A transdiagnostic minority stress intervention for gender diverse sexual minority women's depression, anxiety, and unhealthy alcohol use: A randomized controlled trial

Daily minority stressors, threat appraisal, and identity concealment among trauma-exposed sexual minority women and transgender and gender-diverse people

Recent calls have been made to decolonize White-dominated, Western narratives around concealment (e.g., that disclosure should be prioritized) and instead to examine psychosocial factors associated with concealment. Existing literature lacks exploration into daily variations of sexual or gender identity concealment (hereafter, "concealment") among sexual and gender minority people, especially sexual minority women (SMW) and transgender and gender-diverse (TGD) individuals who have experienced trauma. Additionally, there is little research delving into individual characteristics, such as trait-based avoidance coping, and specific contexts, including daily minority stressors and threat appraisal, prompting trauma-exposed SMW and TGD people to conceal their identities. Addressing these gaps, we aimed to develop and test an innovative model that advances stress and coping frameworks by integrating minority stress and social safety theories. We used data from a 14-day intensive longitudinal study among 57 trauma-exposed SMW and TGD people. Minority stressors and threat appraisal were associated with concealment at both the within- and between-person levels, respectively. Trait-based general avoidance coping predicted identity concealment and moderated the link between daily minority stressors and concealment. Daily minority stressors were associated with greater concealment only among those who reported lower avoidance coping. Concealment may operate as an experiential avoidance behavior among those who habitually cope by using avoidance and as a goal-directed coping response among trauma-exposed SMW and TGD people who face acute minority stressors and report less avoidance coping. Counseling psychologists exploring the function of concealment with trauma-exposed SMW and TGD people should attend to stigma exposure, threat appraisal, and avoidance coping. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Leveraging Community Engagement and Human-Centered Design to Develop Multilevel Implementation Strategies to Enhance Adoption of a Health Equity Intervention

Background Health equity intervention implementation (which promotes positive health outcomes for populations experiencing disproportionately worse health) is often impeded by health-equity-specific barriers like provider bias; few studies demonstrate how to overcome these barriers through implementation strategies. An urgent health equity problem in the U.S. is the mental health of transgender youth. To address this, we developed Gender-Affirming Psychotherapy (GAP), a health equity intervention comprising best-practice mental health care for transgender youth. This paper details the identification of implementation determinants and the development of targeted strategies to promote provider adoption of GAP. Methods This study represents part of a larger study of mental health provider adoption of GAP. Here we describe the first 2 stages of the 3-stage community-engaged and human-centered design process - Discover, Design/Build, and Test - to identify implementation determinants of adoption and develop implementation strategies with transgender youth, their parents, and mental health providers. This process involved collecting data via focus groups, design meetings, usability testing, and champion meetings. Data were analyzed using rapid and conventional content analysis. Qualitative coding of implementation determinants was guided by the Health Equity Implementation Framework, and implementation strategy coding was facilitated by the ERIC Implementation Strategy Compilation. Results We identified 15 determinants of GAP adoption, and all were specific to the transgender population (e.g., inclusive record system, anti-transgender attitudes). Seventeen implementation strategies were recommended and 12 were developed, collectively addressing all identified determinants. Most strategies were packaged into an online self-paced mental health provider training (implementation intervention) with 6 training tools. Additional inner setting strategies were designed to support training uptake (e.g., mandate training) and GAP adoption (e.g., change record system). Conclusions Community-engaged and human-centered design methods can identify health equity intervention implementation determinants and develop targeted strategies. We highlight five generalizable takeaways for health equity implementation scientists: (1) implementer bias may be a key barrier, (2) experience with the health equity population may be an important facilitator, (3) stakeholder stories may be an effective training tool, (4) inner setting-level implementation strategies may be necessary, and (5) teaching implementers how to build implementation strategies can overcome resource-constraints. Trial registration: NCT05626231.

Randomised controlled trial of LGBTQ-affirmative cognitive-behavioural therapy for sexual minority women's minority stress, mental health and hazardous drinking: Project EQuIP protocol

INTRODUCTION

Sexual minority women represent one of the highest-risk groups for hazardous drinking and comorbid mental health problems (eg, depression, anxiety). Research has identified cognitive (eg, expectations of rejection), affective (eg, emotion dysregulation) and behavioural (eg, avoidant coping) pathways through which minority stress (eg, stigma) places sexual minority women at disproportionate risk of hazardous drinking and comorbid depression/anxiety; yet no evidence-based interventions have been tested to address these pathways in this population. This article describes the design of Project EQuIP (Empowering Queer Identities in Psychotherapy), a randomised controlled trial of a transdiagnostic lesbian, gay, bisexual, transgender, queer (LGBTQ)-affirmative cognitive-behavioural therapy intervention (CBT) designed to improve minority stress coping and reduce sexual minority women's hazardous drinking and mental health comorbidities.

