Prediction of depressive distress in a community sample of women: the role of sexual orientation

Identifying pathways from childhood adversity to suicidal thoughts and behaviors among sexual minority adults: An exploratory mediation analysis

BACKGROUND

The current study uses a nationally representative longitudinal dataset of sexual minority adults in the US to investigate the pathways from adverse childhood experiences (ACEs) to adulthood suicidal thoughts and behaviors.

METHODS

ACEs were measured at year one, potential mediators at year two, and suicidal thoughts and behaviors (suicidal ideation, intent, plan, and attempt) at year three. We conducted an exploratory mediation analysis to identify potential mediating factors linking ACEs to suicidal thoughts and behaviors. Ten candidate mediators were examined: social well-being, felt stigma, experiences of everyday discrimination, social support, psychological distress, alcohol and drug use, importance of sexual identity, community connection, and internalized homophobia.

RESULTS

Participants were 1518 adults who identified as lesbian or gay (n = 833; 55 %), bisexual (n = 493; 33 %), or with other sexual minority identities (n = 181; 12 %) and were on average 36.48 years (SD = 14.7) of age. Psychological distress served as a common mediator between ACEs and suicidal ideation, intent, plan, and attempt. Additionally, experiences of everyday discrimination emerged as a specific mediator leading to suicidal intent, whereas social support uniquely mediated the relation between ACEs and suicide plan.

LIMITATIONS

Potential recall bias due to retrospective reporting of ACEs may be a limitation. Future studies should broaden the measurement scope of ACEs and implement intersectional methods.

CONCLUSION

The current findings underscore the urgent need for targeted interventions that address the specific mental health needs of sexual minority individuals, particularly focusing on mitigating psychological distress, combating systemic discrimination, and enhancing social support.

Health Outcomes of Sexual Minority Women Who Have Experienced Adverse Childhood Experiences: A Scoping Review

Sexual minority women (SMW; e.g., lesbian, bisexual) report higher rates of almost every negative physical health (e.g., asthma, arthritis, cardiovascular disease), mental health (e.g., depression, anxiety), and substance use outcome compared to heterosexual women. Adverse Childhood Experiences (ACEs) have been identified as risk factors for negative health outcomes. Despite this, no study to date has synthesized existing literature examining ACEs and health outcomes among SMW. This gap is important because SMW are significantly more likely than heterosexual women to report every type of ACE and a higher total number of ACEs. Therefore, using a scoping review methodology, we sought to expand understanding of the relationship between ACEs and health outcomes among SMW. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for. Scoping Reviews protocol, we searched five databases: Web of Science, PsycInfo, CINAHL, PubMed, and Embase for studies published between January 2000 and June 2021 that examined mental health, physical health, and/or substance use risk factors and outcomes among adult cisgender SMW who report ACEs. Our search yielded 840 unique results. Studies were screened independently by two authors to determine eligibility, and 42 met full inclusion criteria. Our findings provide strong evidence that ACEs are an important risk factor for multiple negative mental health and substance use outcomes among SMW. However, findings were mixed with respect to some health risk behaviors and physical health outcomes among SMW, highlighting the need for future research to clarify these relationships.

Perinatal Depression Screening Among Sexual Minority Women

Importance

A substantial number of births in the US are to sexual minority women (17% based on a nationally representative survey), yet there is little research on perinatal depression screening rates or symptom endorsement among sexual minority women (including women who identify as lesbian, bisexual, queer, pansexual, asexual, demisexual, and kinky as well as other-identified women who have sex with women). High rates of risk factors for perinatal depression (eg, intimate partner violence and history of mental illness) among sexual minority individuals magnify this gap in the literature.

Objective

To describe the prevalence of female-identified sexual minority people giving birth in an academic medical center and compare perinatal depression screening rates and scores among sexual minority women and heterosexual cisgender women.

Design, Setting, and Participants

This retrospective cohort study used deidentified medical record review of 18 243 female-identified individuals who gave birth at an academic medical center in Chicago, Illinois, between January 1 and December 31, 2019. Data were analyzed from April 5, 2021, to August 1, 2022.

Main Outcomes and Measures

Proportion of women identified as having sexual minority status in the medical record, rates of standard care administration of the 9-item Patient Health Questionnaire between sexual minority women and heterosexual women, and depression screening scores and rates of positive depression screening results for sexual minority and heterosexual women.

Results

Among 18 243 women (mean [SD] age, 33.8 [5.1] years; 10 453 [57.3%] of non-Hispanic White race and ethnicity), only 280 (1.5%; 95% CI, 1.3%-1.7%) were identified as having sexual minority status in the medical record. Significantly more sexual minority women vs heterosexual women attended at least 1 prenatal care visit (56 [20.0%] vs 2459 [13.7%]; P = .002) and at least 1 postpartum care visit (52 [18.6%] vs 2304 [12.8%]; P = .004). Sexual minority women were more likely to be screened for depression during postpartum care (odds ratio, 1.77; 95% CI, 1.22-2.52; P = .002) and more likely to screen positive for depression during the postpartum period (odds ratio, 2.38; 95% CI, 0.99-5.02; P = .03) than heterosexual women.

Conclusions and Relevance

In this cohort study, sexual minority women identified in the medical record were highly engaged in obstetric care yet at high risk of postpartum depression. In addition, their sexual orientation was largely undocumented in medical records. These results highlight the need for investigations that include strategies for measuring sexual orientation because medical record review is unlikely to reliably capture these sexual identities during the perinatal period.

Mental health and substance use among sexual minority women who report childhood sexual abuse: A systematic literature review

OBJECTIVE

A growing body of literature provides evidence that sexual minority women (SMW; e.g., lesbian, bisexual) are at greater risk of negative mental health and substance use outcomes than are heterosexual women. While minority stress may partially explain these disparities, it does not fully account for them. Therefore, it is necessary to identify how other risk factors (i.e., childhood sexual abuse [CSA]) contribute to SMW's increased risk of negative mental health and substance use outcomes.

METHOD

We conducted a systematic literature review to identify and synthesize the state of knowledge about CSA and mental health and substance use outcomes among SMW. Two independent reviewers screened 347 articles identified in searches of five databases (Web of Science, PsycInfo, CINAHL, PubMed, and Embase). Eligible articles were peer-reviewed, reported quantitative or mixed methods results focused on mental health or substance use outcomes among adult SMW with a history of CSA.

