Sexual Orientation and Gender Identity-Related State-Level Policies and Perceived Health Among Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults in the United States

Structural Stigma, Racism, and Sexism Studies on Substance Use and Mental Health: A Review of Measures and Designs

PURPOSE

Most research on the structural determinants of substance use and mental health has centered around widely studied factors such as alcohol taxes, tobacco control policies, essential/precursor chemical regulations, neighborhood/city characteristics, and immigration policies. Other structural determinants exist, however, many of which are being identified in the emerging fields of structural stigma, structural racism, and structural sexism. This narrative review surveys the measures and designs used in substance use and mental health studies from these three fields.

SEARCH METHODS

The PubMed, PsycINFO, and Scopus databases were searched on May 11, 2023. A focused search approach used terminology for structural racism, stigma, or sexism combined with terminology for substance use or mental health. Peer-reviewed studies were included if they were written in English and assessed associations between objective structural measures and substance use and mental health outcomes.

SEARCH RESULTS

Of 2,536 studies identified, 2,487 were excluded. Forty-nine studies (30 related to stigma, 16 related to racism, and three related to sexism) met the inclusion criteria. Information was abstracted about the structural measures, outcome measures, research design, sample, and findings of each study.

DISCUSSION AND CONCLUSIONS

The structural determinant measures used in the studies reviewed were diverse. They addressed, for example, community opinions, the gender of legislators, economic vulnerability, financial loan discrimination, college policies, law enforcement, historical trauma, and legislative protections for sexual and gender minorities and for reproductive rights. Most of the structural determinant measures were constructed by combining multiple indicators into indexes or by merging indexes into composite indexes, although some studies relied on single indicators alone. The substance use and mental health outcome measures most frequently examined were related to alcohol and depression, respectively. The studies were conducted in numerous nations and drew samples from an array of groups, including, for example, patients who experienced overdoses from substance use, sexual and gender minorities, racial and ethnic minority groups, women, youth, migrants, and patients subject to involuntary psychiatric hospitalization. Most of the studies used passive-observational (correlational) research designs and, as a result, did not assess whether their structural determinant variables were causally related to substance use and mental health. Nevertheless, the studies reviewed can be used by public health proponents to foster awareness that a wide range of structural determinants correlate with the substance use and mental health of many groups within and across nations.

Health Experiences of LGBTQ+ People Living With Dementia and Their Care Partners: A Scoping Review of Research and Policy

OBJECTIVES

This scoping review aimed to synthesize research on the health experiences of LGBTQ+ people living with dementia (PLWD) and their caregivers, and the impact of health policies on this population.

METHODS

Six databases were searched for research studies and policy literature. Titles, abstracts, and full texts were reviewed by a three-member team. Data was extracted and thematically analyzed. Feedback from 7 LGBTQ+ adults was collected through a community consultation session.

RESULTS

A total of 9257 unique research and 945 policy citations were identified, of which 60 research and 19 policy papers were reviewed. Nine research studies and ten policy papers met eligibility criteria. Themes emerged through the analysis of research findings, the community listening session, and policy findings.

DISCUSSION

Future work needs to disentangle the impact of policies on the health experiences of this population. Dementia-specific and LGBTQ+ inclusive services and policies are needed to address growing health disparities.

Racial and Ethnic Variations in Resilience Factors Among Sexual and Gender Minority Midlife and Older Adults

BACKGROUND AND OBJECTIVES

This study explores resilience factors among sexual and gender minority (SGM) midlife and older adults, identifying historical/environmental, psychological, social, and behavioral predictors, and examining variations across racial/ethnic subgroups. By adopting a resilience-focused perspective, this research contributes to understanding strengths in the SGM community in the context of aging.

RESEARCH DESIGN AND METHODS

Using weighted survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study, this research investigates distinct risk and protective factors associated with resilience among SGM midlife and older adults. Subgroup variations were assessed using regression models. Factors moderated by race/ethnicity were integrated into final interaction models.

RESULTS

Hispanic and Black individuals showed significantly higher resilience than non-Hispanic Whites. Lifetime victimization and day-to-day discrimination were negatively associated with resilience. Positive associations were found for higher income, identity affirmation, larger network size, greater social participation, increased physical activity, and sufficient food intake. Interaction models revealed nuanced patterns by subgroups; education negatively impacted resilience among Black individuals, while income positively influenced Hispanic individuals' resilience. The Other racial/ethnic group demonstrated unique associations between optimal sleep and resilience.

DISCUSSION AND IMPLICATIONS

This study shifts from a deficit-based to a resilience-focused approach among SGM midlife and older adults, revealing key strengths within diverse subgroups. Results underscore the significance of recognizing racial/ethnic differences in factors promoting resilience and posing risks for SGM midlife and older adults. Tailoring interventions to address the intersectional needs of SGM aging populations is essential for enhancing their abilities to bounce back from adverse events.

