Sexual Orientation Differences in Adolescent Health Care Access and Health-Promoting Physician Advice

Novel Latent Profile Analysis of a Test of Concept, Stigma Intervention to Increase PrEP Uptake Among Black Sexual Minority Men

BACKGROUND

Pre-exposure prophylaxis (PrEP) has demonstrated efficacy for HIV prevention, yet uptake of PrEP among populations in urgent need of prevention tools (eg, Black sexual minority men) is limited, and stigma and medical mistrust remain strong barriers to accessing PrEP.

PURPOSE

To evaluate a test of concept brief intervention to address stigma and medical mistrust as barriers to PrEP uptake using novel latent profile analysis.

METHODS

Participants (N = 177) residing in the southeastern US were randomized to 1 of 4 arms to establish the potential impact of a brief, stigma focused counseling intervention (referred to as Jumpstart ) to increase PrEP uptake. We estimated intervention effect size (Cramer's V) for PrEP uptake and then explored differential intervention effects across latent profiles of psychosocial barriers to PrEP use.

RESULTS

The intervention resulted in small, but meaningful effect size, with self-reported PrEP uptake increasing across Jumpstart conditions with the control condition reporting 24% uptake and Jumpstart plus text/phone calls (the most intensive intervention arm) reporting 37% uptake, and a similar pattern emerging for biologically confirmed PrEP use. Among participants 30 and older, Jumpstart participants were more likely to move to a postintervention profile with fewer barriers than control participants and reported the highest uptake of PrEP.

CONCLUSIONS

Addressing social/emotional barriers to PrEP uptake is an essential component of bridging the gap between advances being made in biomedical forms of HIV prevention, and establishing and supporting access to those advances.

A Nationally Representative Study of Sexual Orientation and High-Risk Drinking From Adolescence to Young Adulthood

PURPOSE

To determine whether peer drunkenness, parental knowledge about their adolescent's whereabouts and behaviors, and depressive symptoms contribute to sexual orientation disparities in high-risk drinking behaviors; if they do, they would be potential intervention targets.

METHODS

Longitudinal survey data from 2,051 adolescents who participated in the NEXT Generation Health Study were analyzed. Latent growth curve and longitudinal path analyses were used to test for indirect effects linking sexual orientation in 11th grade (3.4% males and 8.4% females were sexual minorities) to past 30-day heavy episodic drinking (HED) over 6 years and past year high-intensity binge drinking at 4 years after high school.

RESULTS

Sexual minority males were not more likely to engage in high-risk drinking than heterosexual males. In contrast, sexual minority females were more likely than heterosexual females to engage in HED when they were in 11th grade (Odds Ratio = 2.83, 95% confidence interval = 1.43, 5.61), in part because of lower parental knowledge. Sexual minority females also had higher depressive symptoms during the transition from adolescence to young adulthood, which in turn was associated with greater risk of high-intensity binge drinking in young adulthood. Peer drunkenness was a strong risk factor for HED and high-intensity binge drinking among both males and females.

DISCUSSION

Sexual minority females reported lower levels of parental knowledge during adolescence and higher levels of depressive symptoms during the transition to young adulthood than heterosexual females. Both factors were associated with high-risk drinking behavior, suggesting developmentally sensitive opportunities to mitigate sexual orientation disparities in high-risk drinking.

Access to health services among sexual minority people in the United States

Sexual minority people in the United States are less likely to have access to health services when compared to their heterosexual counterparts. Less is known about the within-group sociodemographic memberships among sexual minority people regarding access to health services. Using data from a nationally representative sample, a series of univariate and bivariate analyses were used to determine associations between sociodemographic group membership and access to health services. Results suggest there are significant differences in access to health services within the sexual minority population. Differences in access to health services when considering sex-at-birth, sexual identity, age, race/ethnicity, urbanicity, education level and income status were found. These findings offer insight into the role sociodemographic group membership has on the equity of access to health services. Specifically, results indicated that disproportionate access to health services among sexual minority people were more pronounced among those with group membership who experience social marginalisation. This was particularly true for sexual minority people who were bisexual, younger, Black and Latinx, lower-income earners and sexual minority people with less education attainment. Results from this study may be used to inform policies and practices aimed at improving access to health services including, but not limited to, the expansion of the Affordable Care Act and continued development of Federally Qualified Health Centers, while acknowledging the role of within-group differences among sexual minority people.

