Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors

Providing Lesbian, Gay, Bisexual, Transgender, Nonbinary, and Queer Adolescents With Nurturance, Trustworthiness, and Safety: Protocol for Pilot Cluster Randomized Controlled Trial Design

BACKGROUND

Sexual and gender minority youths (lesbian, gay, bisexual, transgender, nonbinary, and queer individuals) face elevated risks of substance use (eg, alcohol and tobacco) and mental health issues (eg, depressive symptoms and suicidality) compared to their cisgender heterosexual peers. These inequities are hypothesized to be reduced by building supportive high school environments via the training of school staff. An intervention that trains school staff to better understand and support sexual and gender minority youths and engage in positive bystander behaviors that protect them from bullying exposure may reduce disparities in drug and alcohol use among them. Experts, school staff, and sexual and gender minority youths developed Providing LGBTQ+ Adolescents with Nurturance, Trustworthiness, and Safety (PLANTS), a web-based intervention to train school staff on how to support, affirm, and protect sexual and gender minority youths.

OBJECTIVE

This paper describes the design of the PLANTS pilot trial primarily aimed at assessing its acceptability, usability, appropriateness, and feasibility. We hypothesize PLANTS will have high acceptability, usability, appropriateness, and feasibility as rated by the school staff. Secondary objectives focus on implementation, safety, and pre-post changes in high school staff outcomes, including self-efficacy and skills (eg, active-empathic listening and bullying intervention). Exploratory objectives focus on the impact of PLANTS on student health outcomes.

METHODS

In a 2-arm cluster randomized controlled trial, high schools in Massachusetts are allocated to PLANTS or an active comparator group (publicly available sexual and gender minority youths resources or training). High school staff complete pretest and posttest surveys containing validated scales. Primary outcomes are validated measures of acceptability, usability, appropriateness, and feasibility of the intervention completed by staff during posttest surveys. To test our primary hypotheses for each outcome, we will calculate means and 95% CIs and P values using 1-sample 2-sided t tests against a priori thresholds or benchmarks of success. Secondary outcomes include staff's active-empathetic listening skills, self-efficacy for working with sexual and gender minority youths, bystander intervention behaviors for bullying and cyberbullying, and self-efficacy for PLANTS' change objectives completed during pretest and posttest staff surveys. Staff can also complete a posttest interview guided by the Information-Motivation-Behavior model and Consolidated Framework for Implementation Research. Exploratory outcomes include student-level data collected via the 2021 and 2023 MetroWest Adolescent Health Surveys, a health behavior surveillance system in 30 Massachusetts schools.

RESULTS

School enrollment began in May 2023 and participant enrollment began in June 2023. Data collection is expected to be completed by February 2024.

CONCLUSIONS

This pilot trial will yield important information about the PLANTS intervention and provide necessary information to conduct a fully powered trial of the efficacy of PLANTS for reducing the deleterious health inequities experienced by sexual and gender minority youths.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05897827; https://clinicaltrials.gov/study/NCT05897827.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55210.

Improving School Environments for Preventing Sexual Violence Among LGBTQ+ Youth

BACKGROUND

Sexual violence (SV) is a serious public health concern, and lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ+) youth report higher rates than their heterosexual and cisgender peers. This qualitative study aimed to understand LGBTQ+ students' perspectives on how middle and high school environments can better prevent and address SV.

METHODS

In partnership with a school-based LGBTQ+ support group in Washington State, we recruited 31 LGTBQ+ students ages 13-18 for virtual interviews (n = 24) and for providing text-based answers to interview questions (n = 7). We used inductive thematic analysis to analyze data and identify themes.

RESULTS

To prevent and respond to SV, students highlighted schools having: (1) access to gender-neutral spaces; (2) LGBTQ+ competency training for staff; (3) enforcement of school policies (eg, SV, anti-bullying) and accountability; (4) LGBTQ+-competent mental health support; and (5) comprehensive sexual health education that addresses LGBTQ+ relationships and SV.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Students expressed the need for changes in school physical and social environments to address SV among LGBTQ+ youth.

CONCLUSIONS

Incorporating youth perspectives, particularly LGBTQ+ youth at high risk of SV, can help schools implement strategies that are supported by youth and thus potentially more sustainable and effective.

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

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

Alcohol Use Patterns Among Underage Autistic and Non-Autistic Youth

PURPOSE

We explored factors predicting repeated or hazardous alcohol use among autistic and non-autistic U.S. youth ages 16 to 20 years.

METHODS

Autistic (n = 94) and non-autistic (n = 92) youth completed an online survey. By design, half of each group reported past-year alcohol use. We compared drinking patterns for autistic and non-autistic youth, and within each group between abstinent or infrequent drinkers (0-1 drinking episodes in past year) versus those who drank 2 + times in past year.

RESULTS

Autistic (vs. non-autistic) youth who drank did so less frequently and consumed fewer drinks per occasion. However, 15% of autistic youth who drank in the past year reported heavy episodic drinking and 9.3% screened positive for AUDIT-C hazardous drinking. For autistic youth only, a diagnosis of depression, bullying or exclusion histories were positively associated with drinking 2 + times in the past year. Autistic youth who put more effort into masking autistic traits were less likely to report drinking 2 + times in the past year. As compared to non-autistic youth, autistic participants were less likely to drink for social reasons, to conform, or to enhance experiences, but drank to cope at similar rates.

CONCLUSION

Repeated and hazardous underage alcohol occur among autistic youth. Targeted prevention programs designed to address the specific drinking profiles of autistic youth are needed.

State-Level Policies and Health Outcomes in U.S. Transgender Adolescents: Findings from the 2019 Youth Risk Behavior Survey

Purpose: Policies have been shown to bear a considerable influence on transgender health. The few studies that have examined policy-related health outcomes in adolescent transgender populations have rarely included policies that directly affect them. Our study explores associations between four state-level policies and six health outcomes in a sample of transgender adolescents. Methods: Our analytic sample consisted of adolescents residing in 14 states that used the 2019 Youth Risk Behavior Survey's optional gender identity question in their surveys (n = 107,558). Chi-square analyses were performed to examine differences between transgender and cisgender adolescents in demographic variables and suicidal ideation, depression status, cigarette use, binge drinking, grades in school, and perceptions of school safety. Multivariable logistic regression models were run for transgender adolescents only to examine associations between policies and health outcomes, adjusting for demographics. Results: Transgender adolescents comprised 1.7% (n = 1790) of our sample. Compared with cisgender adolescents, transgender adolescents were more likely to experience adverse health outcomes in chi-square analyses. Multivariable models indicated that transgender adolescents who lived in a state that had explicit transgender guidance in their antidiscrimination laws were less likely to experience depressive symptoms, and those who lived in a state with positive or neutral athlete guidance were less likely to report past 30-day cigarette use. Conclusion: Our study is one of the first to show protective associations between affirming transgender-specific policies and health outcomes in transgender adolescents. Findings could have important implications for policymakers and school administrators.

Effects of School Policies and Programs on Violence Among All High School Students and Sexual and Gender Minority Students

BACKGROUND

Youth identifying as lesbian, gay, bisexual (LGB) and/or transgender/gender nonconforming (TGNC) are at increased risk of violence. School policies and practices may mitigate this risk.

METHODS

Researchers merged data from the 2016 New Mexico School Health Profiles and the 2017 New Mexico Youth Risk and Resiliency Survey. Researchers employed multivariable logistic regression to test the associations between school-level measures and violence outcomes.

