Are HIV Prevention Services Reaching all LGBTQ+ Youth? An Intersectional Analysis in a National Sample

Although research has examined disparities in HIV prevention behaviors, intersectional research is needed to understand who may be underserved. This study examines disparities in consistent condom use, HIV testing, and PrEP awareness and use across assigned sex, gender identity, sexual orientation, and racial/ethnic identity in a large sample of sexually active LGBTQ+ youth (mean age = 16.5) who completed the 2022 LGBTQ National Teen Survey. Four social identities were included as indicators in Chi-Square Automated Interaction Detection models to uncover disparate rates of HIV preventive behaviors. Generally, HIV testing and PrEP services were higher among gay/lesbian and queer youth assigned male, and lower among those assigned female. Certain LGBTQ+ youth may be systematically missed by these services, (e.g., those assigned female; those assigned male who also identify as bisexual, pansexual, asexual, questioning, or straight (and trans/gender diverse)). Providers should strive to serve populations who are not being reached by HIV prevention services.

Differences in the Prevalence of Adolescent Sexual Identity: Results of Expanding Survey Response Options

PURPOSE

To describe the prevalence of sexual identity by grade, racial and ethnic identities, and sex assigned at birth.

METHODS

Data came from the statewide 2022 Minnesota Student Survey of eighth, ninth, and 11th grade students (N = 99,688). Chi-square tests compared the prevalence of sexual identity across grades, racial/ethnic groups, and sex assigned at birth.

RESULTS

Over a fifth (22.2%) of students self-reported a minoritized sexual identity. Bisexual and pansexual were most common among Native+ (12.3%, 5.7%, respectively), multiracial (11.6%, 4.4%, respectively), and Latina/x/o (10.4%, 4.1%, respectively) youth. Asexuality was consistently reported across grades, and eighth graders reported gay/lesbian, bisexual, and queer identities less than 11th graders. Youth assigned female at birth were more likely to report gay/lesbian, bisexual, asexual, pansexual, queer, and questioning than youth assigned male at birth.

DISCUSSION

Results support the continued use of further expanded sexual identities in epidemiologic surveys.

Interpersonal protective factors for LGBTQ+ youth at multiple intersecting social identities and positions

Interpersonal supports are protective against multiple negative health outcomes for youth such as emotional distress and substance use. However, finding interpersonal support may be difficult for youth exposed to intersecting racism, heterosexism, and cisgenderism, who may feel they are "outsiders within" their multiple communities. This study explores disparities in interpersonal supports for youth at different sociodemographic intersections. The 2019 Minnesota Student Survey includes data from 80,456 high school students, including measures of four interpersonal supports: feeling cared about by parents, other adult relatives, friends, and community adults. Exhaustive Chi-square Automatic Interaction Detection analysis was used to examine all interactions among four social identities/positions (racialized/ethnic identity, sexual identity, gender identity, sex assigned at birth) to identify groups who report different rates of caring from each source (Bonferroni adjusted p<.05). In the overall sample, 69.24% perceived the highest level of caring ("very much") from parents, 50.09% from other adult relatives, 39.94% from friends, and 15.03% from community adults. Models identified considerable differences in each source of support. For example, more than 72% of straight, cisgender youth reported their parents cared about them very much, but youth who identified as LGBQ and TGD or gender-questioning were much less likely to report high parent caring (less than 36%) across multiple racialized/ethnic identities and regardless of sex assigned at birth. Findings highlight the importance of better understanding the ways interpersonal support might differ across groups, and underscore a need for intersectionality-tailored interventions to develop protective interpersonal supports for LGBTQ+ youth, rather than one-size-fits-all approaches.

Unaccompanied unstable housing among racially, ethnically, sexually, and gender diverse youth: Intersecting identities bearing the greatest burden

Disparities in youth homelessness by racial/ethnic, sexual, and gender identities are well documented, though this literature lacks specificity regarding intersectional social identities of youth who are most likely to experience homelessness. Population-based cross-sectional data on youth from the 2019 Minnesota Student Survey (N = 80,456) were used to examine the relationship between parent caring and intersections of minoritized identities that experience the highest prevalence of two distinct types of unaccompanied unstable housing with expanded categories of sexual and gender identities. Exhaustive chi-square automatic interaction detection models revealed that low parent caring was the most common predictor of unaccompanied homelessness and running away, but there was important variation among youth of color at the intersection of sexual and gender identities. The findings reveal a more complex story of disparities in unaccompanied unstable housing among youth with multiple marginalized social identities and highlight the need to create culturally informed prevention and intervention strategies for parents of LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and questioning) youth of color. The implications for prevention and intervention among subgroups with the highest prevalence are discussed in the context of interlocking systems of power and oppression. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Emotional Distress Disparities Across Multiple Intersecting Social Positions: The Role of Bias-Based Bullying

OBJECTIVES

To apply an intersectional lens to disparities in emotional distress among youth, including multiple social positions and experiences with bias-based bullying.

METHODS

Data are from the 2019 Minnesota Student Survey (n = 80 456). Social positions (race and ethnicity, sexual orientation, gender) and 2 forms of bias-based bullying (racist, homophobic or transphobic) were entered into decision tree models for depression, anxiety, self-injury, suicidal ideation, and suicide attempts. Groups with the highest prevalence are described. Rates of emotional distress among youth with matching social positions but no bias-based bullying are described for comparison.

RESULTS

LGBQ identities (90%) and transgender, gender diverse, and questioning identities (54%) were common among the highest-prevalence groups for emotional distress, often concurrently; racial and ethnic identities rarely emerged. Bias-based bullying characterized 82% of the highest-prevalence groups. In comparable groups without bias-based bullying, emotional distress rates were 20% to 60% lower (average 38.8%).

CONCLUSIONS

Findings highlight bias-based bullying as an important point for the intervention and mitigation of mental health disparities, particularly among lesbian, gay, bisexual, transgender, gender-diverse, queer, and questioning adolescents. Results point to the importance of addressing bias-based bullying in schools and supporting lesbian, gay, bisexual, transgender, gender-diverse, queer, and questioning students at the systemic level as a way of preventing emotional distress.

Views about vaccines and how views changed during the COVID-19 pandemic among a national sample of young gay, bisexual, and other men who have sex with men

We examined perceptions of vaccines and changes during the coronavirus disease 2019 (COVID-19) pandemic. From 2019 to 2021, a national sample of young gay, bisexual, and other men who have sex with men completed an open-ended survey item about vaccine perceptions. Analyses identified themes and polarity (negative, neutral, or positive) within responses and determined temporal changes across phases of the pandemic ("pre-pandemic," "pandemic," "initial vaccine availability," or "widespread vaccine availability"). Themes included health benefits of vaccines (53.9%), fear of shots (23.7%), COVID-19 (10.3%), vaccines being safe (5.6%), and vaccine hesitancy/misinformation (5.5%). Temporal changes existed for multiple themes (p < .05). Overall, 53.0% of responses were positive, 31.2% were negative, and 15.8% were neutral. Compared to the pre-pandemic phase, polarity was less positive for the widespread vaccine availability phase (odds ratio = 0.64, 95% confidence interval: 0.42-0.96). The findings provide insight into how vaccine perceptions change in concert with a public health emergency.

