used chi-square analyses to compare the prevalence of homelessness between gender identity groups. Overall, 2.7% of the sample reported identifying as TGD. Significantly more TGD (vs. cisgender) youth reported experiencing homelessness either with adult family members (6.7% vs. 3.5%) or unaccompanied (3.6% vs. 1.1%; p < .0001). Findings from this population-based survey suggest that TGD youth are more likely to experience homelessness, either with a family member or unaccompanied, than cisgender peers. Ensuring housing stability among this population is critical, given health risks associated with homelessness during adolescence. Data on homelessness experiences of TGD youth are needed to inform practice and policies for this distinct population.

Current Resources for Evidence-Based Practice, November 2019

A review of new resources to support the provision of evidence-based care for women and infants.