RESULTS

Genders and sexualities alliances (GSAs) were associated with reduced odds of lifetime forced sex among all, heterosexual cisgender, and LGB students, reduced odds of sexual violence among heterosexual cisgender students, and reduced odds of dating violence among LGB students. Inclusive sexual health education was associated with reduced odds of lifetime forced sex among LGB and TGNC students, reduced odds of sexual violence among LGB students, and increased odds of dating violence among heterosexual cisgender students. Inclusive teacher training was associated with increased odds of lifetime forced sex among TGNC students.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Inclusive sexual health education and the presence of active GSAs may have the greatest potential for reducing violence, especially among LGB and TGNC students.

CONCLUSIONS

Findings highlight the important role of school policies and practices in addressing violence.

Protective Environmental Factors and Opioid Use Among Sexual Minority Youth

Objectives: Nonmedical use of prescription opioids (NMUPO) is a pressing public health concern and affects sexual minority youth (SMY) at greater rates than heterosexual youth. We investigated whether protective environmental factors-(1) Human Rights Campaign's state equality index (SEI) and (2) supportive school environments for LGBTQ youth, influenced NMUPO among SMY and non-SMY students. Methods: We combined data from the 2017-2019 Youth Risk Behavior Survey, 2016-2018 School Health Profiles, state-level socio-demographic and SEI data across 24 states (N=156,149). Generalized linear mixed models examined associations between (1) SEI and (2) supportive school environments for LGBTQ youth, with NMUPO, accounting for clustering at the school-and state-level. Results: Before adjustment, we found that youth in states with higher SEI were significantly less likely to engage in NMUPO compared to students in states with lower SEI, a relationship that became non-significant after adjustment. After adjusting for individual-and state-level indicators, SMY in states with supportive school environments for LGBTQ youth were less likely to engage in NMUPO. Conclusions: Supportive school environments for LGBTQ youth may play an important role in the health of SMY. Establishing more inclusive policies and supportive environments within schools may reduce NMUPO among SMY.

Interpersonal- and Community-Level Risk Factors for Adolescent Obesity: An Examination of Sexual Identity, School Violence, and School Climate in a Large Sample of Urban Adolescents

Sexual minority adolescents are more likely to have obesity compared to their heterosexual peers, but little is known about potential contributors to this disparity that lie outside of individual-level health behaviors, such as diet and exercise. One possible contributor is school violence victimization, a factor associated with overweight/obesity in adolescence. Another possible contributor is school climate, which is associated with feelings of safety and connectedness that can lower the likelihood of school violence victimization. Moreover, even less is known about relationships among all these factors among sexual minority adolescents. This gap in the literature was addressed by analyzing CDC's district-level data from the Youth Risk Behavior Survey and School Health Profiles (N = 60,625; 50.9% female, M_age = 16 years, 84.7% heterosexual, 15.3% sexual minority). Using multilevel mixed effects logistic regression models and controlling for covariates, it was found that among females and males, those with 2+ counts of last 12-month school violence victimization had higher odds of obesity than those with no school violence victimization (AOR = 1.33; AOR = 1.24). Furthermore, females and males in more positive LGBTQ school climates had lower odds of obesity than those in less positive school climates (AOR = 0.84; AOR = 0.85). There were no sexual identity differences in these models. Findings support the careful consideration of school violence victimization and LGBTQ school climate in future obesity prevention initiatives.

Barriers to oral health care for transgender and gender nonbinary populations

BACKGROUND

Despite health disparities and barriers to medical care being well documented in the literature, transgender and gender nonbinary (TGNB) people's experiences and expectations with regard to oral health care remain understudied. The authors examined gender identity-related factors influencing experiences in the dental setting, aspects of subjective oral health, and avoidance of oral health care.

METHODS

One-hundred eighteen TGNB people aged 13 through 70 years completed a 32-item questionnaire designed for this study. Data analysis relied on descriptive methods and bivariate comparisons using a conventional P < .05 statistical significance criterion. Qualitative description analysis was used to identify emerging themes from responses to an open-ended question.

RESULTS

One-third of participants reported misgendering (that is, had been addressed by their incorrect name and pronouns in the dental setting). Although refusal of oral health care was rare in this sample of TGNB participants, more than one-half felt that their usual source of oral health care was not equipped to provide gender-appropriate care. Participants' avoidance due to gender identity was significantly associated with measures of self-reported suboptimal oral health. Common themes related to participants' oral health care experiences included gender insensitivity, awkward interactions, avoidance of care, and lack of gender-affirming providers.

CONCLUSIONS

Discrepancies between TGNB patients' expectations and actual experiences suggest that their needs are often unmet in the dental setting, possibly contributing to gender identity-associated dental avoidance and oral health disparities.

PRACTICAL IMPLICATIONS

Although these results need to be verified in larger and more diverse samples, they provide actionable information for improvement to this population's oral health and management.

Influence of a national transgender health care directive on receipt of alcohol-related care among transgender Veteran Health Administration patients with unhealthy alcohol use

INTRODUCTION

Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use.

METHODS

The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications.

RESULTS

The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients.

CONCLUSIONS

Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.

At-School Victimization and Alcohol Use Among Minoritized U.S. Youth, 2009-2017

INTRODUCTION

Sexual minority and/or racial/ethnic minority youth may use alcohol at school as a form of minority stress-based coping. Polyvictimization is particularly prevalent among sexual minority and/or racial/ethnic minority youth and may be a useful proxy measure for minority stressors.

METHODS

Data from local administrations of the Youth Risk Behavior Survey were pooled across 42 jurisdiction years (biennially, 2009-2017) and analyzed in 2022, resulting in a sample of 118,052 U.S. youth. The prevalence of alcohol use at school was examined by sexual identity, race/ethnicity, and their intersections, stratified by sex. Multivariable logistic regression models were built to examine the disparities in alcohol use at school and the impact of school-based polyvictimization.

RESULTS

At the intersections of race/ethnicity and sexual identity, 25 of 30 sexual minority and/or racial/ethnic minority subpopulations had greater odds of alcohol use at school than their White heterosexual same-sex peers. Hispanic/Latinx not-sure males (AOR=9.15; 95% CI=5.97, 14.03) and Hispanic/Latinx lesbian females (AOR=11.24; 95% CI=6.40, 19.77) were most likely to report alcohol use at school. After adjusting for polyvictimization, the magnitude of association was attenuated for most sexual minority and/or racial/ethnic minority subpopulations; however, all but 2 significant associations remained.

CONCLUSIONS

Sexual minority and/or racial/ethnic minority youth were more likely than White heterosexual peers to use alcohol at school, with the greatest odds among multiply marginalized and polyvictimized youth. Interventions should consider addressing more than school-based victimization alone because disparities persisted, although at a lower magnitude, after accounting for polyvictimization. Future longitudinal studies are warranted to further explore the associations between multiply marginalized identities, school-based polyvictimization, and alcohol use at school.

Linking minority stress to substance abuse in LGB adults: the mediating effect of sexual harassment

OBJECTIVE

Employing a psychological mediation framework, the study investigated the interaction between minority stress and psychoactive substance abuse mediated by sexual harassment among LGB individuals.

METHOD

One hundred and forty-seven LGB individuals answered a questionnaire measuring internalized homophobia, concealment, discrimination, sexual harassment, and psychoactive substance abuse. Logistic hierarchical regression models were conducted to test the proposed relations and mediating hypotheses.