METHODS AND ANALYSIS

This two-arm randomised controlled trial, funded by the National Institute on Alcohol Abuse and Alcoholism, has two objectives: (1) test the efficacy of 10 sessions of LGBTQ-affirmative CBT compared with 10 sessions of supportive counselling for sexual minority women in the community (anticipated n=450) who report hazardous alcohol use and meet criteria for a Diagnostic and Statistical Manual of Mental Disorders - 5 diagnosis of a depression or anxiety disorder and (2) examine psychosocial mechanisms and demographic factors as potential mediators and moderators, respectively, of the treatment-outcome relationship. This study's primary outcome is change in the proportion of heavy drinking days. Secondary outcomes are changes in depressive and anxious symptoms.

ETHICS AND DISSEMINATION

The Yale University Human Subjects Committee reviewed and approved the research protocol. Results of this study will be disseminated to researchers and practitioners through peer-review publications and conference presentations, and directly to study participants.

TRIAL REGISTRATION NUMBER

Registered on 17 August 2022 (ClinicalTrials.gov identifier: NCT05509166).

Using a Sober Curious Framework to Explore Barriers and Facilitators to Helping Sexual Minority Women Reduce Alcohol-Related Harms: Protocol for a Descriptive Study

BACKGROUND

Globally, women consume less alcohol than men, but alcohol consumption among women has declined less in recent years than among men. Drinking rates and alcohol-related harms vary substantially across population groups of women, and sexual minority women (eg, lesbian, bisexual, and queer) are at notably high risk. An emerging body of literature suggests that in addition to minority stress (eg, stigma, discrimination), drinking norms and drinking cultures likely influence sexual minority women's drinking. Almost no research has explored these factors as possible targets of interventions. Sober curiosity is a rapidly growing wellness movement that may be particularly salient for sexual minority women. It encourages individuals to be "curious" about the reasons they choose to drink and alcohol's effects on their life and health.

OBJECTIVE

The aims of this research are to (1) explore the perspectives of the drinking social worlds of sexual minority women, their awareness of the sober curious movement, perceptions of their own and their peers' drinking and desire to drink less, and perceived barriers and facilitations to changing their drinking behaviors and (2) identify key elements of an alcohol reduction intervention tailored for sexual minority women.

METHODS

We conducted a comprehensive review of the literature on alcohol interventions with sexual minority women. The handful of studies we found paid scant attention to drinking cultures, normative beliefs, or other key elements of sober curiosity. To address the study aims, we are conducting 2 descriptive studies with adult (>18 years) sexual minority women using mixed methods. One includes focus group interviews (n=24-36) and a national survey (n=100-120) with sexual minority women in Scotland. The other includes in-depth interviews (n=18-20) with sexual minority women in the United States. Data from the 2 countries and 3 sources will be analyzed using qualitative and quantitative methods to identify patterns and relationships across data to validate or corroborate findings.

RESULTS

Each of the studies received ethics approval in August 2023 and is currently open for recruitment. We anticipate completing data collection in spring 2025. The results of qualitative analyses will be summarized as themes, and results of survey data analyses will be summarized in tables. Findings will be presented to 2 panels of international experts who will assist in identifying critical elements of an alcohol reduction intervention tailored to the unique needs of sexual minority women.

CONCLUSIONS

With the assistance of the expert panels, we will use Acceptability, Practicability, Effectiveness, Affordability, Side-Effects, and Equity criteria to inform the development of a tailored intervention building on tenants of sober curiosity to assist sexual minority women in reducing harmful drinking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63282.

Event-level contextual and motivational risk factors for cannabis use: Evidence for differing associations based on individual-level patterns of cannabis use among sexual minority women and gender diverse individuals

Few studies have examined event-level contextual and motivational risk factors for cannabis use (CU) among sexual minority women and gender diverse individuals (SMWGD). While existing studies assume the same risk factors are relevant for all individuals regardless of their pattern of CU, this study tests two theories proposing variation in associations between event-level risk factors and CU based on individual-level characteristics, including an individual's typical CU frequency (Koob & Volkow, 2010) and how often they use for different reasons and in different contexts (Creswell, 2021). We used an EMA study of CU among SMWGD to examine: 1) unmoderated event-level associations between contexts and motives for use and CU outcomes (e.g., intoxication, consequences); and 2) whether these event-level associations (e.g., daily motives predicting same-day CU outcome) varied by individual-level characteristics, including typical frequency and how often an individual uses for different reasons and in different contexts (e.g., proportion of CU days with coping motives). When an individual reported social, enhancement, or coping motives on a given occasion, they reported higher cannabis consumption. Further, using in both social and solitary settings during the same period (e.g., an evening) was associated with higher consumption than using in only social or solitary settings. Several moderators were identified. For example, coping motives more strongly predicted intoxication for individuals who tended to endorse coping motives more often. Some event-level risk factors may differentially impact CU as a function of individual-level CU patterns. Findings can help to inform the development of CU interventions for SMWGD.