Exploring Bias-Based Bullying and Intersecting Social Positions as Correlates of Sexual Risk Behaviors Among Adolescents

Purpose: The current study extends the limited body of intersectional research on adolescents' sexual health by examining experiences of bias-based bullying and multiple intersecting social positions associated with engagement in sexual risk behaviors. Methods: Participants were 14,968 sexually active 9th and 11th grade students surveyed as part of the 2019 Minnesota Student Survey (15% lesbian/gay/bisexual/queer/pansexual/questioning [LGBQ] and/or transgender/gender diverse [TGD] or gender questioning). Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify experiences (i.e., bias-based bullying victimization) and intersecting social positions (i.e., sexual orientation identity; gender identity/modality; race/ethnicity; physical disabilities/chronic illness; mental health/behavioral/emotional problems) associated with the highest prevalence of three sexual risk behaviors. Results: Overall, 18% of adolescents reported 3+ sex partners in the last year, 14% reported drug/alcohol use before last sex, and 36% reported not discussing protection from sexually transmitted infections with new sexual partners. Adolescents with 2+ marginalized social positions, some of whom also experienced bias-based bullying, were part of 53% of the highest prevalence risk groups. For example, 42% of Multiracial or Latina/x/o gender questioning adolescents who identified as LGBQ reported 3+ sex partners in the last year-twice the sample average. Adolescents who were Black, American Indian/Alaska Native, Latina/x/o, Multiracial, TGD, or gender questioning were in the highest prevalence nodes across all outcomes. Conclusion: Adolescents with multiple marginalized social positions and who experience bias-based bullying engage in high-risk sexual behaviors at higher-than-average rates. Findings underscore the importance of addressing intersecting experiences of stigma to reduce high-risk sex behaviors and promote health equity among adolescents.

Bullying Involvement at the Intersection of Gender Identity/Modality, Sexual Identity, Race, Ethnicity, and Disability: Prevalence Disparities and the Role of School-Related Developmental Assets

Purpose: This study examines adolescents' self-reported school-based developmental assets and four intersecting social positions as they relate to prevalence of bullying involvement. Methods: Participants were 80,456 ninth and 11th grade students who participated in the 2019 Minnesota Student Survey (30.2% youth of color; 11% lesbian/gay/bisexual/pansexual/queer/questioning; 2.9% transgender/gender diverse [TGD] or gender questioning). Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify school-based developmental assets (i.e., school safety, school adult support) and intersecting social positions (i.e., sexual identity; gender identity/modality; racial/ethnic identity; physical disabilities/chronic illness; and/or mental health/behavioral/emotional problems) associated with the highest prevalence of involvement as physical and relational bullies, victims, and bully-victims. Results: Adolescents with 2+ marginalized social positions who often lacked school-based developmental assets were part of nearly all the highest prevalence bullying involvement groups. TGD and gender questioning adolescents, Native American youth, and youth living with both physical disabilities/chronic illness and mental health/emotional/behavioral problems-most of whom had additional marginalized social positions and lacked school-based assets-were particularly overrepresented in high prevalence groups. For example, 31.1% of TGD or gender questioning youth of color living with both types of disabilities/health problems who did not feel strongly that school was safe reported involvement as physical bully-victims-nearly six times the sample average rate. Conclusion: Adolescents with multiple marginalized social positions and those lacking certain school-based assets-often overlapping categories-were involved in bullying at higher-than-average rates. Findings underscore the need for schools to address intersecting experiences of stigma and structural oppression that may perpetuate bullying involvement disparities.

Application of an intersectional lens to bias-based bullying among LGBTQ+ youth of color in the United States

Bias-based bullying influences health, academic success, and social wellbeing. However, little quantitative work takes an intersectional perspective to understand bias-based bullying among youth with marginalized social positions, which is critical to prevention. This paper describes the application of exhaustive chi-square automatic interaction detection (CHAID) to understand how prevalence of race-, gender-, and sexual orientation-based bullying varies for youth with different intersecting social positions. We used two datasets - the 2019 Minnesota Student Survey (MSS; N=80,456) and the 2017-2019 California Healthy Kids Survey (CHKS; N=512,067). Students self-reported sex assigned at birth, sexual orientation, gender identity, race/ethnicity, and presence of any race-, gender-, and sexual orientation-based bullying (MSS: past 30 days, CHKS: past 12 months). Exhaustive CHAID with a Bonferroni correction, a recommended approach for large, quantitative intersectionality research, was used for analyses. Exhaustive CHAID analyses identified a number of nodes of intersecting social positions with particularly high prevalences of bias-based bullying. Across both datasets, with varying timeframes and question wording, and all three forms of bias-based bullying, youth who identified as transgender, gender diverse, or were questioning their gender and also held other marginalized social positions were frequent targets of all forms of bias-based bullying. More work is needed to understand how systems of oppression work together to influence school-based bullying experiences. Effective prevention programs to improve the health of youth with marginalized social positions must acknowledge the complex and overlapping ways bias and stigma interact.

Bias-Based Bullying and Elevated Depressive Symptoms Among Sexual and Gender-Diverse Asian American, Native Hawaiian, and Pacific Islander Adolescents

This cross-sectional study analyzes data from 2 statewide school surveys to document the experiences of sexual and gender minoritized Asian American, Native Hawaiian, and Pacific Islander students in grades 9 through 12 who reported bullying related to their identity.

How is Time Alone Introduced? Experiences and Preferences of Adolescents and Parents

PURPOSE

Time alone between health care providers and adolescent patients is a core element of quality adolescent primary care, yet not all adolescents receive this care. Clinicians' apprehension about how best to introduce time alone may contribute to lower levels of time alone. This study aims to understand how adolescent patients and their parents or guardians experience the introduction of time alone during adolescent preventive visits.

METHOD

We conducted semistructured interviews with adolescents, aged 11-17 years (n = 35) and a parent or guardian of the adolescent (n = 35) across metropolitan and nonmetropolitan areas of Minnesota. We used thematic analysis to describe (1) parent and adolescent experiences learning about time alone for the first time and (2) parent and adolescent reactions to this experience.

RESULTS

Key findings from this study suggest that adolescents prefer a universal application of time alone with an option to opt out (e.g., "At this age, I always ask parents to step out for a few minutes, are you okay with that?"), rather than opt in (e.g., "Would you like your parent to step out?"). Parents noted that time alone should not be a surprise but rather should be presented as routine, so they are not left to wonder if time alone was offered to their adolescent for a particular reason.

DISCUSSION

Findings suggest universal presentation of time alone with the option for adolescents to opt out may improve acceptability of time alone and support delivery of highquality care.

Efficacy of the Outsmart HPV Intervention: A Randomized Controlled Trial to Increase HPV Vaccination among Young Gay, Bisexual, and Other Men Who Have Sex with Men

BACKGROUND

Routine human papillomavirus (HPV) vaccination is recommended for young adults, yet many young gay, bisexual, and other men who have sex with men (YGBMSM) remain unvaccinated. We report the efficacy of Outsmart HPV, a web-based HPV vaccination intervention for YGBMSM.

METHODS

From 2019 to 2021, we recruited YGBMSM in the United States who were ages 18-25 and unvaccinated against HPV (n = 1,227). Participants were randomized to receive either: (i) Outsmart HPV content online and monthly interactive text reminders (interactive group); (ii) Outsmart HPV content online and monthly unidirectional text reminders (unidirectional group); or (iii) standard information online about HPV vaccine (control group). Regression models compared study groups on HPV vaccination outcomes.

RESULTS

Overall, 33% of participants reported initiating the HPV vaccine series and 7% reported series completion. Initiation was more common among participants in the interactive group compared with the control group [odds ratio (OR) = 1.47, 98.3% confidence interval (CI): 1.03-2.11]. Completion was more common among participants in both the interactive group (OR = 3.70, 98.3% CI: 1.75-7.83) and unidirectional group (OR = 2.26, 98.3% CI: 1.02-5.00) compared with the control group. Participants who received Outsmart HPV content reported higher levels of satisfaction with online content compared with the control group.