FINDINGS

Incidents of discrimination and internalized homophobia correlated with cigarette smoking and alcohol drinking. Sexual harassment was related to the use of cannabis and hard drugs. Sexual harassment mediated the relationships between the dimensions of minority stress and the use of cannabis and hard drugs.

CONCLUSION

Minority stress appears to be linked directly and indirectly, via sexual harassment, to the use of psychoactive substances by LGB individuals. Interventions addressing the prevention or mitigation of sexual harassment experienced by LGB individuals are likely to attenuate the negative effects of minority stress on their levels of substance use.

Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

Adolescents' health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

State LGBTQ policies and binge drinking among sexual minority youth in the US: a multilevel analysis

PURPOSE

Though higher rates of binge drinking have been reported among sexual minority (lesbian, gay, and bisexual) youths compared to their heterosexual peers in the United States, questions remain about which specific structural factors drive these inequities. We test whether state LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) policy climate is associated with youth binge drinking, as well as whether that association is unique to sexual minority youth.

METHODS

We use LGBTQ policy scores compiled by the Movement Advancement Project in 2017 and analyze 2017 Youth Risk Behavior Survey data (126,432 youths living in 24 states). We fit multi-level logistic regression models to estimate odds ratios for binge drinking with state-level LGBTQ policy scores.

RESULT

More progressive state-level overall LGBTQ policies were associated with lower odds of binge drinking among sexual minority youths (interaction term OR = 0.990, CI 0.984-0.996, p = 0.0009), but not among heterosexuals (OR = 1.001, CI 0.992, 1.009, p = 0.881). For sexual minorities, living in the most LGBTQ-affirming state was associated with a probability of binge drinking 27% lower than that of those living in the least LGBTQ-affirming state. In sensitivity analyses, policies specific to LGBTQ youth (opposed to general LGBTQ people) were even more strongly related to sexual minorities' binge drinking (interaction term: state-level youth policy score × individual-level sexual identity-of OR = 0.949, CI 0.927-0.971, p = 0.00001). In sex-stratified models, associations with overall LGBTQ policy scores were significant only for girls (OR = 0.986, CI 0.979-0.993, p < 0.001), not boys (OR = 0.997, CI 0.986-1.008, p = 0.551), while associations with youth-focused LGBTQ policies were significant for both sexual minority girls and boys.

CONCLUSION

Our findings point to state-level LGBTQ policy climate as a potential social determinant of binge drinking problems among sexual minority youths.

Is positive school climate associated with better adolescent mental health? Longitudinal study of young people in England

Background and objectives

Studies suggest that individual student-reported connection to school is associated with better mental health. However, there is less evidence for associations between schools’ overall school climate and the mental health of their students. This may reflect limitations in which mental health outcomes have been examined. We conducted a large longitudinal study in schools, hypothesising that we would find associations at both the student and school levels between student-reported positive school climate, and reduced student conduct and emotional problems and improved mental wellbeing.

Methods

We tracked students in 20 English secondary schools from near the end of the first year of secondary school (age 11/12) over 3 years using reliable measures of school climate and mental health.

Results

We found associations between student-level reports of positive school climate at baseline, and reduced conduct and emotional problems and better mental wellbeing at 3-year follow-up adjusting for various potential confounders. We also found some evidence of adjusted associations between baseline school-level measures of overall positive climate and better student mental health at follow-up. However, these student- and school-level associations reduced considerably when also adjusting for baseline mental health.

Conclusions

Our findings suggest that there are associations between school climate and student mental health at both the student and school level but these associations are complex and not necessarily causal.

•

Previous studies provide little evidence that mental health differ between schools or is influenced by school climate.

•

These studies' ability to identify school effects may have been undermined by choice of outcomes.

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Our study suggests that mental health may be better in schools with more student belonging.

Gender-Sexuality Alliances as a moderator of the association between victimization, depressive symptoms, and drinking behavior among LGBTQ+ youth

BACKGROUND

Victimization and depression are major stressors underlying drinking behavior among LGBTQ+ youth. There remains limited attention to setting-level factors that buffer their effects. Gender-Sexuality Alliances (GSAs) are school clubs that could promote the health of LGBTQ+ youth. We consider whether their presence in schools moderates associations between victimization, depressive symptoms, and recent alcohol use and heavy episodic drinking.

METHODS

LGBTQ+ youth (n = 5776) ages 13-17 in all 50 U.S. states with any prior history of alcohol use reported past 30-day alcohol use and heavy episodic drinking, victimization, depressive symptoms, and covariates including recent mental health counseling, perceived school safety, and demographics. Logistic regression models predicted youth's likelihood of any recent drinking and any heavy episodic drinking, with attention to GSA × victimization and GSA × depressive symptoms interaction effects.

FINDINGS

GSA presence moderated the extent to which victimization and depressive symptoms were associated with greater odds of recent heavy episodic drinking. GSA presence did not moderate these associations for lower thresholds of drinking (i.e., any drinking).

CONCLUSION

For LGBTQ+ youth with any lifetime history of alcohol use, GSAs could protect against heavy alcohol use, particularly when they face victimization and depression. GSAs may provide them with social-emotional support or educate school health professionals on ways to support LGBTQ+ youth facing victimization or mental health concerns. GSAs may not protect against all drinking behavior because youth may view some levels as normative. Our findings begin to suggest for whom GSA presence could be most protective.

Understanding and Caring for LGBTQ+ Youth by the Oral Health Care Provider

With growing visibility, there is an increasing prevalence of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth who feel empowered to own their true identity. Members of the oral health team frequently do not receive sufficient education in their training to recognize the nuance that treating this population may require. Although the tooth-level treatment does not materially change, a deeper appreciation of development of sexuality and gender identity, transgender medicine, and the health disparities LGBTQ+ youth face can promote more meaningful, trusting clinical relationships with this vulnerable population. This article aims to provide members of the oral health team with the requisite knowledge to deliver culturally competent care to LGBTQ+ youth.

Sexual Identity Differences in Health Behaviors and Weight Status among Urban High School Students

Although racial/ethnic disparities in childhood obesity are well documented in the United States (U.S.), fewer studies have investigated elevated body mass index (BMI) and related health behaviors among sexual minority youth (SMY; gay/lesbian, bisexual, not sure). We examined pooled data from the 2009-2017 Youth Risk Behavior Surveys, which included high school students from 12 urban U.S. school districts. We used sex-stratified logistic regression models to estimate the association of sexual identity with health behaviors and elevated BMI (reference = heterosexual participants). A total of 133,615 participants were included. Sexual minority boys were more likely to report physical inactivity than heterosexual boys. Gay and not sure boys were also less likely to consume the recommended daily intake of fruit. Bisexual girls were more likely than heterosexual girls to report watching television ≥ 3 hours on a school day and to consume sugar-sweetened beverages (AOR 1.30, 95% CI= 1.18-1.43). All SMY reported higher rates of current tobacco use than their heterosexual peers. Sexual minority girls and bisexual boys had significantly higher rates of obesity than their heterosexual counterparts. These findings can inform tailored health promotion initiatives to reduce obesity risk in SMY.

Differential Alcohol Use Disparities by Sexual Identity and Behavior Among High School Students

AIMS

Sexual minority youth (SMY) use alcohol at disproportionate rates compared to their heterosexual peers. However, sexual orientation is multidimensional. Analyzing alcohol use disparities only by one dimension of sexual orientation may result in critical disparities being obscured.

METHODS

Data from state and local versions of the Youth Risk Behavior Survey were pooled (2009-2017), resulting in a large, diverse sample (n = 201,671). Multivariable logistic regression models were used to analyze associations between sexual identity/sexual behavior and three alcohol use outcomes among sexually active youth: age at first drink, binge drinking and current drinking.