RESULTS

Twenty-four papers were included in the review. Findings clearly show that SMW report higher rates of CSA than heterosexual women. Findings also suggest that CSA may mediate the relationship between minority sexual identity and some negative outcomes.

CONCLUSIONS

Future studies should include minority stress factors, a broader range of mental health outcomes (apart from substance use and suicide), and more nuanced measures of CSA. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The relationship between school bullying victimization and mental health among high school sexual minority students in China: A cross-sectional study

BACKGROUND

School bullying has become a matter of global concern for the general public. Sexual minority youth (SMY) may experience minority stress and victimization which are known to adversely affect mental health and happiness. However, a few scholars explored and linked sexual orientation with campus bullying, depression, and anxiety symptoms under the specific cultural background of China.

OBJECTIVE

This study was to examine the effect of traditional and cyber bullying victimization on depression and anxiety among Chinese sexual minority adolescents.

METHODS

This is a cross-sectional survey with a total of 3841 subjects among senior high school students in Hunan Province, China. Related information was collected through a series of self-reported questionnaires. The association between variables was examined via a set of logistic regressions.

RESULTS

Homosexuality (OR: 6.398; 95 % CI: 3.321 to 12.325), bisexuality (OR: 3.146; 95 % CI: 1.499 to 6.603) and uncertainty of sexual orientation (OR: 2.341; 95 % CI: 1.516 to 3.615) were significantly associated with a combination of traditional and cyber bullying victimization. Compared to the heterosexual group, the sexual minority students, especially the bisexual students has a higher risk of depressive mood (OR: 2.349; 95 % CI: 1.664 to 3.316) and anxiety mood (OR: 3.049; 95 % CI: 2.150 to 4.324). Further multivariate binary hierarchical regression showed that the effects of sexual orientation and mental health were statistically significant only among those who are not involved in bullying victimization, OR values are from 1.929 (95 % CI: 1.061 to 3.507) to 3.209 (95 % CI: 2.090 to 4.927).

CONCLUSIONS

Homosexuals are most likely to be victims of a combination of traditional and cyber bullying victims. Bisexuals are most at risk for emotional problems. Sexual minorities in particular, showed differences in mental health risks between bullied and non-bullied groups. More attention needs to be paid to bullying and mental health among sexual minority students in China.

Physical Activity is Related to Mental Health and Sexual Orientation Among Women in College

Non-heterosexual women tend to report lower physical activity and poorer mental health than their heterosexual counterparts. The purpose of this study was to examine differences in mental health (stress and depression) and physical activity among female college students by sexual orientation. Students self-reported socio-demographic characteristics, physical activity, perceived stress, and depressive symptoms via an online survey. Correlations, independent samples t-tests, and multiple regression analyses were used to examine relationships between perceived stress, depressive symptoms, physical activity, and sexual orientation. Most participants (n = 1072, 20.0 ± 1.5 years) identified as heterosexual (90.1%), non-Hispanic White (73%), and in their fourth semester or higher. Perceived stress and depressive symptoms differed significantly between heterosexual and non-heterosexual women, but physical activity participation did not. Higher participation in vigorous physical activity and strength training predicted both lower depressive symptoms and lower perceived stress while controlling for sexual orientation. For both heterosexual and non-heterosexual sexual women, depressive symptoms had a positive relationship with perceived stress, and a negative relationship to strength training. Depressive symptoms also had negative correlations with vigorous physical activity among heterosexual women. Findings indicate non-heterosexual women experience greater perceived stress and depressive symptoms, and these mental health issues can have multi-level implications. Greater vigorous physical activity and strength training were associated with lower perceived stress and depression regardless of sexual orientation. Administrators and health promoters should consider ways to promote these forms of physical activity among non-heterosexual women. Further research is needed on the potential barriers impacting engagement in physical activity.

The Mediating Role of Emotion Regulation on Self-harm among Gender Identity and Sexual Orientation Minority (LGBTQ+) Individuals

OBJECTIVE

The present study was conducted to (1) investigate the role of emotion regulation difficulties among self-harming Lesbian, Gay, Bisexual, Transgender, Queer, or Questioning (LGBTQ+) individuals and (2) to test for a mediating role of emotion regulation difficulties in self-harm among LGBTQ + individuals.

METHOD

This study investigated the relationship between LGBTQ + status, self-reported levels of emotion regulation difficulties, and self-harm in a community sample (N = 484, aged 16-63), using an online cross-sectional survey.

RESULTS

LGBTQ + individuals reported more emotion regulation difficulties and were almost seven times more likely to self-harm than non-LGBTQ + participants. Being an LGBTQ + participant was associated with greater self-harm frequency when controlling for age, income, and difficulties in emotion regulation. Emotion regulation difficulties mediated the association between LGBTQ + status and both self-harm status and frequency.

CONCLUSIONS

The present findings suggest that treating emotion regulation difficulties might reduce both the prevalence and lifetime frequency of self-harm episodes among gender identity and sexual orientation minority individuals. Targeting emotion regulation might be used as an early prevention strategy among LGBTQ + individuals who are at risk for self-harm. Further, enhancing emotion regulation skills among self-harming LGBTQ + individuals might replace maladaptive emotion regulation strategies with healthy alternatives, and can, therefore, foster resilience. HIGHLIGHTSLGBTQ + individuals are at high risk for self-harm.ER-mediated the association between LGBTQ + status and self-harm.Targeting emotion regulation in LGBTQ + people may help reduce self-harm.

Effects of Multiple Forms of Information Bias on Estimated Prevalence of Suicide Attempts According to Sexual Orientation: An Application of a Bayesian Misclassification Correction Method to Data From a Systematic Review

Multiple epidemiologic studies demonstrate a disparity in suicide risk between sexual minority (lesbian, gay, bisexual) and heterosexual populations; however, both "exposure" (sexual minority status) and outcome (suicide attempts) may be affected by information bias related to errors in self-reporting. We therefore applied a Bayesian misclassification correction method to account for possible information biases. A systematic literature search identified studies of lifetime suicide attempts in sexual minority and heterosexual adults, and frequentist meta-analysis was used to generate unadjusted estimates of relative risk. A Bayesian model accounting for prior information about sensitivity and specificity of exposure and outcome measures was used to adjust for misclassification biases. In unadjusted frequentist analysis, the relative risk of lifetime suicide attempt comparing sexual minority with heterosexual groups was 3.38 (95% confidence interval: 2.65, 4.32). In Bayesian reanalysis, the estimated prevalence was slightly reduced in heterosexual adults and increased in sexual minority adults, yielding a relative risk of 4.67 (95% credible interval: 3.94, 5.73). The disparity in lifetime suicide attempts between sexual minority and heterosexual adults is greater than previously estimated, when accounting for multiple forms of information bias. Additional research on the impact of information bias in studies of sexual minority health should be pursued.