CONCLUSIONS

Outsmart HPV is an efficacious and acceptable HPV vaccination intervention for YGBMSM. Future efforts are needed to determine how to optimize the intervention and disseminate it to settings that provide services to YGBMSM.

IMPACT

Outsmart HPV is a promising tool for increasing HPV vaccination among YGBMSM with the potential for wide dissemination.

Adolescent substance use at the intersections of foster care, sexual orientation and gender identity, racial/ethnic identity, and sex assigned at birth

BACKGROUND

Lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth are overrepresented in foster care and report greater substance use during adolescence.

OBJECTIVE

Using an intersectional lens, the current study investigates differences in foster care placement and variation in substance use at the intersections of foster care and sexual orientation, gender identity, racial/ethnic identities, and sex assigned at birth.

PARTICIPANTS AND SETTINGS

A sample of 121,910 LGBTQ youth (grades 6-12) completed either the Minnesota Student Survey in 2019, the California Healthy Kids Survey from 2017 to 2019, or the 2017 LGBTQ National Teen Study.

METHODS

Youth reported their substance use in the past 30 days (alcohol, binge drinking, cigarette, marijuana), social positions (sexual orientation, gender identity, racial/ethnic identities, sex assigned at birth), living arrangement (foster care or not), and grade in school. Logistic regression was used to examine the main and interaction effects of foster care and social positions on youth substance use.

RESULTS

Results indicated significant differences in substance use at the intersection of foster care placement and youth social positions. Significant two-way interactions for foster care placement and social positions emerged predicting alcohol, binge drinking, and marijuana use.

CONCLUSIONS

Findings show that LGBTQ youth in foster care are at higher risk for substance use than those not in foster care. Particular support is needed for lesbian, gay, and questioning youth, transgender youth, LGBTQ youth assigned male at birth, and Asian or Pacific Islander LGBTQ youth in foster care.

"What does it matter?" Young sexual minority men discuss their conversations with sexual partners about HPV vaccination

Objective: Human papillomavirus vaccination coverage is suboptimal, especially among males. Social networks influence young adults' health behaviors and could be leveraged to promote vaccination. We sought to describe how young sexual minority men communicate about human papillomavirus (HPV) vaccination with their sexual partners. Participants: National (U.S.) sample of sexual minority men ages 18-26 (n = 42) from January 2019. Methods: We conducted four online focus groups and identified salient themes using inductive content analysis. Results: Across groups, participants described that HPV vaccination is not a focus of their conversations with sexual partners. Other key themes related to HPV vaccine communication included: varying discissions based on relationship type, and valuing conversations with partners about safer sex. Conclusions: Findings provide novel insight into how young sexual minority men communicate with their sexual partners about HPV vaccination and identify potential areas for interventions to promote communication. Future research is needed to investigate associations between partner communication and HPV vaccine uptake.

Sport and Physical Activity Among Transgender, Gender Diverse, and Questioning Adolescents

PURPOSE

We compared rates of sport and physical activity (PA) of transgender and gender diverse adolescents and adolescents questioning their gender (TGDQ) with those of cisgender adolescents. Additionally, we tested for differences in sport and PA among TGDQ youth.

METHODS

We used 2019 Minnesota Student Survey data (N = 125,375). We calculated descriptive statistics, then used chi-squares and one-way analyses of variance to test for differences in involvement in sports, PA lessons, and PA between TGDQ and cisgender adolescents. Then, we used the same tests to compare participation among all TGDQ adolescents, considering their gender identity and sex assigned at birth.

RESULTS

Overall, TGDQ adolescents participated in sport and PA less than cisgender adolescents; TGD youth participated less than questioning youth. Within sex assigned at birth, participation varied by gender identity.

DISCUSSION

TGDQ adolescents need support to participate in sport and PA. Adults should remain cognizant that sport restrictions could impair TGDQ adolescents' health.

Opportunities to Improve Adolescent Sexual and Reproductive Health Services in Primary Care Clinics

Primary care providers are well positioned to address the sexual and reproductive health (SRH) needs of adolescents; however, gaps often exist in the delivery of quality SRH services in primary care. Our objective was to identify specific opportunities to improve the delivery of adolescent SRH services in primary care. We conducted in-depth interviews with 25 primary care providers from various disciplines across rural and urban areas of Minnesota and conducted thematic analysis of transcribed data. Participants identified salient opportunities in three areas: (1) training and resources for providers (e.g., related to minor consent laws or addressing sensitive subjects), (2) practices and procedures (e.g., time-alone procedures and policies for confidential screening and sharing test results), and (3) education for adolescents (e.g., knowing their rights and accessing confidential SRH services). Study findings provide actionable opportunities to improve delivery of adolescent SRH services in primary care.

Effects of a web-based HPV vaccination intervention on cognitive outcomes among young gay, bisexual, and other men who have sex with men

Knowledge, attitudes, and beliefs are important antecedents to HPV vaccination, yet remain suboptimal among young gay, bisexual, and other men who have sex with men (YGBMSM). We report the effects of a theoretically-informed, web-based HPV vaccination intervention on these cognitive outcomes. From 2019-2021, we recruited a national sample of YGBMSM ages 18-25 in the United States who were unvaccinated against HPV (n = 1,227). Participants received either standard HPV vaccination information online (control) or population-targeted, individually-tailored content online (Outsmart HPV intervention). Mixed effects models determined if pre-post changes in cognitive outcomes differed between study groups. For five of seven knowledge items about HPV, there were larger pre-post increases among the intervention group than the control group in the percentage of participants who provided correct responses (all statistically significant at p = .05 after Holm's correction). There were also larger pre-post improvements among the intervention group than the control group for most attitudes and beliefs examined, including response efficacy of HPV vaccine (pre-post increases in means: 0.57 vs. 0.38); self-efficacy for the HPV vaccination process (pre-post increases in means: 0.23 vs. 0.10); and intention to get HPV vaccine (pre-post increases in means: 0.70 vs. 0.28) (all statistically significant at p = .05 after Holm's correction). Outsmart HPV is a promising tool for improving key cognitive antecedents to HPV vaccination among YGBMSM, supporting the use of theoretically-informed interventions to affect such outcomes. If efficacious in increasing HPV vaccine uptake in future analyses, this intervention could be utilized in clinical and other healthcare settings that provide services to YGBMSM.

Substance Use Behaviors Among LGBTQ+ Youth of Color: Identification of the Populations Bearing the Greatest Burden in Three Large Samples

PURPOSE

Research has identified persistent disparities in alcohol, e-cigarette, and marijuana use, by sexual orientation, gender identity, and race/ethnicity. Using an intersectionality framework, the present study analyzes three large datasets to identify intersecting social positions bearing the highest burden of substance use.

METHODS

Data from adolescents in grades 9-12 in three samples (2019 Minnesota Student Survey, 2017-2019 California Healthy Kids Survey, and 2017 National Teen Survey) were harmonized for an analysis (N = 602,470). A Chi-squared Automatic Interaction Detection analysis compared the prevalence of four types of substance use across all combinations of four social positions (six racial/ethnic identities, five sexual orientations, three gender identities, and two sexes assigned at birth). For each substance, 10 intersectional groups with the highest prevalence of use were examined.

RESULTS

In the full sample, 12%-14% of participants reported past 30-day alcohol, e-cigarette, or marijuana use and 7% reported past 30-day binge drinking. Several intersecting marginalized social positions were consistently found to bear a high burden of substance use. For example, transgender and gender diverse (TGD) Latina/x/o young people, particularly those assigned male at birth, were in the high prevalence groups for alcohol use, binge drinking, and marijuana use. Black TGD or gender-questioning youth were commonly in the high prevalence groups.