Prevalence of Epilepsy in People of Sexual and Gender Minoritized Groups

Importance

Epilepsy is a highly treatable condition for many people, but there are large treatment gaps with suboptimal seizure control in minoritized groups. The sexual and gender minority (SGM) community is at risk for health disparities, yet the burden of epilepsy in this community is not known.

Objective

To estimate the prevalence of active epilepsy among SGM people in the United States.

Design, Setting, and Participants

This was a cross-sectional, nationally representative survey study of community-dwelling US adults who answered questions about epilepsy, sexual orientation, and gender identity in the 2022 National Health Interview Survey (NHIS).

Exposure

Self-identification of transgender or gender-diverse identity, or sexual orientation including gay, lesbian, bisexual, or other orientation, excluding straight (ie, heterosexual).

Main Outcomes and Measures

Participants self-reported epilepsy status, medical treatment, seizure frequency, demographic characteristics, sexual orientation, and gender identity. Logistic regression was used to estimate the association of epilepsy with SGM identification.

Results

A total of 27 624 participants (15 050 [54%] women; 3231 [12%] Black; mean [SD] age, 48.2 [18.5] years) completed the NHIS and were included. Active epilepsy was present in 1.2% (95% CI, 1.0%-1.3%) of the population. A higher proportion of SGM adults than non-SGM adults reported active epilepsy (2.4% [95% CI, 1.4%-3.3%] vs 1.1% [95% CI, 1.0%-1.3%], respectively). After adjusting for age, race, ethnicity, income, and education, SGM people were more than twice as likely to report active epilepsy than were non-SGM adults (adjusted odds ratio, 2.14; 95% CI, 1.35-3.37).

Conclusions and Relevance

The findings suggest that SGM adults in the United States have a disproportionate prevalence of epilepsy. The reasons for this disparity are likely complex and may be associated with biological and psychosocial determinants of health unique to this population; as such, these individuals are in need of protected access to medical care.

State LGBTQ policy environments and the cancer burden in sexual and gender minoritized communities in the United States

PURPOSE

Our objective was to assess the association between state policies related to sexual orientation and gender identity (SOGI) and cancer prevalence and survivorship indicators in a sexual and gender minoritized (SGM) population in the United States.

METHODS

Data from the 2017-2021 Behavioral Risk Factor Surveillance System were used to measure cancer diagnosis, physical and mental health, and substance use for SGM adult cancer survivors. A state policy Z-score, ranging from most restrictive to most protective state policies related to SOGI, was computed from data available from the Movement Advancement Project. Survey-weighted logistic regression was used to test the relationship between state policies and cancer-related outcomes for SGM people.

RESULTS

More protective state policies were associated with lower odds of a cancer diagnosis (adjusted odds ratio [AOR]: 0.92; 95% confidence interval [CI]: 0.87-0.97). Among SGM cancer survivors, increasing protective state policies were associated with lower odds of poor physical health (AOR: 0.83; 95% CI: 0.74-0.94), lower odds of difficulty walking or climbing stairs (AOR: 0.90; 95% CI: 0.80-1.00), and lower odds of difficulty concentrating or remembering (AOR: 0.87; 95% CI: 0.78-0.98). No significant associations were found between state policies and mental health, depression, substance use, diabetes, or cardiovascular disease among SGM cancer survivors.

CONCLUSION

SGM people diagnosed with cancer are more likely to live in restrictive policy states, and survivors in those states have worse physical health and cognitive disability. Additional research should investigate potential causal relationships between state policies and SGM cancer outcomes.

Associations Between Structural Stigma and Allostatic Load Among Sexual Minorities: Results From a Population-Based Study

OBJECTIVE

Structural forms of stigma and discrimination are associated with adverse health outcomes across numerous stigmatized groups, including lesbian, gay, and bisexual (LGB) individuals. However, the biological consequences of structural stigma among LGB populations are understudied. To begin to address this gap, we assessed associations between indicators of structural stigma (i.e., state-level policies) targeting LGB individuals and allostatic load (AL) indices representing physiological dysregulations.

METHODS

Pooled data from the continuous 2001-2014 National Health and Nutritional Examination Survey were analyzed (LGB: n = 864; heterosexual: n = 20,310). Ten state-level LGB-related policies (e.g., employment nondiscrimination protections, same-sex marriage) were used to operationalize structural stigma. A sex-specific AL index representing 11 immune, metabolic, and cardiovascular biomarkers was estimated. Multilevel models were used to examine associations between structural stigma and AL, net of nine individual-level characteristics (e.g., education, race/ethnicity, age, and health behaviors).

RESULTS

Sexual minority men living in states with low levels of structural stigma experienced significantly lower AL ( β = -0.45, p = .02) compared with sexual minority men living in states with high structural stigma (i.e., fewer protective policies). There was no significant association between structural stigma and AL among sexual minority women.

CONCLUSIONS

By demonstrating direct associations between structural stigma and indices of physiological dysregulation, our findings provide a mechanistic understanding of how the social environment can "get under the skin and skull" for sexual minority men in the United States. Future research should explore whether these mechanisms generalize to other marginalized groups exposed to structural stigma.

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

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