Non-Suicidal Self-Injury, Sexuality Concerns, and Emotion Regulation among Sexually Diverse Adolescents: A Multiple Mediation Analysis

Despite increasing interest in the prevalence and correlates of Non-Suicidal Self-Injury (NSSI) in adolescent populations, relatively few studies have examined NSSI among lesbian, gay and bisexual (LGB) adolescents. The current study explored sexuality concerns and elevated emotion dysregulation as potential mechanisms underlying the relationship between sexual orientation and elevated non-suicidal self-injury (NSSI). A community sample of 1,799 adolescents completed a questionnaire assessing NSSI, sexual orientation, sexuality concerns, and emotion regulation. Across the study, 20.6% of adolescents reported a history of NSSI. Adolescents who identify as "mostly heterosexual," "bisexual," and "mostly homosexual" were more likely to engage in NSSI than gay/lesbian, heterosexual, and asexual adolescents. Multiple mediation analysis showed that emotion regulation, but not sexuality concerns, mediated the relationship between sexual orientation and NSSI. The current study tested two theoretical pathways by which sexual orientation could predict NSSI engagement. Findings suggest that literature on general psychological processes, as well as group-specific minority stressors, can shed light on high rates of NSSI among LGB populations. Specifically, the challenges faced by LGB adolescents may undermine the development of emotion regulation. As such, this should be a key target of intervention with LGB adolescents engaging in NSSI.

Health Care of Sexual Minority Women

Sexual minority women may be invisible in health care settings unless practitioners ask every patient about sexual attractions/behaviors and identity. Sexual minority women need to feel comfortable and able to share information about their sexual identity, partners, and lives. No medical diagnoses are found more commonly in sexual minority women, but problems such as overweight/obesity, increased tobacco and alcohol use, increased mental health problems, and a past history of childhood sexual abuse are common. These factors intertwine when treating sexual minority women.

Relationship of Religiosity and Spirituality to Hazardous Drinking, Drug Use, and Depression Among Sexual Minority Women

Using data from Wave 3 of the Chicago Health and Life Experiences of Women (CHLEW) study (N = 699), we explored whether religiosity and spirituality were associated with risk of hazardous drinking, drug use, and depression among sexual minority women (SMW; i.e., lesbian, bisexual) and possible differences by race/ethnicity. Participants were more likely to endorse spirituality than religiosity, and endorsement of each was highest among African American SMW. We found no protective effect of religiosity or spirituality for hazardous drinking or drug use. An association initially found between identifying as very spiritual and past-year depression disappeared when controlling for help-seeking. Among SMW with high religiosity, African American SMW were more likely than White SMW to report hazardous drinking. Latina SMW with higher spirituality were more likely than White SMW to report drug use. Results suggest that religiosity and spirituality affect subgroups differently, which should be considered in future research on resiliency among SMW.

Addressing Health Care Disparities Among Sexual Minorities

There is evidence of health disparities between sexual minority and heterosexual populations. Although the focus of lesbian, gay, bisexual, and transgender health research has been human immunodeficiency virus/acquired immunodeficiency syndrome and sexually transmitted infection among men who have sex with men, there are health disparities among sexual minority women. Using the minority stress framework, these disparities may in part be caused by individual prejudice, social stigma, and discrimination. To ensure equitable health for all, there is urgent need for targeted culturally sensitive health promotion, cultural sensitivity training for health care providers, and intervention-focused research.

Patterns of Mental Health Care Utilization Among Sexual Orientation Minority Groups

Prior studies of the utilization of mental health professionals by sexual minority populations have relied on data that are now dated or not nationally representative. These studies have also provided mixed findings regarding gender differences in the utilization of mental health professionals among sexual minority individuals. Using data from the 2013-2015 National Health Interview Surveys, this study investigates (1) how sexual minority individuals compare to heterosexual participants in their utilization of mental health professionals; and (2) gender differences in that utilization. The results indicate sexual minority individuals utilize mental health care professionals at higher rates than heterosexual individuals even after controlling for measures of mental health and other demographic characteristics; this is true for both men and women. However, gender moderates the sexual minority effect on utilization rates. Sexual minority men utilize mental health professionals at a high rate, such that their utilization rates are similar to sexual minority women, contrary to the gender gap seen among heterosexuals.

Sexual Identity Mobility and Depressive Symptoms: A Longitudinal Analysis of Moderating Factors Among Sexual Minority Women

Sexual minority identity (bisexual, lesbian) is a known risk factor for depression in women. This study examined a facet of minority stress prevalent among women-sexual identity mobility-as an identity-related contributor to higher levels of depressive symptoms. We used three waves of data from the Chicago Health and Life Experiences of Women study, a longitudinal study of sexual minority women (N = 306). Random effects OLS regression models were constructed to examine the effect of sexual identity changes on depressive symptoms. We found that 25.6 % of the sample reported a sexual identity change between Wave I and Wave II, and 24.9 % reported a sexual identity change between Waves II and III. Women who reported a change in sexual identity also reported more depressive symptoms subsequent to identity change. This effect was moderated by the number of years participants had reported their baseline identity and by whether the participant had initiated a romantic relationship with a male partner.

Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis

BACKGROUND

Previous reviews have demonstrated a higher risk of suicide attempts for lesbian, gay, and bisexual (LGB) persons (sexual minorities), compared with heterosexual groups, but these were restricted to general population studies, thereby excluding individuals sampled through LGB community venues. Each sampling strategy, however, has particular methodological strengths and limitations. For instance, general population probability studies have defined sampling frames but are prone to information bias associated with underreporting of LGB identities. By contrast, LGB community surveys may support disclosure of sexuality but overrepresent individuals with strong LGB community attachment.

OBJECTIVES

To reassess the burden of suicide-related behavior among LGB adults, directly comparing estimates derived from population- versus LGB community-based samples.