DISCUSSION

Findings suggest that support, resources, and structural changes specifically tailored to youth with multiple marginalized identities (especially TGD) may be needed. The results argue for intersectional efforts that explicitly address racial/ethnic and cultural differences, while also integrating awareness and understanding of sexual and gender diversity.

School-Based Diversity Education Activities and Bias-Based Bullying Among Secondary School Students

Bias-based bullying (e.g., bullying related to race, weight, sexual orientation) is a common experience among youth, yet few school-based prevention programs explicitly address this type of bullying. This study explores whether schools that offer diversity education activities have lower rates of bias-based bullying among students compared to schools that do not offer these activities. Data came from two sources: the 2018 CDC School Profiles Survey (N = 216 schools) and the 2019 Minnesota Student Survey (N = 64,510 students). Multilevel logistic regression tested associations between diversity education activities (diversity clubs, lessons, or special events) and eight types of bias-based bullying among students, with attention to effect modification by relevant demographic characteristics. Students attending schools that offer a wider variety of diversity education opportunities had significantly lower odds of bullying about race, ethnicity, or national origin among boys of color (OR = 0.89, CI: 0.80, 1.00), about sexual orientation for gay, bisexual, and questioning boys (OR = 0.81, CI: 0.67, 0.97), and about disability for boys with a physical health problem (OR = 0.86, CI: 0.76, 0.99). Attending a school with more types of diversity education activities may protect vulnerable students against specific types of bias-based bullying and advance health equity. A diversity education is recommended as a key component of antibullying efforts and policy.

Has the COVID-19 pandemic affected general vaccination hesitancy? Findings from a national study

Extensive media coverage and potential controversy about COVID-19 vaccination during the pandemic may have affected people’s general attitudes towards vaccination. We sought to describe key psychological antecedents related to vaccination and assess how these vary temporally in relationship to the pandemic and availability of COVID-19 vaccination. As part of an ongoing online study, we recruited a national (U.S.) sample of young gay, bisexual and other men who have sex with men (N = 1,227) between October 2019 and June 2021, and assessed the “4Cs” (antecedents of vaccination; range = 1–5). Overall, men had high levels of confidence (trust in vaccines; M = 4.13), calculation (deliberation; M = 3.97) and collective responsibility (protecting others; M = 4.05) and low levels of complacency (not perceiving disease risk; M = 1.72). In multivariable analyses, confidence and collective responsibility varied relative to the pandemic phase/vaccine availability, reflecting greater hesitancy during later stages of the pandemic. Antecedents also varied by demographic characteristics. Findings suggest negative effects of the COVID-19 pandemic on key antecedents of general vaccination and identify potential targets for interventions.

Diverse Sexual and Gender Identity, Bullying, and Depression Among Adolescents

Surveillance data indicate youth have many sexual and gender identities that should be included in clinical forms and surveys to document and improve health equity.

Mental Health and Protective Factors for Transgender and Gender-Diverse Youths Who Trade Sex: A Minnesota Statewide School-Based Study, 2019

Objectives. To describe the prevalence of sex trading by gender and by associations with mental health concerns and protective factors. Methods. We used data from 9th and 11th graders who completed the 2019 Minnesota Student Survey. The analytic sample (n = 67 806) included transgender and gender-diverse (TGD) youths and cisgender youths who reported trading sex. Data on 7 mental health measures and 4 school-related and health care-related protective factors were collected. Results. The prevalence of sex trading (5.9%) was 5 times higher among TGD students than cisgender students (1.2%). In addition, the prevalence of all mental health concerns was high among TGD students who traded sex (e.g., 75.9% reported a lifetime suicide attempt, as compared with 45.9% of cisgender students who traded sex). Fewer statistical differences were found across protective factors. When TGD students who traded sex were compared according to sex assigned at birth, no statistically significant differences were found. Conclusions. Our findings support strong calls for increased competence regarding gender and sex trading or exploitation in clinical and school-based settings to decrease health disparities among TGD youths. Public Health Implications. In this study, we have presented unique prevalence estimates of mental health disparities among TGD students in the United States who trade sex. Our results indicate that TGD students who trade sex are at risk for mental health symptoms and that sensitivity to both gender and sex trading or exploitation will be critical to meeting the needs of this group in clinical as well as school-based settings.

First- and Second-Hand Experiences of Enacted Stigma Among LGBTQ Youth

Research on enacted stigma, or stigma- and bias-based victimization, including bullying and harassment, among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth often focuses on one context (e.g., school) or one form (e.g., bullying or microaggressions), which limits our understanding of these experiences. We conducted qualitative go-along interviews with 66 LGBTQ adolescents (14-19 years) in urban, suburban, town, and rural locations in the United States and Canada identified through purposive and snowball sampling. Forty-six participants (70%) described at least one instance of enacted stigma. Three primary themes emerged: (1) enacted stigma occurred in many contexts; (2) enacted stigma restricted movement; and (3) second-hand accounts of enacted stigma shaped perceptions of safety. Efforts to improve well-being among LGBTQ youth must address the diverse forms and contexts of enacted stigma that youth experience, which limit freedom of movement and potential access to opportunities that encourage positive youth development. School nurses can play a critical role in reducing enacted stigma in schools and in collaboration with community partners.

Health and adverse childhood experiences among homeless youth

BACKGROUND

Homelessness is associated with health problems and with adverse childhood experiences (ACEs). The risk of chronic health conditions for homeless compared to housed youth, and how this risk interacts with ACEs remains unclear. This study investigated the relationship between ACEs, housing, and child health, and whether: 1) ACEs and health vary by housing context; 2) ACEs and homelessness confer independent health risks; and 3) ACEs interact with housing with regard to adolescent health.

METHODS

Using data from 119,254 8th-11th graders, we tested independent and joint effects of ACEs and past-year housing status (housed, family homelessness, unaccompanied homelessness) on overall health and chronic health conditions, controlling for sociodemographic covariates.

RESULTS

The prevalence of ACEs varied by housing status, with 34.1% of housed youth experiencing ≥1 ACE vs. 56.3% of family-homeless and 85.5% of unaccompanied-homeless youth. Health status varied similarly. Homelessness and ACEs were independently associated with low overall health and chronic health conditions, after adjusting for covariates. Compared to housed youth, both family-homeless youth and unaccompanied-homeless youth had increased odds of low overall health and chronic physical and/or mental health conditions. All ACE x housing-status interactions were significant (all p < 0.001), such that ACE-related health risks were moderated by housing status.

CONCLUSIONS

ACEs and housing status independently predict health status during adolescence beyond other sociodemographic risks. Experiencing homelessness, whether unaccomapnied or with family, is associated with increased health risk, and every additional ACE increases this risk. Clinicians and health systems should advocate for policies that include stable housing as a protective factor.