Predictors of Past-Year Health Care Utilization Among Young Men Who Have Sex with Men Using Andersen's Behavioral Model of Health Service Use

Purpose: This study examined factors associated with past-year health care utilization among young gay, bisexual, and other men who have sex with men (YMSM) using Andersen's behavioral model of health service use. Methods: From 2018 to 2020, 751 YMSM (aged 13-18) recruited online and offline for the MyPEEPS mHealth HIV prevention study completed an online survey. Hierarchical logistic regression models assessed associations between past-year health care utilization (i.e., routine checkup) and predisposing (parental education, race/ethnicity, age, and internalized homonegativity), enabling (health literacy, health care facility type, U.S. Census Divisions), and need factors (ever testing for HIV). Results: The sample included 31.8% Hispanic, 23.9% White, and 14.6% Black YMSM; median age was 16. Most (75%) reported past-year health care utilization, often from private doctor's offices (29.1%); 6% reported no regular source of care. In the final regression model, higher odds of past-year health care utilization were found for younger participants (age 13-14, adjusted odds ratio [AOR] = 1.91; 95% confidence interval [CI]: 1.07-3.43; age 15-16 AOR = 1.55; 95% CI: 1.04-2.30; reference: 17-18) and those with increasing health literacy (AOR = 1.71; 95% CI: 1.36-2.16). YMSM with lower parental education had lower odds of past-year health care utilization (AOR = 0.56; 95% CI: 0.38-0.84), as did those relying on urgent care facilities (AOR = 0.60; 95% CI: 0.41-0.87; reference: routine care facilities) and those who identified as Mixed/Other race (AOR = 0.50; 95% CI: 0.28-0.91; reference: White). Conclusions: Findings highlight opportunities to intervene in YMSM's health risk trajectory before age 17 to reduce drop-off in routine health care utilization. Interventions to improve routine health care utilization among YMSM may be strengthened by building resilience (e.g., health literacy) while removing barriers maintained through structural disadvantage, including equity in education. Clinical Trial Registration Number: NCT03167606.

A retrospective study of HIV pre-exposure prophylaxis counselling among non-Hispanic Black youth diagnosed with bacterial sexually transmitted infections in the United States, 2014-2019

INTRODUCTION

Youth account for a disproportionate number of new HIV infections; however, pre-exposure prophylaxis (PrEP) use is limited. We evaluated PrEP counselling rates among non-Hispanic Black youth in the United States after a bacterial sexually transmitted infection (STI) diagnosis.

METHODS

We conducted a retrospective cohort study of Black youth receiving care at two academically affiliated clinics in Philadelphia between June 2014 and June 2019. We compared PrEP counselling for youth who received primary care services versus those who did not receive primary care services, all of whom met PrEP eligibility criteria due to STI diagnosis per U.S. Centers for Disease Control and Prevention clinical practice guidelines. Two logistic regression models for receipt of PrEP counselling were fit: Model 1 focused on sexual and gender minority (SGM) status and Model 2 on rectal STIs with both models adjusted for patient- and healthcare-level factors.

RESULTS

Four hundred and sixteen patients met PrEP eligibility criteria due to STI based on sex assigned at birth and sexual partners. Thirty patients (7%) had documentation of PrEP counselling. Receipt of primary care services was not significantly associated with receipt of PrEP counselling in either Model 1 (adjusted OR (aOR) 0.10 [95% CI 0.01, 0.99]) or Model 2 (aOR 0.52 [95% CI 0.10, 2.77]). Receipt of PrEP counselling was significantly associated with later calendar years of STI diagnosis (aOR 6.80 [95% CI 1.64, 29.3]), assigned male sex at birth (aOR 26.2 [95% CI 3.46, 198]) and SGM identity (aOR 317 [95% CI 39.9, 2521]) in Model 1 and later calendar years of diagnosis (aOR 3.46 [95% CI 1.25, 9.58]), assigned male sex at birth (aOR 18.6 [95% CI 3.88, 89.3]) and rectal STI diagnosis (aOR 28.0 [95% CI 8.07, 97.5]) in Model 2. Fourteen patients (3%) started PrEP during the observation period; 12/14 (86%) were SGM primary care patients assigned male sex at birth.

CONCLUSIONS

PrEP counselling and uptake among U.S. non-Hispanic Black youth remain disproportionately low despite recent STI diagnosis. These findings support the need for robust investment in PrEP-inclusive sexual health services that are widely implemented and culturally tailored to Black youth, particularly cisgender heterosexual females.