SEARCH METHODS

In 2014, we searched MEDLINE, EMBASE, PsycInfo, CINAHL, and Scopus databases for articles addressing suicide-related behavior (ideation, attempts) among sexual minorities.

SELECTION CRITERIA

We selected quantitative studies of sexual minority adults conducted in nonclinical settings in the United States, Canada, Europe, Australia, and New Zealand.

DATA COLLECTION AND ANALYSIS

Random effects meta-analysis and meta-regression assessed for a difference in prevalence of suicide-related behavior by sample type, adjusted for study or sample-level variables, including context (year, country), methods (medium, response rate), and subgroup characteristics (age, gender, sexual minority construct). We examined residual heterogeneity by using τ(2).

MAIN RESULTS

We pooled 30 cross-sectional studies, including 21,201 sexual minority adults, generating the following lifetime prevalence estimates of suicide attempts: 4% (95% confidence interval [CI] = 3%, 5%) for heterosexual respondents to population surveys, 11% (95% CI = 8%, 15%) for LGB respondents to population surveys, and 20% (95% CI = 18%, 22%) for LGB respondents to community surveys (Figure 1). The difference in LGB estimates by sample type persisted after we accounted for covariates with meta-regression. Sample type explained 33% of the between-study variability.

AUTHOR'S CONCLUSIONS

Regardless of sample type examined, sexual minorities had a higher lifetime prevalence of suicide attempts than heterosexual persons; however, the magnitude of this disparity was contingent upon sample type. Community-based surveys of LGB people suggest that 20% of sexual minority adults have attempted suicide.

PUBLIC HEALTH IMPLICATIONS

Accurate estimates of sexual minority health disparities are necessary for public health monitoring and research. Most data describing these disparities are derived from 2 sample types, which yield different estimates of the lifetime prevalence of suicide attempts. Additional studies should explore the differential effects of selection and information biases on the 2 predominant sampling approaches used to understand sexual minority health.

Sexual identity development: relationship with lifetime suicidal ideation in sexual minority women

AIMS AND OBJECTIVES

This study draws on a life course perspective to evaluate in a sample of sexual minority women: (1) the relationship between age at reaching sexual identity milestones and risk of suicidal ideation, (2) developmental stages or stages of sexual identity development that represent greatest risk and (3) the relationship between age of reaching milestones and parental support.

BACKGROUND

Research shows higher rates of suicidal ideation among sexual minority women than heterosexual women. Evidence suggests this is partly accounted for by risk factors including sexual identity development and parental support. However, it remains unclear whether there are stages of particularly high risk.

DESIGN

This is a cross-sectional study. Data come from a prospective study of sexual minority women that used convenience and respondent-driven sampling methods.

METHODS

Using logistic regression, we examined associations among age at sexual identity developmental milestones, parental support and suicidal ideation in a large (N = 820), ethnically diverse sample of sexual minority women.

RESULTS

Compared with women who first wondered about their sexual identity in adulthood, those who first wondered in early, middle or late adolescence had greater odds of lifetime suicidal ideation. Younger age at subsequent milestones (first decided or first disclosed) was not associated with heightened risk of suicidal ideation. Parental support was independently associated with suicidal ideation.

CONCLUSIONS

Findings suggest that where one is in the process of identifying as a sexual minority may be more important than age in understanding risk of suicidal ideation in this population. As individuals come to accept and integrate their sexual minority identity risks associated with younger age diminish.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other healthcare providers who work with youth should routinely ask about sexual orientation and suicidal ideation and be aware that youth in the earliest stages of coming out as sexual minority may be at particularly high risk of suicide.

Primary care of women who have sex with women. Recommendations from the research

Research on women who have sex with women has increased in the last decade. Attention has been brought to this group of women through the IOM report, which noted a lack of research related to their care. Most of the research has not been published in nursing literature. This article reviews this literature with recommendations for primary care practice.

Non-suicidal self-injury and suicidal thoughts and behaviors in heterosexual and sexual minority young adults

OBJECTIVE

Despite consistently greater rates of non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs; i.e., suicidal ideation, method/plan, and attempts) in lesbian, gay, and bisexual (LGB) individuals, prevalence, characteristics, and relations between these dangerous thoughts and behaviors are equivocal. The present study sought to examine and compare the rates of NSSI and STBs in a large sample of sexual minority and majority young adults.

METHODS

Participants were 12,422 college students (ages 18-29; 57.3% female) who self-reported demographic characteristics, NSSI frequency, the number of NSSI forms used, the number of NSSI functions, as well as STB history (i.e., ideation, method/plan, and attempts). Each participant's degree of SA was assessed via a 7-point scale (i.e., K0-K6) from Alfred Kinsey's research of sexual attraction and sexual experiences. This scale was collapsed to create five categories of SA: exclusively other SA (K0), mostly other SA (K1/2), equally other and same SA (K3), mostly same SA (K4/5), and exclusively same SA (K6).

RESULTS

Consistent with previous research, we found that being a sexual minority young adult was associated with significantly higher odds of STBs compared to being a heterosexual young adult. In addition, compared to the exclusively other SA group (K0), being in the mostly other SA group (K1/2), equally other and same SA group (K3), or mostly same SA group (K4/5) was associated with significantly higher odds of NSSI engagement. Among those with NSSI, we found that the number of NSSI forms was significantly associated with suicide attempts, but was not associated with either suicidal ideation or suicide method/plan in the mostly other SA group (K1/2) or in the equally other and same SA group (K3). We also found a significant curvilinear relation between NSSI frequency and STBs in the mostly other SA group (K1/2) and between NSSI frequency and suicide method/plan and attempt in the exclusively other SA group (K0). In addition, we revealed specificity with regard to the relation between the number of lifetime NSSI episodes and risk for STBs among the equally other and same SA (K3), mostly same SA (K4/5), and exclusively same SA (K6) groups.

CONCLUSION

Our findings suggest that among sexual minority young adults, equally other and same SA individuals may be at higher risk of NSSI and STBs than their sexual minority counterparts. In addition, these findings extend previous research by suggesting that the relations between NSSI frequency, number of forms, and number of functions and STBs might vary according to SA. A multi-theory based explanation is provided to explain the key findings and the study implications are discussed.