Associations between LGBTQ+-supportive school and community resources and suicide attempts among adolescents in Massachusetts

Supportive school and community resources are associated with reduced risk of suicidality among lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ +) adolescents as well as their cisgender, heterosexual peers. This study examined whether adolescents attending schools and living in communities with more versus fewer LGBTQ +-supportive resources were at lower risk of a past-year suicide attempt. Data on sexual orientation and past-year suicide attempt were obtained from student surveys administered in 30 Massachusetts public high schools between 2014 and 2017 (N = 20,790). Data on school resources were obtained from a questionnaire administered to school officials, and community resources were assessed through internet searching. Modified Poisson generalized estimating equations tested associations between school and community LGBTQ +-supports and suicide attempt separately by sex/gender, adjusting for student, school, and community covariates. Several school resources and the availability of community-wide LGBTQ +-supportive resources were associated with lower risk of a suicide attempt among several subgroups of students, even after controlling for the presence of multiple school and community resources and covariates. For example, the risk of a suicide attempt among gay, bisexual and questioning boys in schools with a gender-neutral restroom was approximately half compared to gay, bisexual and questioning boys in schools without this resource. Past year suicide attempts were also significantly lower among questioning, RR = 0.56, CI [0.37-0.86], and heterosexual, RR = 0.59, CI [0.50-0.68], girls living in communities with more supportive resources compared to those in communities with fewer resources. LGBTQ +-supportive resources in schools and communities may be beneficial for all adolescents regardless of sexual orientation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

"It's kind of hard to go to the doctor's office if you're hated there." A call for gender-affirming care from transgender and gender diverse adolescents in the United States

Research has identified discrimination and a lack of knowledgeable providers as major barriers for transgender and gender diverse (TGD) individuals seeking care, which contributes to greater stress and significant health disparities affecting this population. However, research involving TGD youth is limited. The aim of this study, therefore, was to describe TGD adolescents' experiences, concerns and needs in healthcare settings, including their feedback on themes previously identified by healthcare providers (i.e. discomfort with gender-related topics, reasons for not asking patients about gender and previous training regarding gender diversity). The authors conducted semi-structured interviews with 12 TGD-identified adolescents aged 14-17, living in Minnesota, USA in 2017-2018. Inductive thematic analysis was used to summarise participant comments into themes and subthemes. Two main themes were directly relevant to concerns and needs of TGD youth in healthcare settings and their views on healthcare providers' concerns: (a) asking about gender and pronouns and (b) training for healthcare providers. Findings suggest the need for revisions to clinic materials, infrastructure and protocols. Adding training to all general medical and nursing education to increase knowledge, comfort and competence around gender identity would further improve care and ultimately reduce healthcare disparities affecting TGD youth.

Profiles of Risk and Protection for Violence and Bullying Perpetration Among Adolescent Boys

BACKGROUND

Violence and bullying perpetration among boys are major public health problems. We address gaps in the literature by examining: (1) how risk and protective factors co-occur, and (2) how different risk/protection profiles are associated with violence and bullying perpetration among adolescent boys.

METHODS

Data came from the population-based 2016 Minnesota Student Survey. The analytic sample included boys in grades 8, 9, and 11 (N = 63,818). Latent profile analyses identified patterns of 22 behavioral, intrapersonal, family, and school and community risk/protective factors. Logistic regression analyses examined how these patterns related to violence and bullying perpetration.

RESULTS

We identified 5 groups: Class 1: Low risk, high safety, high connectedness; Class 2: Low risk, moderate safety, moderate connectedness; Class 3: Moderate risk, high safety, moderate connectedness; Class 4: High risk, moderate safety, low connectedness; and Class 5: High risk, low safety, low connectedness. Compared to Class 1, Class 5 students had the highest odds of all for violence and bullying perpetration. Class 4 students also demonstrated high odds of violence and bullying, compared to Class 1. Though not as high as Classes 4 or 5, Class 2 and 3 students showed higher odds for both outcomes, compared to Class 1.

CONCLUSIONS

Substantive variations exist in boys who engage in violence and bullying. We highlight cumulative, co-occurring risk factors, connectedness to parents and other prosocial adults (eg, teachers), and school and neighborhood safety as important factors to address in school health programs seeking to prevent violence and bullying perpetration among boys.

A Web-Based Human Papillomavirus Vaccination Intervention for Young Gay, Bisexual, and Other Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

Gay, bisexual, and other men who have sex with men experience several disparities related to human papillomavirus (HPV) infection, including high incidence rates of anal cancer. Although the HPV vaccine is currently recommended for young adults, HPV vaccine coverage is modest among young gay, bisexual, and other men who have sex with men (YGBMSM).

Objective

We describe the design and methods for a randomized controlled trial (RCT) to rigorously evaluate Outsmart HPV, a population-targeted, individually tailored, Web-based HPV vaccination intervention for YGBMSM. The RCT is designed to determine the efficacy of the intervention, the mechanism by which the intervention has an effect (ie, mediation), and whether efficacy varies by participant characteristics (ie, moderation).

Methods

Outsmart HPV was previously developed and pilot-tested. This study is a 3-arm prospective RCT that will enroll a projected 1995 YGBMSM who are aged 18 to 25 years, live in the United States, and have not received any doses of the HPV vaccine. Participants will be recruited by means of paid advertisements on social media sites and randomized to receive (1) standard information on the Web about HPV vaccine (control group), (2) Outsmart HPV content on the Web with monthly unidirectional vaccination reminders sent via text messages, or (3) Outsmart HPV content on the Web with monthly interactive vaccination reminders sent via text messages. Participants will complete Web-based surveys at 4 time points during the study: baseline, immediately after engaging with Web-based content, 3 months after randomization, and 9 months after randomization. Primary outcomes will include both HPV vaccine initiation (ie, receipt of 1 or more doses of the HPV vaccine) and completion (receipt of all 3 doses recommended for this age range). We will examine constructs from the intervention’s theoretical framework as potential mediators and demographic and health-related characteristics as potential moderators of intervention effects.

Results

The institutional review board at The Ohio State University has approved the study. Materials have been developed and finalized for all study groups. Recruitment for the RCT began in fall 2019.

Conclusions

If shown to be efficacious, Outsmart HPV has the potential to fill an important gap by promoting HPV vaccination among a population at increased risk of HPV infection and HPV-related disease.

Trial Registration

ClinicalTrials.gov NCT04032106; http://clinicaltrials.gov/show/NCT04032106

International Registered Report Identifier (IRRID)

PRR1-10.2196/16294

Adverse Childhood Experiences and School-Based Victimization and Perpetration

Retrospective studies using adult self-report data have demonstrated that adverse childhood experiences (ACEs) increase risk of violence perpetration and victimization. However, research examining the associations between adolescent reports of ACE and school violence involvement is sparse. The present study examines the relationship between adolescent reported ACE and multiple types of on-campus violence (bringing a weapon to campus, being threatened with a weapon, bullying, fighting, vandalism) for boys and girls as well as the risk of membership in victim, perpetrator, and victim-perpetrator groups. The analytic sample was comprised of ninth graders who participated in the 2013 Minnesota Student Survey (n ~ 37,000). Multinomial logistic regression models calculated the risk of membership for victim only, perpetrator only, and victim-perpetrator subgroups, relative to no violence involvement, for students with ACE as compared with those with no ACE. Separate logistic regression models assessed the association between cumulative ACE and school-based violence, adjusting for age, ethnicity, family structure, poverty status, internalizing symptoms, and school district size. Nearly 30% of students were exposed to at least one ACE. Students with ACE represent 19% of no violence, 38% of victim only, 40% of perpetrator only, and 63% of victim-perpetrator groups. There was a strong, graded relationship between ACE and the probability of school-based victimization: physical bullying for boys but not girls, being threatened with a weapon, and theft or property destruction (ps < .001) and perpetration: bullying and bringing a weapon to campus (ps < .001), with boys especially vulnerable to the negative effects of cumulative ACE. We recommend that schools systematically screen for ACE, particularly among younger adolescents involved in victimization and perpetration, and develop the infrastructure to increase access to trauma-informed intervention services. Future research priorities and implications are discussed.

Association Among Internal Assets, Bullying, and Emotional Distress in Eighth Grade Students

BACKGROUND

Adolescents are in a unique developmental stage, ideal for initiating healthy behaviors and benefiting from health promotion interventions. In this study, we used positive youth development and resilience frameworks, to investigate the role of internal assets as a protective factor for bullying and emotional distress among early adolescents, with attention to whether those associations vary by sex.