Same, opposite and both-sex attracted adolescents' mental health, safe-sex practices and substance use

This study examined mental health, substance use, and sexual health across sexual attraction groups. 428 adolescents recruited from school-based health centers completed self-report measures. 72% were only opposite-sex attracted, 19% both-sex attracted, 3% same-sex attracted, 4% not sure. Reported partners did not always align with reported attraction. Compared to opposite-sex attracted youth, 1) both-sex attracted youth had significantly higher rates of marijuana use (OR=1.75, p=.04), depressive symptoms (OR=2.62, p=.001) and inconsistent condom use (OR=1.71, p=.05); 2) the "not sure" group had higher anxiety symptoms (OR=4, p=.01). This study highlights the importance of considering sexual attraction in providing quality care to young people.

Sexual Minority Status and Age of Onset of Adolescent Suicide Ideation and Behavior

OBJECTIVES

To determine if sexual minority adolescents have earlier onset of suicidality and faster progressions from ideation to plan and attempt than heterosexual adolescents.

METHODS

A population-based longitudinal cohort of 1771 adolescents participated in the NEXT Generation Health Study. Participants reported sexual minority status (defined by sexual attraction) in 2010-2011 and retrospectively reported age at onset of suicidality in 2015-2016.

RESULTS

Sexual minority adolescents (5.8% of weighted sample) had higher lifetime risk of suicide ideation (26.1% vs 13.0%), plan (16.6% vs 5.4%), and attempt (12.0% vs 5.4%) than heterosexual adolescents. Survival analyses adjusted for demographic characteristics and depressive symptoms revealed positive associations of sexual minority status with time to first onset of suicide ideation (hazard ratio [HR] = 1.77; 95% confidence interval [CI] 1.03-3.06) and plan (HR = 2.69; 95% CI 1.30-5.56). The association between sexual minority status and age at onset of suicide attempt was stronger at age <15 (HR = 3.26; 95% CI 1.25-8.47) than age ≥15 (HR = 0.59; 95% CI 0.21-1.66). The association between sexual minority status and progression from ideation to plan was stronger in the same year of first ideation (HR = 2.01; 95% CI 1.07-3.77) than ≥1 year after first ideation (HR = 1.33; 95% CI 0.26-6.77).

CONCLUSIONS

Sexual minority adolescents had earlier onset of suicidality and faster progression from suicide ideation to plan than heterosexual adolescents. The assessment of sexual minority status in routine pediatric care has the potential to inform suicide risk screening, management, and intervention efforts among early sexual minority adolescents.

Social-Ecological Barriers to Access to Healthcare for Adolescents: A Scoping Review

Access to healthcare for adolescents is often overlooked in the United States due to federal and state-sponsored insurance programs such as Medicaid and the Children's Health Insurance Program. While these types of programs provide some relief, the issue of healthcare access goes beyond insurance coverage and includes an array of ecological factors that hinder youths from receiving services. The purpose of this scoping review was to identify social-ecological barriers to adolescents' healthcare access and utilization in the United States. We followed the PRISMA and scoping review methodological framework to conduct a comprehensive literature search in eight electronic databases for peer-reviewed articles published between 2010 and 2020. An inductive content analysis was performed to thematize the categories identified in the data extraction based on the Social-Ecological Model (SEM). Fifty studies were identified. Barriers across the five SEM levels emerged as primary themes within the literature, including intrapersonal-limited knowledge of and poor previous experiences with healthcare services, interpersonal-cultural and linguistic barriers, organizational-structural barriers in healthcare systems, community-social stigma, and policy-inadequate insurance coverage. Healthcare access for adolescents is a systems-level problem requiring a multifaceted approach that considers complex and adaptive behaviors.

Misinformation, Gendered Perceptions, and Low Healthcare Provider Communication Around HPV and the HPV Vaccine Among Young Sexual Minority Men in New York City: The P18 Cohort Study

Human papillomavirus (HPV) is the most common sexually transmitted infection among adults in the United States, and can cause several types of cancer. This is of particular concern for sexual minority men, as their increased risk of HIV acquisition increases risk for HPV and HPV-associated cancers, particularly when coupled with low rates of HPV vaccination. As part of a larger study of the syndemic of HIV, substance use, and mental health among young sexual minority men in New York City, we sought to explore what sexual minority men know about HPV and the HPV vaccine, along with their experiences have been communicating about the virus and vaccine. We interviewed 38 young sexual minority men with diverse sociodemographic characteristics and identified three main themes: low knowledge about HPV infection and vaccination, highly gendered misconceptions about HPV only affecting women, and lack of communication from healthcare providers about HPV. The prevalence of incorrect HPV knowledge, coupled with inadequate education and vaccination in healthcare settings, indicates a missed opportunity for HPV prevention in a high-risk and high-need population.

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.

Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department

In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.