Mental Health Disparities Within the LGBT Population: A Comparison Between Transgender and Nontransgender Individuals

Purpose: This study assessed within a Midwestern LGBT population whether, and the extent to which, transgender identity was associated with elevated odds of reported discrimination, depression symptoms, and suicide attempts.

Methods: Based on survey data collected online from respondents who self-identified as lesbian, gay, bisexual, and/or transgender persons over the age of 19 in Nebraska in 2010, this study performed bivariate t- or chi-square tests and multivariate logistic regression analysis to examine differences in reported discrimination, depression symptoms, suicide attempts, and self-acceptance of LGBT identity between 91 transgender and 676 nontransgender respondents.

Results: After controlling for the effects of selected confounders, transgender identity was associated with higher odds of reported discrimination (OR=2.63, p<0.01), depression symptoms (OR=2.33, p<0.05), and attempted suicides (OR=2.59, p<0.01) when compared with nontransgender individuals. Self-acceptance of LGBT identity was associated with substantially lower odds of reporting depression symptoms (OR=0.46, p<0.001).

Conclusion: Relative to nontransgender LGB individuals, transgender individuals were more likely to report discrimination, depression symptoms, and attempted suicides. Lack of self-acceptance of LGBT identity was associated with depression symptoms among transgender individuals.

Coming out in color: racial/ethnic differences in the relationship between level of sexual identity disclosure and depression among lesbians

Disclosing one's sexual minority identity, or "coming out," has varying effects on the mental health of lesbians. Previous research indicates a negative association between disclosure and depression. However, these findings are based on research with White lesbians. To date, there is a paucity of studies that examined how the relationship between disclosure and depression may differ by race/ethnicity among lesbians. To address this gap, we examined the relationship between disclosure and depression among African American (26.5%), Latina (19.7%), and White (53.8%) self-identified lesbians (N = 351) in 2 survey-interviews (∼ 3-years apart). Over 50% of the participants reported a history of lifetime depression at baseline and 35.9% reported depression at Time 2 (T2). Disclosure levels varied: 78.9% had disclosed to their mother, 58.4% to their father, and 83.3% to a sibling. The mean level for disclosure to nonfamily individuals was 6.29 (SD 2.64; range 0-9). Disclosure results varied by race/ethnicity showing African American lesbians (vs. White lesbians) were less likely to disclose to nonfamily individuals when controlling for covariates. Results for the relationship between disclosure and depression showed disclosure to either parent or sibling was not associated with depression for the total sample. Among Latinas only, disclosure to nonfamily individuals was associated with less depression. Additional research is needed to explore racial/ethnic differences in disclosure with certain individuals and to better understand the relation between disclosure and depression. Findings have implications for reducing overall rates of depression among lesbians living with multiple-minority identities.

Sexual orientation identity change and depressive symptoms: a longitudinal analysis

Several new studies have documented high rates of sexual identity mobility among young adults, but little work has investigated the links between identity change and mental health. This study uses the National Longitudinal Study of Adolescent to Adult Health (N = 11,727) and employs multivariate regression and propensity score matching to investigate the impact of identity change on depressive symptoms. The results reveal that only changes in sexual identity toward more same-sex-oriented identities are associated with increases in depressive symptoms. Moreover, the negative impacts of identity change are concentrated among individuals who at baseline identified as heterosexual or had not reported same-sex romantic attraction or relationships. No differences in depressive symptoms by sexual orientation identity were found among respondents who reported stable identities. Future research should continue to investigate the factors that contribute to the relationship between identity change and depression, such as stigma surrounding sexual fluidity.

Gender, age, and place of residence as moderators of the internalized homophobia-depressive symptoms relation among Australian gay men and lesbians

Internalized homophobia is a risk factor for depression among gay men and lesbians. The aim of the study was to test whether the internalized homophobia-depression relation was moderated by gender (stronger among gay men compared with lesbians), age (stronger among younger compared with older gay men and lesbians), and place of residence (stronger among gay men and lesbians who live in rural areas compared with those who live in urban areas). An Australian sample of 311 self-identified gay men and 570 self-identified lesbians, aged 18 to 70 years, completed the Internalized Homophobia Scale and the Centre for Epidemiological Studies Depression Scale. Results indicated that age and gender did not moderate the internalized homophobia-depressive symptoms relation. Place of residence was a significant moderator for gay men but not lesbians. In contrast to the hypothesis, the internalized homophobia-depression relation was significant only among gay men who resided in urban areas. Those who work with gay men should be particularly aware of the significant relationship between internalized homophobia and depressive symptoms among gay men who reside in urban areas.

Stressful childhood experiences and health outcomes in sexual minority populations: a systematic review

PURPOSE

Stressful childhood experiences (SCE) are associated with many different health outcomes, such as psychiatric symptoms, physical illnesses, alcohol and drug abuse, and victimization experiences. Lesbian, gay, bisexual, and transgender (LGBT) people are at risk to be victims of SCE and show higher prevalence of SCE when compared with heterosexual controls.

METHODS

This review analyzed systematically 73 articles that addressed different types of SCE in sexual minority populations and included items of household dysfunction. The samples included adults who identified either their sexual orientation as non-heterosexual or their gender identity as transgender.

RESULTS

The studies reported childhood sexual abuse (CSA), childhood physical abuse (CPA), childhood emotional abuse (CEA), childhood physical neglect, and childhood emotional neglect. Items of household dysfunction were substance abuse of caregiver, parental separation, family history of mental illness, incarceration of caregiver, and witnessing violence. Prevalence of CSA showed a median of 33.5 % for studies using non-probability sampling and 20.7 % for those with probability sampling, the rates for CPA were 23.5 % (non-probability sampling) and 28.7 % (probability sampling). For CEA, the rates were 48.5 %, non-probability sampling, and 47.5 %, probability sampling. Outcomes related to SCE in LGBT populations included psychiatric symptoms, substance abuse, revictimization, dysfunctional behavioral adjustments, and others.

CONCLUSIONS

LGBT populations showed high prevalence of SCE. Outcomes related to SCE ranged from psychiatric symptoms and disorders to physical ailments. Most studies were based in the USA. Future research should aim to target culturally different LGBT population in the rest of the world.