METHODS

This is a secondary analysis of the 2013 Minnesota Student Survey, a cross-sectional, population-based survey of Minnesota youth. Participating eighth grade students (N = 42,841) reported on internal assets, physical, relational and cyberbullying involvement, and emotional distress.

RESULTS

Logistic regression analyses, stratified by sex and controlling for sociodemographic characteristics, revealed that students with higher internal assets had lower odds of all forms of bullying victimization and perpetration than those with lower internal assets. Higher levels of internal assets were also associated with lower odds of emotional distress. All associations were significant for boys and girls, but appeared stronger for girls.

CONCLUSIONS

Findings indicate that internal assets may buffer young teens from bullying and from the emotional distress that may result from bullying involvement. Approaches bolstering internal assets may be beneficial for combating bullying and emotional distress during early adolescence.

School Practices to Foster LGBT-Supportive Climate: Associations with Adolescent Bullying Involvement

Lesbian, gay, bisexual, and transgender (LGBT) youth experience disproportionate rates of bullying compared to their heterosexual peers. Schools are well-positioned to address these disparities by creating supportive school climates for LGBT youth, but more research is needed to examine the variety of practices and professional development opportunities put in place to this end. The current study examines how school practices to create supportive LGBT student climate relate to student reports of bullying. Student-level data come from the 2013 Minnesota Student Survey, a state-wide survey of risk and protective factors. Ninth and eleventh grade students (N = 31,183) reported on frequency of physical and relational bullying victimization and perpetration and sexual orientation-based harassment. School administrators reported on six practices related to creating supportive LGBT school climate (N = 103 schools): having a point person for LGBT student issues, displaying sexual orientation-specific content, having a gay-straight alliance, discussing bullying based on sexual orientation, and providing professional development around LGBT inclusion and LGBT student issues. An index was created to indicate how many practices each school used (M = 2.45; SD = 1.76). Multilevel logistic regressions indicated that students attending schools with more supportive LGBT climates reported lower odds of relational bullying victimization, physical bullying perpetration, and sexual orientation-based harassment compared to students in schools with less supportive LGBT climates. Sexual orientation did not moderate these relations, indicating that LGBT-supportive practices may be protective for all students, regardless of their sexual orientation. Findings support school-wide efforts to create supportive climates for LGBQ youth as part of a larger bullying prevention strategy.

Perspectives From Nurses and Physicians on Training Needs and Comfort Working With Transgender and Gender-Diverse Youth

INTRODUCTION

Nurses and physicians receive minimal training about providing competent care to transgender and gender-diverse (TGD) patients, and training specific to TGD youth is particularly lacking. This qualitative study examined health care providers' experiences and attitudes about working with TGD youth to identify specific training needs.

METHOD

Semistructured interviews were conducted with 14 nurses and physicians who work with adolescents. Thematic analysis was used to characterize participants' responses.

RESULTS

Five themes summarized participants' responses to interview questions: Training Regarding Gender Diversity, Discomfort With Gender-Related Topics, Reasons for Not Asking About Gender, Talking About Gender With Patients, and Need for Resources.

DISCUSSION

Findings highlight multiple opportunities to improve provider education and care experiences of TGD youth. Specific training is needed to help providers manage discomfort with gender-related topics and simultaneously develop their knowledge of and skills for discussing gender issues.

The LGBTQ Supportive Environments Inventory: Methods for Quantifying Supportive Environments for LGBTQ Youth

The social environment in which lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth live influences health and wellbeing. We describe the development of the LGBTQ Supportive Environments Inventory (LGBTQ SEI), designed to quantify the LGBTQ-inclusiveness of social environments in the US and Canada. We quantify aspects of the social environment: 1) Presence/quality of LGBTQ youth-serving organizations; 2) LGBTQ-inclusive Community Resources; 3) Socioeconomic and Political environment. Using GIS tools, we aggregated data to buffers around 397 schools in 3 regions. The LGBTQ SEI can be used to assess the role of the social environment in reducing health disparities for LGBTQ youth.

Gambling Behaviors and Problem Gambling: A Population-Based Comparison of Transgender/Gender Diverse and Cisgender Adolescents

Most gambling research utilizes general youth samples and focuses on binary gender categories; few studies examine and compare gambling behaviors between transgender and gender diverse (TGD) youth and their cisgender peers. The current study used population-based data from the 2016 Minnesota Student Survey to compare the prevalence of gambling behaviors and problem gambling among TGD versus cisgender adolescents, in addition to examining differences by birth-assigned sex. The analytic sample consisted of 80,929 students (including, n = 2168 [2.7%] TGD) in 9th and 11th grades. Chi-square tests and Cohen's d effect sizes were used for all comparisons. TGD youth reported greater involvement in most gambling behaviors and problem gambling compared to cisgender youth. In comparisons by birth-assigned sex, TGD youth assigned male at birth were particularly at risk for gambling involvement and problem gambling. TGD youth assigned female at birth also reported higher rates of problem gambling than both cisgender youth assigned male and female at birth. Results suggest that examining rates of gambling behavior and problem gambling as well as identifying disparities in vulnerable youth populations is crucial in order to develop culturally responsive and gender inclusive prevention, intervention, and outreach programs.

Perceptions of Sexual Orientation and Gender Identity Minority Adolescents About Labels

Young peoples' acceptance and use of nontraditional, descriptive identity labels (e.g., pansexual, genderqueer) require nurses to consider moving beyond use of traditional terms (e.g., gay, transgender). This mixed methods study explores (a) labels used by sexual orientation and gender identity (SOGI) minority youth, (b) their expressed importance and meaning of these labels, and (c) differences in label usage. Sixty-six SOGI minority adolescents in British Columbia, Minnesota, and Massachusetts (mean age = 16.6) participated in "go-along" interviews; during interviews, 42 (63.6%) commented on labels. Chi-square and t tests were used to compare traditional versus nontraditional labels across participant demographic categories. Inductive thematic analysis was used to identify representative themes. Approximately, 1/3 of participants used nontraditional sexual orientation identity labels; this finding was associated with a trans identity and nontraditional gender labels. Using terminology that is meaningful and representative to the youth themselves has potential to facilitate representative research and welcoming environments in practice.

At the Intersection of Sexual Orientation and Gender Identity: Variations in Emotional Distress and Bullying Experience in a Large Population-based Sample of U.S. Adolescents

This study examines the intersection of sexual and gender identities among adolescents, including the prevalence of these groups and rates of emotional distress and bullying victimization. Data come from a large population-based sample; two measures of sexual orientation and gender identity create eight identity groups. Youth who report identifying both as lesbian, gay, bisexual, or queer/questioning (LGBQ) and as transgender/gender diverse (TGD) had significantly higher levels of two measures of emotional distress and four measures of bullying victimization than those who report only identifying as LGBQ non-TGD or straight TGD. Implications for research and practice are discussed.

Bullying Victimization among LGBTQ Youth: Current and Future Directions

PURPOSE OF REVIEW

This paper examines recent research on bullying victimization among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth to identify critical issues and advocate for future research priorities.

RECENT FINDINGS

Recent studies have begun to document the importance of bullying in general, and bias-based bullying (rooted in stigma) in particular, on the health and wellbeing of this vulnerable subgroup of adolescents, as well as drivers of disparities. Current research demonstrates the role of multiple identities for and important differences among LGBTQ youth and has begun to identify protective factors for youth who are the targets of bullying.