Sexual attraction and experiences in the primary care setting: Examining disparities in satisfaction with provider and health self-efficacy

INTRODUCTION

To test whether sexual minority males and females report lower satisfaction with primary care providers and lower health self-efficacy relative to heterosexual males and females.

METHODS

Data from 535 adolescents who participated in one of two randomized clinical trials conducted in a primary care setting were analyzed. Multiple linear regressions controlling for demographic characteristics and treatment condition were used to examine sexual attraction differences in indicators of satisfaction with provider and health self-efficacy.

RESULTS

Sexual minority and heterosexual youth both endorsed high satisfaction with providers. Relative to heterosexual males, sexual minority males reported lower self-efficacy in reaching their health goals. Relative to heterosexual females, sexual minority females reported lower confidence in positively impacting their own health, and lower self-efficacy in setting goals and working actively to improve their health.

CONCLUSIONS

Sexual minority youth may benefit from additional support from health care providers to enhance their health self-efficacy and reach their health goals.

Identification of Sexual Minority Youth in Pediatric Primary Care Settings Within a Large Integrated Healthcare System Using Electronic Health Records

PURPOSE

The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire.

METHODS

This study assessed SMY status in youth aged 12.5-18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as self-reported attraction to the same sex or both sexes.

RESULTS

A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n = 5,329) of respondents (N = 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6-2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth.

CONCLUSIONS

This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.

Navigating the Long Road Forward for Maximizing PrEP Impact Among Adolescent Men Who Have Sex with Men

Preexposure prophylaxis (PrEP) has tremendous potential to decrease new HIV infections among populations at high risk, such as men who have sex with men (MSM). That potential is already becoming realized among adult MSM, where PrEP uptake has increased rapidly in the past several years. However, expanding PrEP access to adolescent MSM (AMSM) will be more challenging. This commentary reviews the existing scientific literature relevant to PrEP use for AMSM and highlights critical areas in need of further attention before PrEP is likely to impact the HIV epidemic among adolescents. We highlight concerns that need to be addressed in the areas of (1) achieving adequate coverage of PrEP in the adolescent population, (2) increasing awareness and access, (3) supporting adherence and maintenance, and (4) ensuring that PrEP does not perpetuate existing disparities. Across all of these domains, we highlight the central roles of parents and healthcare providers in supporting AMSM PrEP utilization. Finally, we suggest a number of areas of future research that must be addressed before PrEP is likely to see wide implementation among AMSM.

Acne and the Lesbian, Gay, Bisexual, or Transgender Teenager

Although most teenagers experience acne, for sexual and gender minority teenagers, acne could be more challenging and require specific psychosocial considerations. Acne may be more strongly associated with mental health issues in sexual and gender minority adolescents. Acne development during puberty may trigger gender dysphoria in transgender patients. Transgender and gender nonbinary patients receiving testosterone therapy may experience new or worsening acne. Comprehensive care for moderate to severe acne in sexual and gender minority adolescents should include culturally competent discussions about sexual behaviors, contraception, and/or gender-affirmation treatment plans.

Utilization and avoidance of sexual health services and providers by YMSM and transgender youth assigned male at birth in Chicago

Young men who have sex with men (YMSM) and transgender youth assigned male at birth (AMAB) bear a disproportionate burden of the HIV epidemic, yet are sub optimally engaged by sexual health service providers and HIV prevention services. To increase sexual health and HIV prevention behaviors and address disparities in HIV incidence and outcomes among YMSM and AMAB transgender youth, it is critical to understand patterns of service utilization and avoidance. This study examined how and why YMSM and AMAB transgender youth use or avoid sexual health services and service providers in a large Midwestern city within a survey administered to 890 participants from a longitudinal cohort study (RADAR). Results demonstrate low overall use of sexual health services and minimal interest in seeking pre-exposure prophylaxis (PrEP), consistent with prior research. Low awareness of available services was associated with how and where YMSM and trans youth AMAB seek care, with 76% of our sample reporting this as their primary reason for not seeking specific sexual health services. Additional associations are discussed, and recommendations are made for how to improve available services and access.

Engaging Young Men in the HIV Prevention and Care Continua: Experiences From Young Men of Color Who Have Sex With Men

Sexual minority individuals experience barriers to receiving equitable health care. Research also indicates that young men who have sex with men (YMSM), particularly young men of color, have limited engagement in the HIV care continuum and there are significant disparities across the continuum. This study aims to uncover how providers can engage YMSM of color in all forms of care, including primary care and HIV prevention through an HIV prevention continuum. This qualitative study reports data from the Healthy Young Men's Cohort Study; a total of 49 YMSM participated in the eight focus groups. This study provides a description of YMSM's overall health concerns, experiences with health care, and under what circumstances YMSM seek care. We then present a model describing the salient characteristics of a HIV prevention continuum for YMSM of color and provide clear areas for education, intervention, and policy change to support better overall health for YMSM of color.