A social ecological approach to understanding correlates of lifetime sexual assault among sexual minority women in Toronto, Canada: results from a cross-sectional internet-based survey

Stigma, discrimination and violence contribute to health disparities among sexual minorities. Lesbian, bisexual and queer (LBQ) women experience sexual violence at similar or higher rates than heterosexual women. Most research with LBQ women, however, has focused on measuring prevalence of sexual violence rather than its association with health outcomes, individual, social and structural factors. We conducted a cross-sectional online survey with LBQ women in Toronto, Canada. Multivariate logistic regression analyses were conducted to assess correlates of lifetime sexual assault (LSA). Almost half (42%) of participants (n = 415) reported experiences of LSA. Participants identifying as queer were more likely to have experienced LSA than those identifying as lesbian. When controlling for socio-demographic characteristics, experiencing LSA was associated with higher rates of depression, sexually transmitted infections (STIs), receiving an STI test, belief that healthcare providers were not comfortable with their LBQ sexual orientation, and sexual stigma (overall, perceived and enacted). A history of sexual violence was associated with lower: self-rated health, overall social support, family social support and self-esteem. This research highlights the salience of a social ecological framework to inform interventions for health promotion among LBQ women and to challenge sexual stigma and sexual violence.

Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: what does the literature tell us?

Research suggests that both the military and veteran and the lesbian, gay, bisexual, and transgender (LGBT) populations may be at increased risk for suicide. A literature review was conducted to identify research related to suicide risk in the LGBT military and veteran populations. Despite the paucity of research directly addressing this issue, themes are discussed evident in the literature on LGBT identity and suicide risk as well as LGBT military service members and veterans. Factors such as social support and victimization appear to be particularly relevant. Suggestions are made with respect to future research that is needed on this very important and timely topic.

Toward Formulating Evidence-Based Principles of LGB-Affirmative Psychotherapy

In this commentary, we review eight potential LGB-affirmative psychotherapy principles for improving minority stress coping among sexual minority clients. We illustrate these principles with examples from both Mandel's (2014) treatment approach and our clinical research team's recent attempt to create and test the efficacy of a treatment employing these principles in an ongoing randomized controlled trial. These principles are grounded in empirical research regarding the mechanisms through which minority stress compromises the mental health of sexual minority individuals and are supported by clinical expert consensus. The specific principles that we review include: 1) normalizing the mental health impact of minority stress, 2) facilitating emotion awareness, regulation, and acceptance, 3) decreasing avoidance, 4) restructuring minority stress cognitions, 5) empowering sexual minority clients to communicate assertively, 6) validating sexual minority individuals' unique strengths, 7) building supportive relationships, and 8) affirming healthy, rewarding expressions of sexuality. We believe that Mandel's skillful approach to helping her hybrid client Adam cope with minority stressors, such as internalized homophobia, and associated mental health problems such as substance abuse and depression, to form a healthy identity as a gay man represents an exemplary demonstration of these principles in action.

The relationships of sexual identity, hazardous drinking, and drinking expectancies with risky sexual behaviors in a community sample of lesbian and bisexual women

This study examined the influence of demographic characteristics, sexual identity, hazardous drinking, and sexuality/intimacy enhancement alcohol expectancies on rates of risky sexual behaviors in a community sample of women who self-identified as lesbian, mostly lesbian, and bisexual (N = 349). Structured interview data were collected as part of a larger longitudinal study of sexual minority women's health, the Chicago Health and Life Experiences of Women study. We used structural equation modeling, controlling for demographic characteristics, to evaluate the influence of sexual identity, hazardous drinking, and alcohol-related sexuality/intimacy enhancement expectancies on sexual risk behaviors. Controlling for demographic characteristics and for sexual identity, higher levels of both hazardous drinking and sexuality/intimacy enhancement alcohol expectancies were associated with higher sexual risk scores. The final model predicted 36% of the variance in risky sexual behavior scores. Our findings regarding the central role of alcohol use and sexuality/intimacy enhancement expectancies in sexual risk behaviors among sexual minority women are consistent with previous research focusing on predominantly heterosexual women. Future efforts at sexual risk reduction in sexual minority women will need to address the influences of alcohol use and drinking-related expectancies on sexual behaviors and decision making.

Sexual identity group differences in child abuse and neglect

Childhood abuse and neglect are pervasive problems among girls and young women that have numerous health consequences. Research suggests that sexual minority women are more likely than heterosexual women to report childhood abuse and neglect, but little is known about which sexual minority women are at greatest risk for these early adverse experiences. Using data from a pooled sample of women in a national probability study and in a large community-based study of sexual minority women designed to replicate the national study's methodology (pooled n = 953), we investigated rates and characteristics of childhood sexual abuse, physical abuse, and neglect among women from five sexual identity groups. As predicted, heterosexual women reported significantly less childhood abuse and neglect than did women who identified as mostly heterosexual, bisexual, mostly lesbian, or lesbian. We found considerable variability across the sexual minority subgroups, including severity of abuse, highlighting the need for research that distinguishes among these groups. To the extent that differences reported by women in the sample reflect the actual prevalence and severity of abuse experiences, sexual identity group differences in childhood abuse have important clinical and public health implications.

Sexual orientation and self-reported mood disorder diagnosis among Canadian adults

BACKGROUND

The prevalence and correlates of mood disorders among people who self-identify as lesbian, gay or bisexual (LGB) are not well understood. Therefore, the current analysis was undertaken to estimate the prevalence and correlates of self-reported mood disorders among a nationally representative sample of Canadian adults (ages 18 to 59 years). Stratified analyses by age and sex were also performed.

METHODS

Using data from the 2007-2008 Canadian Community Health Survey, logistic regression techniques were used to determine whether sexual orientation was associated with self-reported mood disorders.

RESULTS

Among respondents who identified as LGB, 17.1% self-reported having a current mood disorder while 6.9% of heterosexuals reported having a current mood disorder. After adjusting for potential confounders, LGB-respondents remained more likely to report mood disorder as compared to heterosexual respondents (AOR: 2.93; 95% CI: 2.55-3.37). Gay and bisexual males were at elevated odds of reporting mood disorders (3.48; 95% CI: 2.81-4.31), compared to heterosexual males. Young LGB respondents (ages 18-29) had higher odds (3.75; 95% CI: 2.96-4.74), compared to same-age heterosexuals.

CONCLUSIONS

These results demonstrate elevated prevalence of mood disorders among LGB survey respondents compared to heterosexual respondents. Interventions and programming are needed to promote the mental health and well being of people who identify as LGB, especially those who belong to particular subgroups (e.g., men who are gay or bisexual; young people who are LGB).