SUMMARY

Researchers, clinicians, and those working with and on behalf of LGBTQ youth must measure and acknowledge the multiple reasons for which LGBTQ youth are the targets of bullying. Intervention and prevention efforts should focus on improving the supportiveness of the climates within which LGBTQ youth live.

Supporting Transgender and Gender Diverse Youth: Protection Against Emotional Distress and Substance Use

INTRODUCTION

Important mental and physical health disparities exist for transgender and gender diverse youth compared with cisgender youth (i.e., those whose birth-assigned sex and gender identity align), yet little is known about factors that protect transgender and gender diverse youth from health problems. The objective of this paper is to identify modifiable protective factors in the lives of transgender and gender diverse adolescents, with the goal of informing efforts to eliminate disparities in depression, suicidality, and substance use in this population.

METHODS

Secondary data analysis of the 2016 Minnesota Student Survey examined associations between eight protective factors (connectedness to parents, adult relatives, friends, adults in the community, and teachers; youth development opportunities; and feeling safe in the community and at school) and depression, suicidality, and substance use (alcohol, binge drinking, marijuana, nicotine) among 2,168 adolescents who identified as transgender, genderqueer, genderfluid, or questioning their gender. Logistic regressions assessed the role of each protective factor separately and simultaneously.

RESULTS

Each protective factor was associated with lower odds of emotional distress and substance use. When protective factors were examined simultaneously, parent connectedness was protective for all measures. Feeling safe at school and connected to adults in one's community protected against depression and suicidality; teacher connectedness buffered risk of substance use.

CONCLUSIONS

Given that transgender and gender diverse youth report lower levels of connectedness and safety, bolstering an explicitly transgender and gender diverse-friendly network of caring parents, safe and supportive schools, and connections to adults in the community may support efforts to eliminate disparities in depression, suicidality, and substance use.

Adverse Childhood Experiences and Early Initiation of Marijuana and Alcohol Use: The Potential Moderating Effects of Internal Assets

INTRODUCTION

Early adolescence is a critical risk period for initiation of substance use. Internal assets (IAs), which are individual qualities guiding positive choices, and adverse childhood experiences (ACEs) are important protective and risk factors, respectively, against substance use. The purpose of this study is to investigate whether IAs modify associations between ACEs and early initiation of alcohol and marijuana use.

METHOD

Data were from 9th and 11th graders who completed the 2013 Minnesota Student Survey (n = 79,339). Students reported on experiences of abuse, household dysfunction, and substance use. Multivariable logistic regressions examined associations between different types of ACEs and substance use. Interactions between IAs and ACEs were added to models to test effect modification. For significant interactions, main effects models were re-estimated at different percentiles of IAs.

RESULT

IAs moderated associations of both abuse and household dysfunction with early initiation of marijuana (p <.003) and alcohol (p =.007) for females but not for males. For females with low IAs, odds of early initiation of marijuana were approximately twice as high as students without any ACEs. A similar pattern was detected for females' initiation of alcohol use. No effect modification was detected for IAs and experiencing only abuse or household dysfunction on initiation.

CONCLUSION

Special attention should be paid to improving IAs among girls who have already experienced ACEs. Future research should examine protective factors that buffer the effects of ACEs for boys.

Emotional Distress, Bullying Victimization, and Protective Factors Among Transgender and Gender Diverse Adolescents in City, Suburban, Town, and Rural Locations

PURPOSE

Understanding the root causes of the substantial disparities in risk and protective factors among transgender and gender diverse (TGD) adolescents is essential to the development and expansion of resources and supports for this vulnerable population. This study examines differences in emotional distress, bullying victimization, and protective factors among TGD high school students in city, suburban, town, and rural locations.

METHODS

Data come from a statewide school-based survey conducted in Minnesota in 2016 (n = 2,168 TGD youth). Analysis of covariance models were used to predict the prevalence of multiple indicators of emotional distress, bullying victimization, and protective factors across the 4 location categories, with multiple adjustments.

FINDINGS

Significant linear trends were observed for 2 emotional distress outcomes and 2 bullying victimization outcomes, with urban TGD students having the lowest rates and rural having the highest prevalences. Additional significant differences in emotional distress were noted, with unexpectedly high rates of depressive symptoms and suicidal ideation among suburban students.

CONCLUSIONS

Helping TGD adolescents in all types of locations identify resources and supportive professionals is critical to supporting this population.

Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress

PURPOSE

As measures of birth-assigned sex, gender identity, and perceived gender presentation are increasingly included in large-scale research studies, data analysis approaches incorporating such measures are needed. Large samples capable of demonstrating variation within the transgender and gender diverse (TGD) community can inform intervention efforts to improve health equity. A population-based sample of TGD youth was used to examine associations between perceived gender presentation, bullying victimization, and emotional distress using two data analysis approaches.

METHODS

This secondary data analysis of the Minnesota Student Survey included 2168 9th and 11th graders who identified as "transgender, genderqueer, genderfluid, or unsure about their gender identity." Youth reported their biological sex, how others perceived their gender presentation, experiences of four forms of bullying victimization, and four measures of emotional distress. Logistic regression and multifactor analysis of variance (ANOVA) were used to compare and contrast two analysis approaches.

RESULTS

Logistic regressions indicated that TGD youth perceived as more gender incongruent had higher odds of bullying victimization and emotional distress relative to those perceived as very congruent with their biological sex. Multifactor ANOVAs demonstrated more variable patterns and allowed for comparisons of each perceived presentation group with all other groups, reflecting nuances that exist within TGD youth.

CONCLUSION

Researchers should adopt data analysis strategies that allow for comparisons of all perceived gender presentation categories rather than assigning a reference group. Those working with TGD youth should be particularly attuned to youth perceived as gender incongruent as they may be more likely to experience bullying victimization and emotional distress.

Preventive healthcare services use among transgender young adults

BACKGROUND/AIMS

Existing research on the health of transgender young adults focuses largely on gender-related care with little attention to important preventive healthcare services such as well-visits, vaccination and screening.

METHODS

We analyzed data from a national sample of transgender young adults in the United States who were 18-26 years of age and completed an online survey during Fall 2013 (n=34). Most respondents were 22-26 years old (59%) and non-Hispanic White (68%). We calculated descriptive statistics (i.e., frequencies and percentages) to describe transgender young adults use of preventive healthcare services, with particular attention to vaccination against human papillomavirus (HPV) and sexual health services. We also examined the acceptability of home-based self-testing for sexually-transmitted infections (STIs), which could be a novel strategy for increasing screening among this population.

RESULTS

Only 35% of respondents reported either receiving a routine check-up (past year) or initiating the HPV vaccination series (≥1 dose). Among unvaccinated respondents, the most commonly reported reasons for not getting HPV vaccine were: not being sexually active (32%); having only 1 sexual partner (23%); and being unaware of the vaccine (23%). Fewer than half of respondents had been tested for STIs (47%) but most (71%) were willing to use an STI self-test at home.

DISCUSSION

Findings suggest that the healthcare needs of transgender young adults are not being adequately addressed. Efforts to increase providers' capacity to effectively and appropriately serve transgender young adults-such as a wider variety of exam, preventive services, and testing options (e.g., self-collected samples)-are needed.

Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study

BACKGROUND

Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are TGNC and cisgender and across perceived gender expressions within the TGNC sample.

METHODS

Data came from the 2016 Minnesota Student Survey, which consisted of 80 929 students in ninth and 11th grade (n = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for demographic covariates) were used to compare groups.

RESULTS

We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For example, 62.1% of youth who are TGNC reported their general health as poor, fair, or good versus very good or excellent, compared with 33.1% of cisgender youth (χ² = 763.7, P < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long-term mental health problems compared with those with other gender presentations.