A Systematic Review of Sexual Orientation Disparities in Disordered Eating and Weight-Related Behaviors among Adolescents and Young Adults: Toward a Developmental Model

Adolescence is a sensitive period for the development of disordered eating and weight-related behaviors, and sexual minorities may be particularly at risk due to heightened minority stress and challenges related to sexual identity development. This review synthesized findings from 32 articles that examined sexual orientation disparities (each with a heterosexual referent group) in four disordered eating behaviors (binging, purging, restrictive dieting, diet pill use) and four weight-related behaviors (eating behaviors, physical activity, body image, and Body Mass Index [BMI]). Potential variations by outcome, sex, race/ethnicity, and developmental stage were systematically reviewed. Evidence supporting sexual orientation disparities in disordered eating and weight-related behaviors was more consistent among males than females. Among females, sexual orientation disparities in disordered eating behaviors appeared to be more pronounced during adolescence than in young adulthood. Sexual minority females generally reported more positive body image than heterosexual females but experienced disparities in BMI. Sexual orientation differences in eating behaviors and physical activity were especially understudied. Incorporating objectification and minority stress theory, a developmental model was devised where body image was conceptualized as a key mechanism leading to disordered eating behaviors. To advance understanding of sexual orientation disparities and tailor intervention efforts, research in this field should utilize longitudinal study designs to examine developmental variations and incorporate multi-dimensional measurements of sexual orientation and body image.

Cyber Behaviors Among Heterosexual and Sexual Minority Youth: Subgroup Differences and Associations with Health Indicators

To examine the associations of adolescent sexual orientation with cyber behaviors and health indicators 5 years later during young adulthood and test whether cyber behaviors contribute to sexual orientation health disparities. Data were drawn from Waves 2 and 7 from the NEXT Generational Health Study, a nationally representative cohort of U.S. adolescents (n = 2012). Multiple linear regressions were used to examine differences between sexual orientation subgroups (defined based on sexual attraction) in five cyber behaviors and five health indicators. Mediation analyses were conducted to examine whether cyber behaviors mediated the associations between bisexual attraction and health indicators. Relative to heterosexual peers, bisexual youth spent more time engaging in cyber behaviors and social media, and reported more psychosomatic symptoms and poorer general health. Gay and questioning males spent less time playing video games than heterosexual males. Bisexual females reported more depressive symptoms and less optimism and happiness than heterosexual females. Time spent on cyber behaviors and social media was a significant mediator of adolescent bisexual attraction and worse health outcomes in young adulthood. Frequency of cyber behaviors differed between sexual minority subgroups. Bisexual youth in particular had more psychosomatic symptoms and poorer general health. Engagement in cyber behaviors and social media use contributed to increased health disparities among bisexual youth.

Sexual Orientation and Depressive Symptoms in Adolescents

OBJECTIVES

Sexual orientation disparities in adolescent depressive symptoms are well established, but reasons for these disparities are less well understood. We modeled sexual orientation disparities in depressive symptoms from late adolescence into young adulthood and evaluated family satisfaction, peer support, cyberbullying victimization, and unmet medical needs as potential mediators.

METHODS

Data were from waves 2 to 6 of the NEXT Generation Health Study (n = 2396), a population-based cohort of US adolescents. We used latent growth models to examine sexual orientation disparities in depressive symptoms in participants aged 17 to 21 years, conduct mediation analyses, and examine sex differences.

RESULTS

Relative to heterosexual adolescents, sexual minority adolescents (those who are attracted to the same or both sexes or are questioning; 6.3% of the weighted sample) consistently reported higher depressive symptoms from 11th grade to 3 years after high school. Mediation analyses indicated that sexual minority adolescents reported lower family satisfaction, greater cyberbullying victimization, and increased likelihood of unmet medical needs, all of which were associated with higher depressive symptoms. The mediating role of cyberbullying victimization was more pronounced among male than female participants.

CONCLUSIONS

Sexual minority adolescents reported higher depressive symptoms than heterosexual adolescents from late adolescence into young adulthood. Collectively, low family satisfaction, cyberbullying victimization, and unmet medical needs accounted for >45% of differences by sexual orientation. Future clinical research is needed to determine if interventions targeting these psychosocial and health care-related factors would reduce sexual orientation disparities in depressive symptoms and the optimal timing of such interventions.