RESULTS

SMY, when categorized by sexual identity and sexual behavior, reported greater alcohol use than their heterosexual peers, though the magnitude of these disparities varied by subgroup. Both those who identified as bisexual and those who reported sexual behavior with both males and females reported the greatest levels of alcohol use. Decomposition analysis revealed that youth whose reported sexual behavior was not aligned with stereotypical behavioral expectations based on their sexual identity had higher odds of current drinking and drinking before 13 years as compared to other youth.

CONCLUSIONS

Results highlight the need to incorporate multiple methods of sexual orientation measurement into substance use research. Interventions based solely on identity, rather than both identity and behavior, may not be sufficient; targeted research into the causes of alcohol use disparities is needed, especially for bisexual youth, youth whose sexual behavior and sexual identity are not stereotypically aligned, and youth who report a sexual identity of 'not sure.'

LGB-Affirming School Climates and Sexual Health Outcomes Among U.S. High School Students 2015-2017: Differences by Sex and Sexual Identity

PURPOSE

Lesbian, gay, and bisexual (LGB) adolescents face disparities in sexual health outcomes compared to their heterosexual peers, which has implications for health outcomes and developmental trajectories. We examined whether adolescents living in jurisdictions with school climates that were more exclusionary toward LGB individuals engaged in higher risk sexual behaviors than those in jurisdictions with more inclusive school climates.

METHODS

Data on sexual identity, age at first sex, condom use at last sex and the number of lifetime partners came from the 2015 (20 jurisdictions) and 2017 (19 jurisdictions) Youth Risk Behavior Surveillance Surveys. Data on LGB climates in schools, aggregated to the state level, came from the School Health Profile Survey of the Centers for Disease Control and Prevention. Multilevel multivariable regressions examined the association between LGB school climate and sexual behaviors, including effect modification.

RESULTS

Overall, living in jurisdictions with more exclusionary LGB school climates was significantly associated with a lower age at first sex (β = -.04[-.07, -.02]) and a lower likelihood of condom use (OR = .94[.90, .98]), but not the number of lifetime partners. Associations differed by subgroup: sexual identity modified the relationship between school climate and age at first sex (β = -.09[-.15, -.03]) for bisexual adolescents, and school climate and condom use for bisexual (OR = .86[.76, .98]) and gay adolescents (OR = .66[.64, .68]).

CONCLUSIONS

Exclusionary LGB school climates are associated with a lower age at first sex and a lower likelihood of condom use for all adolescents, and particularly bisexual individuals. Additional research and practice should address school-level climates to support adolescents' healthy sexual development.

Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey

BACKGROUND

Prescription drug (PD) misuse, particularly opioid misuse, is a major US public health concern. While transgender and gender nonbinary (TGNB) individuals experience numerous health disparities, including substance use disparities, little research has focused on PD misuse in this population.

METHODS

Data for this secondary analysis come from the US Transgender Survey (N = 26,689). First, we examined bivariate differences in past 12-month PD misuse among binary transgender women, binary transgender men, nonbinary individuals assigned-female-at-birth (AFAB), and nonbinary individuals assigned-male-at-birth (AMAB). We then used multivariable logistic regression (separately based on sex-assigned-at-birth) to examine the relationship between gender-identity related discrimination and PD misuse.

RESULTS

PD misuse was significantly more common among binary transgender men (17.3 %), nonbinary AFAB individuals (18.7 %), and nonbinary AMAB individuals (18.0 %); compared to binary transgender women (13.5 %). In multivariable analyses, nonbinary identity was associated with higher odds of PD misuse among TGNB AFAB individuals (OR = 1.121; 95 %CI 1.021-1.232) and AMAB individuals (OR = 1.315; 95 % CI 1.133-1.527). Controlling for overall health status and psychological distress, public accommodations discrimination was associated with PD misuse among TGNB AMAB individuals (OR = 1.578, 95 %CI 1.354-1.839). Among both groups, healthcare discrimination was associated with PD misuse (AFAB OR = 1.388, 95 %CI 1.255-1.534; AMAB OR = 1.227, 95 %CI 1.073-1.404).

CONCLUSION

In this national sample of TGNB individuals, nonbinary individuals were at greater risk for PD misuse than binary individuals, possibly due to less societal affirmation. Similar to other TGNB health disparities, discrimination based on gender identity/expression was associated with PD misuse. This highlights the importance of interventions to reduce discrimination against TGNB individuals.

Research Priorities to End the Adolescent HIV Epidemic in the United States: Viewpoint

Youth represent 21% of new HIV diagnoses in the United States. Gay, bisexual, and transgender (GBT) youth, particularly those from communities of color, and youth who are homeless, incarcerated, in institutional settings, or engaging in transactional sex are most greatly impacted. Compared with adults, youth have lower levels of HIV serostatus awareness, uptake of antiretroviral therapy (ART), and adherence. Widespread availability of ART has revolutionized prevention and treatment for both youth at high risk for HIV acquisition and youth living with HIV, increasing the need to integrate behavioral interventions with biomedical strategies. The investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) completed a research prioritization process in 2019, focusing on research gaps to be addressed to effectively control HIV spread among American youth. The investigators prioritized research in the following areas: (1) innovative interventions for youth to increase screening, uptake, engagement, and retention in HIV prevention (eg, pre-exposure prophylaxis) and treatment services; (2) structural changes in health systems to facilitate routine delivery of HIV services; (3) biomedical strategies to increase ART impact, prevent HIV transmission, and cure HIV; (4) mobile technologies to reduce implementation costs and increase acceptability of HIV interventions; and (5) data-informed policies to reduce HIV-related disparities and increase support and services for GBT youth and youth living with HIV. ATN’s research priorities provide a roadmap for addressing the HIV epidemic among youth. To reach this goal, researchers, policy makers, and health care providers must work together to develop, test, and disseminate novel biobehavioral interventions for youth.

An Analysis of the Presence and Composition of OutLists at United States, Canadian, and European Medical Institutions

Sexual and gender minority (SGM) medical students and physicians are exposed to bias in professional contexts. One strategy for promoting SGM visibility and inclusion within medicine is the development of institutional OutLists, which are online, opt-in lists of SGM-identified individuals affiliated with an academic institution. We present the first quantitative evaluation of publicly accessible OutLists at medical institutions in the United States, Canada, and Europe. Nineteen OutLists were identified in the United States; no OutLists were identified in other countries. All OutLists in the United States were identified at allopathic institutions with no institutional religious affiliation. Clinicians in high-prestige specialties and more senior clinicians were underrepresented on OutLists. A state-level measure of SGM equality predicted presence of OutLists within the state (odds ratio 1.429, p = .047) but was not associated with the total number of individuals on OutLists. Future research would benefit from incorporating qualitative methodologies to explore the effectiveness of OutLists and the individual experiences of participants in these lists.