CONCLUSIONS

Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.

Weight Status and Weight Perception in Relation to Mental Distress and Psychosocial Protective Factors Among Adolescents

OBJECTIVE

To measure how weight status and weight perception relate to mental distress and psychosocial protective factors in adolescents.

METHODS

Adolescents in 8th, 9th, and 11th grade participating in the 2013 Minnesota Student Survey (N = 122,180) were classified on the basis of weight perception (overweight or not overweight) and weight status (not overweight, overweight, obese). Bivariate tests were used to assess the relationship of weight status and weight perception with internal mental distress, and generalized linear models were used to measure the association between weight status and weight perception with psychosocial protective factors including parent, school, and friend connectedness, social competency, and positive identity. Logistic regressions measured the relationship between psychosocial protective factors and internal mental distress.

RESULTS

Prevalence of internal mental distress ranged from 14.5% for overweight boys who perceived themselves as not overweight to 55.0% for girls who were not overweight but self-perceived as overweight. Across all weight-status categories, adolescents who perceived themselves as overweight, compared to those who did not, had higher internal mental distress and lower mean levels of psychosocial protective factors. All psychosocial protective factors were related to lower odds of internal mental distress, with significant small differences by weight status and weight perception.

CONCLUSIONS

Weight status and weight perception affected both mental distress and psychosocial protective factors. Those who perceived themselves as overweight, regardless of weight status, had the highest prevalence of mental distress and the lowest levels of psychosocial protective factors. Health care providers should consider screening for weight perception to provide a tailored approach to adolescent care.

Associations Between Peer Harassment and School Risk and Protection Profiles

BACKGROUND

Peer harassment can have serious implications for students' success and well-being, and prevention programs need to consider the school context. This study aimed to: (1) identify groups of similar schools based on their risk and protective factors and demographic characteristics and (2) examine associations between school profiles and students' bullying involvement.

METHODS

Data came from 505 schools and 122,106 students who completed the 2013 Minnesota Student Survey. School-level risk and protective factors and demographic characteristics were included in a latent profile analysis (LPA) to identify profiles of schools. Multilevel logistic regression was used to assess associations between school profiles and peer harassment.

RESULTS

Six qualitatively different school profiles were identified. Unadjusted models showed that schools with higher levels of risk had greater odds of peer harassment. However, after controlling for student-level risk and protection, regardless of school-level risk, students in metro-area schools with a more diverse student body reported lower odds of bullying involvement.

CONCLUSIONS

These findings highlight the importance of the social environment into peer harassment. In addition to addressing student-level risk and protection, larger community factors and norms also need to be taken into account for developing, selecting, and implementing the most effective approaches to bullying prevention.

Risk and Protective Factors in the Lives of Transgender/Gender Nonconforming Adolescents

PURPOSE

Research suggests that transgender and gender nonconforming (TGNC) youth may be at greatly increased risk of high-risk health behaviors compared with cisgender youth, but existing studies are limited by convenience samples and small numbers. This study uses a large school-based sample of adolescents to describe the prevalence of TGNC identity, associations with health risk behaviors and protective factors, and differences across birth-assigned sex.

METHODS

This study analyzes existing surveillance data provided by 9th and 11th grade students in Minnesota in 2016 (N = 81,885). Students who were transgender, genderqueer, genderfluid, or unsure about their gender identity (TGNC) were compared with those who were not, using χ2 and t-tests. Outcome measures included four domains of high-risk behaviors and experiences and four protective factors.

RESULTS

The prevalence of TGNC identity was 2.7% (n = 2,168) and varied significantly across gender, race/ethnicity, and economic indicators. Involvement in all types of risk behaviors and experiences was significantly higher, and reports of four protective factors were significantly lower among TGNC than cisgender youth. For example, almost two-thirds (61.3%) of TGNC youth reported suicidal ideation, which is over three times higher than cisgender youth (20.0%, χ2 = 1959.9, p < .001). Among TGNC youth, emotional distress and bullying experience were significantly more common among birth-assigned females than males.

CONCLUSIONS

This research presents the first large-scale, population-based evidence of substantial health disparities for TGNC adolescents in the United States, highlighting numerous multilevel points of intervention through established protective factors. Health care providers are advised to act as allies by creating a safe space for young people, bolstering protective factors, and supporting their healthy development.

Helping Young People Stay Afloat: A Qualitative Study of Community Resources and Supports for LGBTQ Adolescents in the United States and Canada

LGBTQ youth are at increased risk of poor health outcomes. This qualitative study gathered data from LGBTQ adolescents regarding their communities and describes the resources they draw on for support. We conducted 66 go-along interviews with diverse LGBTQ adolescents (mean age = 16.6) in Minnesota, Massachusetts, and British Columbia in 2014-2015, in which interviewers accompanied participants in their communities to better understand those contexts. Their responses were systematically organized and coded for common themes, reflecting levels of the social ecological model. Participants described resources at each level, emphasizing organizational, community, and social factors such as LGBTQ youth organizations and events, media presence, and visibility of LGBTQ adults. Numerous resources were identified, and representative themes were highly consistent across locations, genders, orientations, racial/ethnic groups, and city size. Findings suggest new avenues for research with LGBTQ youth and many opportunities for communities to create and expand resources and supports for this population.

LGBTQ Youth's Views on Gay-Straight Alliances: Building Community, Providing Gateways, and Representing Safety and Support

BACKGROUND

Gay-Straight Alliances (GSAs) are school-based clubs that can contribute to a healthy school climate for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. While positive associations between health behaviors and GSAs have been documented, less is known about how youth perceive GSAs.

METHODS

A total of 58 LGBTQ youth (14-19 years old) mentioned GSAs during go-along interviews in 3 states/provinces in North America. These 446 comments about GSAs were thematically coded and organized using Atlas.ti software by a multidisciplinary research team.

RESULTS

A total of 3 themes describe youth-perceived attributes of GSAs. First, youth identified GSAs as an opportunity to be members of a community, evidenced by their sense of emotional connection, support and belonging, opportunities for leadership, and fulfillment of needs. Second, GSAs served as a gateway to resources outside of the GSA, such as supportive adults and informal social locations. Third, GSAs represented safety.

CONCLUSIONS

GSAs positively influence the physical, social, emotional, and academic well-being of LGBTQ young people and their allies. School administrators and staff are positioned to advocate for comprehensive GSAs. Study findings offer insights about the mechanisms by which GSAs benefit youth health and well-being.

Patterns of Bullying and Sexual Harassment: Connections with Parents and Teachers as Direct Protective Factors

Involvement in bullying and sexual harassment in adolescence is associated with a variety of internalizing, externalizing, and health-risk behaviors. Yet, the two behaviors are often studied independently. The current study examined how bullying and sexual harassment co-occur and whether social connections protected youth from risk patterns. The data for this study come from the 2013 Minnesota Student Survey (N = 121,311; 50% female, 74% White, 26% received free or reduced-price lunch; M _age = 14.9, SD = 1.3). Students reported on bullying and sexual harassment victimization and perpetration. Using latent class analysis, youth were classified into five patterns: High-Risk of All Forms of Victimization and Perpetration (7%), Relational and Cyberbullying Victimization (17%), Sexual Harassment Victimization and Perpetration (8%), Physical Bullying Perpetration (6%), and Low-Risk (62%). Compared to the low-risk class, the four other classes had lower levels of social connections, particularly with teachers and parents. Older youth (9th and 11th grade students) were at greater risk for the sexual harassment pattern, while younger youth (8th grade students) were at greater risk for bullying patterns. The results indicate that efforts to reduce bullying should also address sexual harassment and social connections with adults.