The interrelations between age, sense of belonging, and depressive symptoms among Australian gay men and lesbians

Researchers have demonstrated that age is related to depression among gay men and lesbians, with younger adults experiencing more depression than older adults. Other researchers have indicated that a sense of belonging is related to lower levels of depression. This study investigated whether sense of belonging to the gay and lesbian community moderates and mediates the relationship between age and depressive symptoms among gay men and lesbians. An Australian sample of self-identified gay men (n = 346) and lesbians (n = 270) completed the Psychological subscale of the Sense of Belonging Instrument and the Center for Epidemiologic Studies Depression Scale. Results indicated that age and sense of belonging were directly and independently related to depressive symptoms for gay men and lesbians. In addition, for lesbians only, sense of belonging moderated the age-depressive symptom relation. For lesbians with low levels of sense belonging to the lesbian community, age was not associated with depressive symptoms. In contrast, for lesbians with high levels of sense of belonging to the lesbian community, the association between sense of belonging and depressive symptoms decreased with increasing age. Encouraging gay men and lesbians (especially younger lesbians) to become involved in the gay and lesbian community is likely to be beneficial for their mental health.

Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric morbidity

OBJECTIVES

Lesbian, gay, and bisexual (LGB) populations exhibit elevated rates of psychiatric disorders compared to heterosexuals, and these disparities emerge early in the life course. We examined the role of exposure to early-life victimization and adversity-including physical and sexual abuse, homelessness, and intimate partner violence-in explaining sexual orientation disparities in mental health among adolescents and young adults.

METHODS

Data were drawn from the National Longitudinal Study of Adolescent Health, Wave 3 (2001-2002), a nationally representative survey of adolescents. Participants included gay/lesbian (n=227), bisexual (n=245), and heterosexual (n=13,490) youths, ages 18-27. We examined differences in the prevalence of exposure to child physical or sexual abuse, homelessness or expulsion from one's home by caregivers, and physical and sexual intimate partner violence according to sexual orientation. Next we examined the associations of these exposures with symptoms of psychopathology including suicidal ideation and attempts, depression, binge drinking, illicit drug use, tobacco use, alcohol abuse, and drug abuse. Finally, we determined whether exposure to victimization and adversity explained the association between sexual orientation and psychopathology.

RESULTS

Gay/lesbian and bisexual respondents had higher levels of psychopathology than heterosexuals across all outcomes. Gay/lesbian respondents had higher odds of exposure to child abuse and housing adversity, and bisexual respondents had higher odds of exposure to child abuse, housing adversity, and intimate partner violence, than heterosexuals. Greater exposure to these adversities explained between 10 and 20% of the relative excess of suicidality, depression, tobacco use, and symptoms of alcohol and drug abuse among LGB youths compared to heterosexuals. Exposure to victimization and adversity experiences in childhood and adolescence significantly mediated the association of both gay/lesbian and bisexual orientation with suicidality, depressive symptoms, tobacco use, and alcohol abuse.

CONCLUSIONS

Exposure to victimization in early-life family and romantic relationships explains, in part, sexual orientation disparities in a wide range of mental health and substance use outcomes, highlighting novel targets for preventive interventions aimed at reducing these disparities.

Measurement of sexual identity in surveys: implications for substance abuse research

Researchers are increasingly recognizing the need to include measures of sexual orientation in health studies. However, relatively little attention has been paid to how sexual identity, the cognitive aspect of sexual orientation, is defined and measured. Our study examined the impact of using two separate sexual identity question formats: a three-category question (response options included heterosexual, bisexual, or lesbian/gay), and a similar question with five response options (only lesbian/gay, mostly lesbian/gay, bisexual, mostly heterosexual, only heterosexual). A large probability-based sample of undergraduate university students was surveyed and a randomly selected subsample of participants was asked both sexual identity questions. Approximately one-third of students who identified as bisexual based on the three-category sexual identity measure chose "mostly heterosexual" or "mostly lesbian/gay" on the five-category measure. In addition to comparing sample proportions of lesbian/gay, bisexual, or heterosexual participants based on the two question formats, rates of alcohol and other drug use were also examined among the participants. Substance use outcomes among the sexual minority subgroups differed based on the sexual identity question format used: bisexual participants showed greater risk of substance use in analyses using the three-category measure whereas "mostly heterosexual" participants were at greater risk when data were analyzed using the five-category measure. Study results have important implications for the study of sexual identity, as well as whether and how to recode responses to questions related to sexual identity.

Alcohol-Related Problems among Sexual Minority Women

In this article I describe the historical context for research on sexual minority women's drinking, including the age-old tendency to link homosexuality and alcoholism; I summarize gaps and limitations that characterized much of the research on sexual minority women's drinking over the past several decades; and I review recent literature to highlight progress in the field-with a particular focus on my own research related to risk and protective factors for heavy drinking and drinking-related problems among sexual minority women. I conclude with a discussion of barriers to treatment for sexual minority women and recommendations for substance abuse treatment providers.

A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals

OBJECTIVES

We compared the likelihood of childhood sexual abuse (under age 18), parental physical abuse, and peer victimization based on sexual orientation.

METHODS

We conducted a meta-analysis of adolescent school-based studies that compared the likelihood of childhood abuse among sexual minorities vs sexual nonminorities.

RESULTS

Sexual minority individuals were on average 3.8, 1.2, 1.7, and 2.4 times more likely to experience sexual abuse, parental physical abuse, or assault at school or to miss school through fear, respectively. Moderation analysis showed that disparities between sexual minority and sexual nonminority individuals were larger for (1) males than females for sexual abuse, (2) females than males for assault at school, and (3) bisexual than gay and lesbian for both parental physical abuse and missing school through fear. Disparities did not change between the 1990s and the 2000s.

CONCLUSIONS

The higher rates of abuse experienced by sexual minority youths may be one of the driving mechanisms underlying higher rates of mental health problems, substance use, risky sexual behavior, and HIV reported by sexual minority adults.

A comparative study of complementary and alternative medicine use among heterosexually and lesbian identified women: data from the ESTHER Project (Pittsburgh, PA, 2003-2006)

OBJECTIVES

The prevalence of complementary and alternative medicine (CAM) use among women in the United States is high. Little is known about how CAM use may differ based on sexual orientation. Study aims were to measure the prevalence of CAM use in a community sample of women, explore differences in CAM use patterns by sexual orientation, and identify correlates of CAM use.