Associations Between LGBTQ-Affirming School Climate and Intimate Partner Violence Victimization Among Adolescents

Intimate partner violence (IPV) impacts sexual minority adolescents at rates equal to or greater than the rate it impacts heterosexual adolescents. We investigated whether reports of physical and sexual IPV were less frequent in school jurisdictions with more affirming climates for lesbian, gay, bisexual, transgender, and queer (LGBTQ) students; and whether these associations varied for sexual orientation subgroups. We combined student-level data from the 2015 Youth Risk Behavior Surveys on demographics and experiences with physical and sexual IPV with jurisdiction-level data from the 2014 School Health Profiles on LGBTQ-affirming school climate. Multilevel logistic regression models examined associations between LGBTQ-affirming school climates and IPV. We stratified our data by sex and examined whether these associations differed by sexual orientation subgroups using cross-level interaction terms between school climate and sexual orientation (assessed via sexual identity and behavior). Sexual minority youth were more likely to report experiencing past-year physical and sexual IPV than their heterosexual counterparts. Attending schools with more LGBTQ-affirming climates reduced the likelihood of reporting physical IPV, but not sexual IPV, for female students. More LGBTQ-affirming school climates increased risk for sexual IPV among gay male students. Establishing LGBTQ-affirming school climates may reduce physical IPV for female students, but may have unintended consequences on sexual IPV prevalence for gay male students. More work is necessary to ensure that these climates are affirming for all sexual minority students and to address sexual violence prevention.

SUBSTANCE USE AMONG SEXUAL AND GENDER MINORITIES: ASSOCIATION WITH POLICE DISCRIMINATION AND POLICE MISTRUST

We investigated associations between experiences with police discrimination, police mistrust, and substance use in a convenience sample of 237 sexual and gender minority (SGM) adults in California. In a cross-sectional survey, collected between January 2016 and July 2017, participants reported substance use, lifetime experiences with SGM-related police discrimination, police mistrust, demographics and SGM visibility. In adjusted logistic regression models, we found a positive association between lifetime police discrimination and past-two-week heavy episodic drinking. Police mistrust also was positively associated with past-month marijuana use. Several significant interactions between lifetime police discrimination or police mistrust with other socially stigmatized identities including being African American, insecure housing, and being a gender minority on a few substance use outcomes suggest that effects of police discrimination and mistrust on substance use are stronger among participants with multiple stigmatized identities. Results suggest the importance of policies and interventions that focus on eliminating police discrimination and increasing police legitimacy to reduce risk of substance use among SGM individuals.

Sexual Orientation-Based Alcohol, Tobacco, and Other Drug Use Disparities: The Protective Role of School-Based Health Centers

This study investigated whether the presence of school-based health centers (SBHCs) was associated with six substance use behaviors among sexual minority youth (SMY) and their heterosexual peers. Data from the 2015 Oregon Healthy Teens Survey, including 13,608 11th graders in 137 schools (26 with SBHCs) were used in the current study. Multilevel logistic regression analyses were performed. Results revealed significant SBHC by SMY status interactions indicating a relatively lower likelihood of past 30-day alcohol use (23%), binge drinking (43%), use of e-cigarettes (22%), marijuana (44%), and unprescribed prescription drugs (28%) among SMY in SBHC schools compared with non-SMY at SBHC schools. Furthermore, SMY in SBHC schools reported lower likelihood of aforementioned substance use behaviors than SMY attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY in SBHC and non-SBHC schools. Findings from this study suggest SBHCs may help to mitigate substance use disparities among marginalized populations, such as SMY.

Sexual Orientation and Suicide Attempt Disparities Among US Adolescents: 2009-2017

BACKGROUND

Sexual minority adolescents face mental health disparities relative to heterosexual adolescents. We evaluated temporal changes in US adolescent reported sexual orientation and suicide attempts by sexual orientation.

METHODS

We used Youth Risk Behavioral Surveillance data from 6 states that collected data on sexual orientation identity and 4 states that collected data on sex of sexual contacts continuously between 2009 and 2017. We estimated odds ratios using logistic regression models to evaluate changes in reported sexual orientation identity, sex of consensual sexual contacts, and suicide attempts over time and calculated marginal effects (MEs).

RESULTS

The proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017 (ME: 0.8 percentage points [pp] per year; 95% confidence interval [CI]: 0.6 to 0.9 pp). The proportion of adolescents reporting any same-sex sexual contact increased by 70%, from 7.7% in 2009 to 13.1% in 2017 (ME: 0.6 pp per year; 95% CI: 0.4 to 0.8 pp). Although suicide attempts declined among students identifying as sexual minorities (ME: -0.8 pp per year; 95% CI: -1.4 to -0.2 pp), these students remained >3 times more likely to attempt suicide relative to heterosexual students in 2017. Sexual minority adolescents accounted for an increasing proportion of all adolescent suicide attempts.

CONCLUSIONS

The proportion of adolescents reporting sexual minority identity and same-sex sexual contacts increased between 2009 and 2017. Disparities in suicide attempts persist. Developing and implementing approaches to reducing sexual minority youth suicide is critically important.

Substance use and misuse among sexual and gender minority youth

Sexual and gender minority youth are at greater risk for substance use and misuse compared to their heterosexual and cisgender peers. This select review of the literature found that recent studies continue to document disparities in substance use. These disparities are partially explained by general and unique stressors as well as social, interpersonal, and cultural factors experienced by sexual and gender minority youth. There are many gaps in the literature, including limited research on protective factors or interventions to prevent or decrease substance use. Despite emerging empirical literature over the past two years, more research is needed to address sexual and gender minority youth's greater risk for substance use. Innovative methodologies and interdisciplinary efforts are needed to help advance our understanding of disparities in substance use in order to reduce and eliminate them and create more affirming experiences for sexual and gender minority youth.

Trends in Alcohol Use Behaviors by Sexual Identity and Behavior Among High School Students, 2007-2017

PURPOSE

Certain groups, particularly sexual minority youth, demonstrate notable disparities in alcohol use risk. Assessing trends in alcohol use behaviors by sexual orientation over time is therefore important to the epidemiologic study of adolescent health equity.

METHODS

We analyzed age at first drink, lifetime drinking behavior, current drinking, and binge drinking in a large, national sample of high school youth across six time points, beginning in 2007 and biennially through 2017. We assessed trends by sex, sexual identity, and sexual behavior, controlling for race/ethnicity and age.

RESULTS

Our results demonstrated that, although overall alcohol use is decreasing among youth, disparities between heterosexual and sexual minority youth remain significant. The largest decreases were seen in current alcohol use among lesbian youth, which fell from a prevalence of 56.1% in 2007 to 38.9% in 2017, and among bisexual females (64.3% in 2007 to 41.1% in 2017). Despite this, alcohol use behaviors were still elevated among lesbian and bisexual female youth compared with heterosexual sex-matched counterparts. Heterosexual-identified male students saw significant decreases in alcohol use, whereas most alcohol use behaviors among sexual minority males decreased but not to a statistically significant degree, with the exception of binge drinking among those who identified as gay (2007: 36.0% to 2017: 12.6%) and bisexual (2007: 24.7% to 2017: 11.6%). Results by sexual behavior are presented within.

CONCLUSIONS

Sexual minority youth continued to demonstrate markedly high prevalence of alcohol use behaviors compared with heterosexual peers across all time points. Downward trends in alcohol use may thus mask serious population health risks if not adequately explored. Research and health promotion efforts must consider sexual minority orientation to avoid incomplete or inaccurate representation of findings.