DESIGN/SUBJECTS

Analyses were based on women (Total N = 879; n = 479 lesbians) enrolled in the Epidemiologic STudy of HEalth Risk in Women (ESTHER) Project, a cross-sectional heart-disease risk-factor study.

SETTINGS/LOCATION

Data were collected through convenience sampling of adult females in Pittsburgh, PA (2003-2006).

OUTCOME MEASURES

Main outcome measures included lifetime and past 12-month CAM use, and types of CAM modalities used in the past 12 months.

RESULTS

The prevalence of having ever used CAM was 49.8%, with 42% having reported CAM use within the past 12 months. Lesbians had greater odds of having ever used CAM (adjusted odds ratio [AOR] = 1.68 [95% confidence interval (CI): 1.23, 2.28]) and of having used CAM in the past 12 months (AOR = 1.44 [CI: 1.06, 1.97]) than heterosexuals. In multivariate analyses, correlates of lifetime and past 12-month CAM use included being lesbian, white, higher educated, and a large-city resident; experiencing perceived discrimination in a health care setting; and having a greater spirituality rating and a history of a diagnosed mental health disorder. Past 12-month CAM use was also associated with having a provider of usual health care. Among women who used CAM within the past 12 months, heterosexuals had significantly higher yoga participation rates than lesbians.

CONCLUSIONS

Sexual orientation is important in understanding lifetime and past 12-month CAM use. Because of the high prevalence of CAM use found in this study, medical practitioners should inquire about the CAM practices of female patients, particularly lesbians.

The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: a systematic review

This article systematically reviews 75 studies that examine the prevalence of sexual assault victimization among gay or bisexual (GB) men, and lesbian or bisexual (LB) women, in the United States. All studies were published between 1989 and 2009 and report the results of quantitative research. The authors reviewed the reported prevalence of lifetime sexual assault victimization (LSA), and where available, childhood sexual assault (CSA), adult sexual assault (ASA), intimate partner sexual assault (IPSA), and hate crime-related sexual assault (HC). The studies were grouped into those that used a probability or census sampling technique (n=25) and those that used a non-probability or ''community-based'' sampling technique (n=50). A total of 139,635 gay, lesbian, and bisexual (GLB) respondents participated in the underlying studies reviewed. Prevalence estimates of LSA ranged from 15.6-85.0% for LB women and 11.8-54.0% for GB men. Considering the median estimates derived from the collective set of studies reviewed, LB women were more likely to report CSA, ASA, LSA, and IPSA than GB men, whereas GB men were more likely to report HC than LB women. Across all studies, the highest estimates reported were for LSA of LB women (85.0%), CSA of LB women (76.0%), and CSA of GB men (59.2%). With some exceptions, studies using non-probability samples reported higher sexual assault prevalence rates than did population-based or census sample studies. The challenges of assessing sexual assault victimization with GLB populations are discussed, as well as the implications for practice, policy, and future research.

Examining sexual health differences between lesbian, gay, bisexual, and heterosexual adults: the role of sociodemographics, sexual behavior characteristics, and minority stress

Many studies focus on the differences in mental health between lesbian, gay, bisexual (LGB), and heterosexual individuals. Less attention has been paid to the differences in various aspects of sexual health and the potential explanations for these differences. Data from a Dutch population study on sexual health (aged 19-70 years; N = 4,333) were used to examine the potential differences in sexual satisfaction, sexual victimization, sexual dysfunction, and sexual health care need. At the same time, this study examined whether the differences could be attributed to differences in general factors influencing sexual health (sociodemographic variables and sexual behavior characteristics) or to LGB-specific factors (minority stress). The results showed that bisexual women and bi- and homosexual men had more often experienced sexual coercion and reported a higher need for sexual health care than their heterosexual counterparts. Both general determinants (e.g., a higher number of sexual partners or being single) and LGB-specific factors (e.g., internalized homonegativity or negative social reactions related to sexual orientation) were associated with different aspects of sexual health. Interventions aimed at improving the sexual health of LGB individuals should focus on general risk factors, as well as on LGB-specific stressors. Methodological limitations of the study and implications for further research are discussed.

The mediating effect of childhood abuse in sexual orientation disparities in tobacco and alcohol use during adolescence: results from the Nurses' Health Study II

OBJECTIVE

To examine the mediating effect of childhood abuse on sexual orientation disparities in tobacco and alcohol use during adolescence.

METHODS

We carried out analyses with data from over 62,000 women in the ongoing Nurses' Health Study II cohort who provided information on sexual orientation, childhood abuse occurring by age 11, and tobacco and alcohol use in adolescence. We used multivariate regression analyses, controlling for confounders, to estimate the mediating effect of childhood abuse on the association between sexual orientation and tobacco and alcohol use in adolescence.

RESULTS

Lesbian and bisexual orientation and childhood abuse were positively associated with greater risk of tobacco and alcohol use during adolescence. For lesbians, the estimated proportion of excess tobacco and alcohol use in adolescence relative to use among heterosexual women that was mediated by abuse in childhood ranged from 7 to 18%; for bisexual women, the estimated proportion of excess use mediated by abuse ranged from 6 to 13%.

CONCLUSIONS

Elevated childhood abuse in lesbian and bisexual women partially mediated excess tobacco and alcohol use in adolescence relative to heterosexual women. Interventions to prevent child abuse may reduce sexual orientation disparities in some of the leading causes of cancer in women.

The health and health care of lesbian, gay, and bisexual adolescents

Adolescents face a variety of challenges in their transition to adulthood; lesbian, gay, and bisexual adolescents face these typical challenges as well as additional challenges that are related to the social stigma of their sexual orientation. For some lesbian, gay, and bisexual adolescents, this stigma may induce psychosocial stress, leading to increased health risk behaviors and poorer health outcomes. In this article, we review data on the health and health care of LGB adolescents. We examine health indicators and health risks for LGB youth, including substance use, eating disorders, suicidality, risky sexual behaviors, violence exposure and victimization, and homelessness. We also examine health care provision and utilization for LGB youth. Lastly, we discuss ways in which researchers and clinicians can improve LGB adolescent health and health care.