School Climate & Sexual and Gender Minority Adolescent Mental Health

Sexual/gender minority (Sexual/gender minority people are also referred to as Lesbian, Gay, Bisexual, Transgender, Queer) youth are more likely than cisgender heterosexual youth to exhibit depressive symptoms and be victimized. School climate research indicates that the presence of a Gay-Straight Alliance (a Gay-Straight Alliance or Gender-Sexuality Alliance is also referred to as a GSA and is a youth group to support sexual/gender minority youth), a supportive school climate, and seeking help from teachers are associated with more positive mental health outcomes; however, they are not typically measured together. This study uses a survey that measures all four measures of school environment with a national sample of 240 sexual/gender minority high school students ages 14-18 (mean age 15.77) where 53% of participants had a Gay-Straight Alliance in their school. The sample is 53% cisgender, 100% sexual minority and 62% white. Adjusting for demographics and presence of a Gay-Straight Alliance, fewer depressive symptoms were associated with lower help-seeking intentions for suicidal thoughts. The presence of Gay-Straight Alliance was not statistically associated with past-month help-seeking intentions or behaviors. Additionally, a more supportive school climate was associated with lower anxiety and depressive symptoms. However, the presence of a Gay-Straight Alliance was not statistically associated with anxiety or depressive symptoms. These findings suggest that a supportive school climate and supportive school personnel may be important for supporting the mental health of sexual/gender minority students.

Understanding predictors of improvement in risky drinking in a U.S. multi-site, longitudinal cohort study of transgender individuals: Implications for culturally-tailored prevention and treatment efforts

OBJECTIVE

While transgender people report higher rates of risky drinking than the general population, no studies have examined transgender alcohol use longitudinally. This study investigated minority stress and identity development predictors of improvement in risky drinking among transgender individuals.

METHODS

Data come from a multi-site, longitudinal cohort study of U.S. transgender individuals (N = 330) and include measures of enacted stigma, felt stigma, identity development, and risky alcohol use. Theory-driven, hierarchical multivariable logistic regression was used to investigate the hypothesis that minority stress and identity development factors are related to improvement in risky drinking between baseline and 1-year follow-up.

RESULTS

Baseline risky drinkers (n = 106; 37.1%) were younger and more likely to have female sex assigned at birth. At 1-year follow-up, 68 baseline risky drinkers (64.2%) reported persistent risky drinking, while 38 (35.8%) reported improved drinking. Controlling for demographics and study site, female sex assigned at birth and enacted stigma were associated with lower odds of improved drinking. Non-white/Hispanic race/ethnicity, felt stigma, change in gender role/expression for 1-5 years, and diffuse-avoidant identity style were associated with higher odds of improvement.

CONCLUSIONS/IMPORTANCE

This is the first study to identity predictors of improvement in risky drinking among transgender individuals. Compared to trans-feminine individuals (assigned male at birth), trans-masculine individuals (assigned female at birth) were more likely to report risky drinking at baseline and had lower odds of improvement at 1-year follow-up. Improved drinking may be facilitated by preventing anti-transgender discrimination. Felt stigma and diffuse-avoidant identity style may lower alcohol risk via avoidance of drinking venues. Further research is needed to explicate these relationships and to inform culturally-tailored alcohol interventions for this at-risk population.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review

CONTEXT

Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions.

OBJECTIVE

To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY.

DATA SOURCES

PubMed, PsycINFO, and Education Resources Information Center.

STUDY SELECTION

Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY.

DATA EXTRACTION

Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor.

RESULTS

With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality.

LIMITATIONS

There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY.

CONCLUSIONS

The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

Supportive Community Resources Are Associated with Lower Risk of Substance Use among Lesbian, Gay, Bisexual, and Questioning Adolescents in Minnesota

Research has indicated that lesbian, gay, bisexual, and queer/questioning (LGBQ) adolescents have disproportionately high rates of substance use compared to heterosexual peers; yet certain features of schools and communities have been associated with lower substance use rates in this population. To advance this field, research examining multiple levels of influence using measures developed with youth input is needed. With community, school, and student data, this study tested hypotheses that LGBQ students attending high schools and living in communities with more LGBQ-supportive environments (assessed with a novel inventory tool) have lower odds of substance use behaviors (cigarette smoking, alcohol use, marijuana use, prescription drug misuse, and other drug use) than their peers in less supportive LGBQ environments. Multilevel models using data from 2454 LGBQ students (54.0% female, 63.9% non-Hispanic white) in 81 communities and adjusting for student and school covariates found that LGBQ adolescents who lived in areas with more community support had lower odds of frequent substance use, particularly among females. Expanding and strengthening community resources (e.g., LGBQ youth-serving organizations, LGBQ events such as a Pride parade, and LGBQ-friendly services) is recommended to further support LGBQ adolescents and reduce substance use disparities.

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.

Social Context of Sexual Minority Adolescents and Relationship to Alcohol Use

PURPOSE

Peer relationships are especially relevant during adolescence and may contribute to sexuality-based disparities in substance use. This study uses social network analysis to examine how social networks may serve as risk or protective factors for sexual minority youth in the context of alcohol use.

METHODS

Social network analysis was applied to 11th to 12th graders in three diverse high schools in a rural area of the Southeast United States. The network consists of 1,179 students, 607 of whom were participants in the study and nominated friends. Regression models were used to examine how potential predictors of alcohol use may function differently for sexual minority and majority students.

RESULTS

Approximately one fourth of students were classified as sexual minorities, inclusive of students who self-identified or reported any same-sex romantic attraction or sexual experience. These students did not use alcohol in greater amounts than students in the sexual majority. They received fewer incoming friendship nominations (p < .05) although a higher percentage of friendships were reciprocated (p < .05). They exhibited lower eigenvector centrality (p = .01), and their networks were less cohesive (p < .001). However, low centrality and low density did not predict greater alcohol consumption. Sexual minorities appeared to be influenced less strongly by peers' alcohol use, and friendships with sexual minorities further mitigated peer influence.

CONCLUSION

Sexual minorities occupied less prominent positions within their social networks. However, these network differences did not place sexual minorities at increased risk of alcohol use.

Associations of Lesbian, Gay, Bisexual, Transgender, and Questioning-Inclusive Sex Education With Mental Health Outcomes and School-Based Victimization in U.S. High School Students

PURPOSE

Homophobic school climates are related to increased victimization for sexual minority youth (SMY), leading to increased risk of adverse mental health outcomes. Interventions that promote positive school climate may reduce the risk of victimization and adverse mental health outcomes in SMY. This study explored whether lesbian, gay, bisexual, transgender, and questioning (LGBTQ)-inclusive sex education is associated with adverse mental health and school-based victimization in U.S. youth.

METHODS

Data analysis of representative data from the 2015 Youth Risk Behavior Survey and the 2014 School Health Profiles was conducted using multilevel logistic models testing whether youth in states with higher proportions of schools teaching LGBTQ-inclusive sex education had lower odds of reporting being bullied in school and experiencing adverse mental health outcomes, including depressive symptoms and suicidality.

RESULTS

After controlling for covariates, protective effects for all youth were found for suicidal thoughts (adjusted odds ratio [AOR]: .91, 95% confidence interval [CI]: .89-.93) and making a suicide plan (AOR: .79; 95% CI: .77-.80). Lesbian and gay youth had lower odds of experiencing bullying in school as the proportion of schools within a state teaching LGBTQ-inclusive sex education increased (AOR: .83; CI: .71-.97). Bisexual youth had significantly lower odds of reporting depressive symptoms (AOR: .92; 95% CI: .87-.98).

CONCLUSIONS

Students in states with a greater proportion of LGBTQ-inclusive sex education have lower odds of experiencing school-based victimization and adverse mental health. These findings can be used to guide intervention development at the school and state levels.

Substance Use and School Characteristics in Lesbian, Gay, Bisexual, and Heterosexual High School Students

BACKGROUND

Tobacco, alcohol, and illicit drug use among lesbian, gay, and bisexual (LGB) high school students as well as related environment and school-level risk and protective factors were examined.

METHODS

Data was acquired from the 2015 CDC's Youth Behavior Risk Survey for Kentucky (N = 2577). Prevalence of substance use was calculated for all high school respondents by reported sexual orientation. Multivariate analyses estimated the relationship between school and environmental-level factors (eg, having an adult to talk to) and tobacco, alcohol, and illicit drug use via logistic regressions. Sexual orientation, gender, age, and race/ethnicity were covariates.

RESULTS

LGB students used tobacco, alcohol, and illicit drugs more frequently than their heterosexual counterparts. More LGB teens report facing school risk factors (eg, 37% LGB vs 20% heterosexual bullied at school, p ≤ .001; 17% LGB vs 5% heterosexual ever threatened or injured at school, p < .001; 13% LGB vs 7% heterosexual involved in a school fight, p = .001). Adjusting for school related risk factors, having an adult to talk to was associated with a reduced likelihood of daily smoking (adjusted odds ratio [aOR]: 0.43; 95% confidence interval [CI]: 0.26-0.73), past 30-day alcohol use (aOR: 0.71; 95% CI: 0.50-0.95), and ever marijuana use (aOR: 0.71; 95% CI: 0.50-1.00).

CONCLUSION

Innovative strategies are needed to create safe, supportive school environments. These strategies are particularly needed in predominately rural states like Kentucky.

Latent Classes of Polysubstance Use Among Adolescents in the United States: Intersections of Sexual Identity with Sex, Age, and Race/Ethnicity

PURPOSE

We aimed to estimate latent classes of concurrent polysubstance use and test for sexual orientation differences in latent class memberships with representative data from adolescents living in 19 U.S. states. We also tested whether sex, race/ethnicity, and age moderated the sexual identity differences in polysubstance use class memberships.

METHODS

We analyzed data from 119,437 adolescents from 19 states who participated in the 2015 Youth Risk Behavior Survey. Latent class analysis characterized polysubstance use patterns based on self-reported frequency of lifetime and past-month use of alcohol (including heavy episodic drinking), tobacco (cigarettes, cigars, and smokeless tobacco), and marijuana. Multinomial logistic regression models tested differences in latent class memberships by sexual identity. Interaction terms tested whether sex, race/ethnicity, and age moderated the sexual identity differences in polysubstance use class memberships.

RESULTS

A six-class model of polysubstance use fit the data best and included nonusers (61.5%), experimental users (12.2%), marijuana-alcohol users (14.8%), tobacco-alcohol users (3.8%), medium-frequency three-substance users (3.6%), and high-frequency three-substance users (4.1%). Gay/lesbian- and bisexual-identified adolescents had significantly higher odds than heterosexual-identified adolescents of being in all of the user classes compared with the nonuser class. These sexual identity differences in latent polysubstance use class memberships were generally larger for females than for males, varied occasionally by race/ethnicity, and were sometimes larger for younger ages.

CONCLUSION

Compared with their heterosexual peers, gay/lesbian and bisexual adolescents-especially females-are at heightened risk of engaging in multiple types of polysubstance use. Designing, implementing, and evaluating interventions will likely reduce these sexual orientation disparities.

Pilot Testing the Feasibility of a Game Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Protocol for a Randomized Controlled Trial

Background

Sexual and gender minority youth (SGMY; eg, lesbian, gay, bisexual, and transgender youth) experience myriad substance use and mental health disparities compared with their cisgender (nontransgender) heterosexual peers. Despite much research showing these disparities are driven by experiences of bullying and cyberbullying victimization, few interventions have aimed to improve the health of bullied SGMY. One possible way to improve the health of bullied SGMY is via a Web-accessible game intervention. Nevertheless, little research has examined the feasibility of using a Web-accessible game intervention with SGMY.

Objective

This study aimed to describe the protocol for a randomized controlled trial (RCT) pilot, testing the feasibility and limited efficacy of a game-based intervention for increasing help-seeking–related knowledge, intentions, self-efficacy, behaviors, productive coping skills use, and coping flexibility and reducing health risk factors and behaviors among SGMY.

Methods

We enrolled 240 SGMY aged 14 to 18 years residing in the United States into a 2-arm prospective RCT. The intervention is a theory-based, community-informed, computer-based, role playing game with 3 primary components: encouraging help-seeking behaviors, encouraging use of productive coping, and raising awareness of Web-based resources. SGMY randomized to both the intervention and control conditions will receive a list of SGMY-inclusive resources, covering a variety of health-related topics. Control condition participants received only the list of resources. Notably, all study procedures are conducted via the internet. We conveniently sampled SGMY using Web-based advertisements. Study assessments occur at enrollment, 1 month after enrollment, and 2 months after enrollment. The primary outcomes of this feasibility study include implementation procedures, game demand, and game acceptability. Secondary outcomes include help-seeking intentions, self-efficacy, and behaviors; productive coping strategies and coping flexibility; and knowledge and use of Web-based resources. Tertiary outcomes include bullying and cyberbullying victimization, loneliness, mental health issues, substance use, and internalized sexual and gender minority stigma.

Results

From April to July 2018, 240 participants were enrolled and randomized. Half of the enrolled participants (n=120) were randomized into the intervention condition and half (n=120) into the control condition. At baseline, 52.1% (125/240) of the participants identified as gay or lesbian, 26.7% (64/240) as bisexual, 24.2% (58/240) as queer, and 11.7% (28/240) as another nonheterosexual identity. Nearly half (113/240) of participants were a gender minority: 36.7% (88/240) were cisgender boys, and 16.3% (39/240) were cisgender girls. There were no differences in demographic characteristics between intervention and control condition participants.

Conclusions

Web-accessible game interventions overcome common impediments of face-to-face interventions and present a unique opportunity to reach SGMY and improve their health. This trial will provide data on feasibility and limited efficacy that can inform future Web-based studies and a larger RCT aimed at improving health equity for SGMY.

Trial Registration

ClinicalTrials.gov NCT03501264; https://clinicaltrials.gov/ct2/show/NCT03501264 (Archived by WebCite at http://www.webcitation.org/72HpafarW)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12164

Rural Primary Care Providers' Experiences and Knowledge Regarding LGBTQ Health in a Midwestern State

PURPOSE

Health disparities among LGBTQ people have been documented across various settings and recent research has indicated that many disparities are heightened in the context of rurality. Among these disparities is the decreased rate of primary care utilization by rural LGBTQ individuals. Understanding and addressing provider knowledge and attitudes related to LGBTQ health provides a relevant avenue for addressing underutilization.

METHODS

The study presented was a mail-out survey regarding rural primary care providers' knowledge and experiences regarding LGBTQ health. Publicly available records were compiled to recruit a total sample of 113 primary care providers, at a response rate of 19.8%.

FINDINGS

A majority of respondents reported experience providing care to LGBTQ patients, while only slightly over half had received LGBTQ health education. Data analyses revealed significant associations between reported experiences and patient characteristics including religion, religiousness, age, length of time practicing in current provider role, and gender identity. Provider knowledge of LGBTQ health varied greatly across the items assessed. Provider profession (physician, nurse practitioner, physician assistant) and length of current county residence were significantly predictive of LGBTQ knowledge scores.

CONCLUSION

Results provide insight into rural health care for LGBTQ people. Preeminent findings were: (1) an existing need for LGBTQ health education, (2) variation in knowledge across content areas, and (3) association between knowledge, profession, and length of current county residence. Promotion of rural LGBTQ health may benefit by addressing identified gaps in current care.

The Effects of Gender- and Sexuality-Based Harassment on Lesbian, Gay, Bisexual, and Transgender Substance Use Disparities

PURPOSE

We tested three competing models about whether gender- and sexuality-based harassment at school have nonindependent, additive, or interactive effects on adolescents' electronic cigarette use (i.e., vaping), cigarette smoking, alcohol use, and heavy episodic drinking (HED). We also tested whether harassment mediated substance use disparities between lesbian, gay, bisexual, transgender (LGBT) adolescents and their cisgender heterosexual peers.

METHODS

We analyzed cross-sectional data from the 2013-2014 California Healthy Kids Survey, including 316,766 students in grades 7, 9, and 11 from more than 1,500 middle and high schools. We used logistic regression models and interaction terms to estimate associations of past-year gender- and sexuality-based harassment at school on past-month substance use, and the Karlson-Holm-Breen method to test whether harassment mediated LGBT disparities in substance use.

RESULTS

Vaping, smoking, drinking, HED, and gender- and sexuality-based harassment were higher for transgender adolescents than for cisgender males and females, and for adolescents who were lesbian, gay, or bisexual only versus heterosexual only. Gender- and sexuality-based harassments were independently associated with greater odds of using each substance in every grade. These two types of harassment had positive interactions with each other for vaping in grade 11, smoking in grade 11, and HED in grades 9 and 11. Gender- and sexuality-based harassment significantly mediated many of the LGBT disparities in substance use.

CONCLUSIONS

Gender- and sexuality-based harassment at school independently or interactively produced LGBT disparities in substance use. Reducing these types of discrimination in schools will likely mitigate these disparities.

Risk and Protective Factors for Substance Use among Sexual and Gender Minority Youth: A Scoping Review

Purpose of Review

Alcohol and drug use are common among youth. Rates are especially high among sexual and gender minority youth (SGMY; lesbian, gay, bisexual, transgender). We conducted a scoping review of research on risk and protective factors for substance use among SGMY published between 2013-2017.

Recent Findings

Ninety-seven studies met our inclusion criteria. Most focused on individual-level minority stress risk factors, particularly stigma. Fewer studies addressed protective factors such as social support or affirming policies, and few focused on gender minority youth (GMY). We identified important, yet understudied differences by race/ethnicity, sex assigned at birth, and sexual orientation.

Summary

Findings highlight growing interest in this topic as well as methodological/topical gaps in the literature. Research is needed to examine SGMY substance use in nationally representative samples; expand information about GMY; investigate racial/ethnic and sex/gender differences; improve measurement; and increase translation of findings to support prevention and treatment interventions for this at-risk population.

Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies

BACKGROUND

There is a recent and growing research literature on alcohol use and related harms among transgender and other gender minority populations; however, current definitions and measures of hazardous drinking do not consider the complexity of physiological sex characteristics and socially constructed gender, raising doubts regarding their validity, applicability, and use with these populations. To address this, we reviewed current research on alcohol-related outcomes in transgender populations and critically summarized key issues for consideration in future research.

METHODS

We conducted a systematic review of transgender alcohol research in English language, peer-reviewed journals, published 1990-2017, and extracted key details (e.g., sample composition, alcohol measures, results).

RESULTS

Forty-four studies met all inclusion criteria for the review, the majority of which were conducted in the United States. The prevalence of hazardous drinking was high; however, estimates varied widely across studies. We noted frequent methodological weaknesses, including few attempts to differentiate sex and gender, poor attention to appropriate definitions of hazardous drinking, and reliance on cross-sectional study designs and non-probability sampling methods.

CONCLUSION

Given findings that suggest high need for ongoing public health attention, we offer recommendations to improve future alcohol studies with transgender and other gender minority populations, such as being explicit as to whether and how sex and/or gender are operationalized and relevant for the research question, expanding the repertoire of alcohol measures to include those not contingent on sex or gender, testing the psychometric performance of established screening instruments with transgender populations, and shifting from descriptive to analytic study designs.

Sexual-orientation differences in alcohol use trajectories and disorders in emerging adulthood: results from a longitudinal cohort study in the United States

AIMS

We estimated sexual-orientation differences in alcohol use trajectories during emerging adulthood, and tested whether alcohol use trajectories mediated sexual-orientation differences in alcohol use disorders (AUDs).

DESIGN

Longitudinal self-reported survey data from the Growing Up Today Study.

SETTING

United States.

PARTICIPANTS

A total of 12 493 participants aged 18-25 during the 2003, 2005, 2007 or 2010 surveys.

MEASUREMENTS

Stratified by gender, longitudinal latent class analyses estimated alcohol use trajectories (using past-year frequency, quantity and binge drinking from 2003 to 2010). Multinomial logistic regression tested differences in trajectory class memberships by sexual orientation [comparing completely heterosexual (CH) participants with sexual-minority subgroups: mainly heterosexual (MH), bisexual (BI) and gay/lesbian (GL) participants]. Modified Poisson regression and mediation analyses tested whether trajectories explained sexual-orientation differences in AUDs (past-year DSM-IV abuse/dependence in 2010).

FINDINGS

Six alcohol use trajectory classes emerged for women and five for men: these included heavy (23.5/36.9% of women/men), moderate (31.8/26.4% of women/men), escalation to moderately heavy (9.7/12.0% of women/men), light (17.0% for women only), legal (drinking onset at age 21; 11.1/15.7% of women/men) and non-drinkers (7.0/9.1% of women/men). Compared with CH women, MH and BI women had higher odds of being heavy, moderate, escalation to moderately heavy and light drinkers versus non-drinkers (odds ratios = 2.02-3.42; P-values < 0.01-0.04). Compared with CH men, MH men had higher odds of being heavy, moderate and legal drinkers versus non-drinkers (odds ratios = 2.24-3.34; P-values < 0.01-0.01). MH men and women, BI women and GLs had higher risk of AUDs in 2010 than their same-gender CH counterparts (risk ratios = 1.34-2.17; P-values < 0.01). Alcohol use trajectories mediated sexual-orientation differences in AUDs for MH and GL women (proportion of effect mediated = 30.8-31.1%; P-values < 0.01-0.02), but not for men.

CONCLUSIONS

In the United States, throughout emerging adulthood, several sexual-minority subgroups appear to have higher odds of belonging to heavier alcohol use trajectories than completely heterosexuals. These differences partially explained the higher risk of alcohol use disorders among mainly heterosexual and gay/lesbian women but not among sexual-minority men.

Trends in Secondary Schools' Practices to Support Lesbian, Gay, Bisexual, Transgender, and Questioning Students, 2008-2014

OBJECTIVES

To examine trends in the percentage of US secondary schools that implemented practices related to the support of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) students.

METHODS

This analysis used data from 4 cycles (2008-2014) of School Health Profiles, a surveillance system that provides results representative of secondary schools in each state. Each school completed 2 self-administered questionnaires (principal and teacher) per cycle. We used logistic regression models to examine linear trends.

RESULTS

Of 8 examined practices to support LGBTQ youths, only 1-identifying safe spaces for LGBTQ youths-increased in most states (72%) from 2010 to 2014. Among the remaining 7, only 1-prohibiting harassment based on a student's perceived or actual sexual orientation or gender identity-had relatively high rates of adoption (a median of 90.3% of schools in 2014) across states.

CONCLUSIONS

Many states have seen no change in the implementation of school practices associated with LGBTQ students' health and well-being.