Cognitive behavioural therapy for internalizing symptoms in LGBTQ+ people: a preliminary meta-analysis

Internalizing disorders are common in lesbian, gay, bisexual, transgender, queer, questioning, and otherwise non-heterosexual or non-cisgender (LGBTQ+) people. Few studies have evaluated the efficacy of cognitive behavior therapy (CBT), a well-established treatment for internalizing disorders, in LGBTQ+ people. The current study quantitatively synthesized outcomes from existing trials of CBT for internalizing disorders in LGBTQ+ people. Seven databases were searched, identifying 14 relevant studies with a total of 414 participants. A medium within-group effect size was found for depressive symptoms from pre-treatment to post-treatment (k = 14; g = 0.60; 95% CI: 0.44-0.76; I2 = 71.59) and pre-treatment to 2-6-month follow-up (k = 7; g = 0.63; 95% CI: 0.40-0.86; I2 = 71.59). For anxiety and related disorder symptoms, a medium within-group effect size was found from both pre-treatment to post-treatment (k = 10; g = 0.73; 95% CI: 0.47-0.99; I2 = 71.59) and to 3-9-month follow-up (k = 5; g = 0.70; 95% CI: 0.54-0.87; I2 = 36.04). Exploratory analyses indicated small between-group effects at post-treatment between intervention and control groups. Effect sizes were comparable to those in the general population, indicating preliminary support for treating internalizing disorders in LGBTQ+ people with CBT.

Exploring Help-Seeking Behaviors among Black Sexual Minority Cisgender Women in Late Adolescence: The Role of Abuse Experiences

Sexual minority youth (e.g., lesbian, queer, bisexual) encounter higher rates of abuse compared to their heterosexual peers. Similarly, Black youth are disproportionately affected by adverse experiences, including abuse. Seeking help after experiencing abuse has been shown to improve both mental and physical health outcomes. There is a lack of research on how the intersection of these identities affects help-seeking behaviors when experiencing different types of abuse. To address this gap, our study analyzed national data from 716 Black cisgender sexual minority women (SMW) aged 18 to 21 (Mage = 19.5) who participated in the Healthy Minds Study and examined the likelihood of seeking formal and informal support based on past year emotional, physical, and sexual abuse experiences. Formal help-seeking was assessed by whether participants received counseling or therapy, and informal help-seeking was defined as seeking support from a non-professional source (e.g., family member, friend, and significant other). We found participants who reported abuse experiences, including physical abuse, sexual abuse, emotional abuse, or combined abuse experiences, were significantly more likely to seek informal support, with odds ratios of 2.20, 1.66, 2.77, and 2.38, respectively. However, there was no difference in formal help-seeking compared to participants without abuse experiences. Specific sources of informal support sought were explored descriptively by participants with and without abuse experiences, showing that participants who experienced abuse primarily sought informal support from friends, family members, significant others, and roommates. This trend was consistent among participants who did not report any abuse experiences. Overall, findings suggest that there were no significant differences in the likelihood of seeking formal support regardless of participants' abuse history. However, those who experienced abuse were significantly more likely to seek informal support compared to those who did not. Findings suggest Black adolescent SMW who have endured abuse may face barriers accessing formal support networks; therefore, targeted interventions are needed.

A Scoping Review of Suicide Prevention Interventions for Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Individuals

Purpose: This scoping review summarizes the literature on suicide-specific psychological interventions among lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people to synthesize existing findings and support future intervention research and dissemination. Methods: Electronic databases PsycInfo and PubMed were searched for reports of psychological intervention studies with suicide-related outcome data among LGBTQ+ people. A total of 1269 articles were screened, and 19 studies met inclusion criteria (k = 3 examined suicide-specific interventions tailored to LGBTQ+ people, k = 4 examined nontailored suicide-specific interventions, k = 11 examined minority stress- or LGBTQ+ interventions that were not suicide-specific, and k = 1 examined other types of interventions). Results: Synthesis of this literature was made challenging by varied study designs, and features limit confidence in the degree of internal and external validity of the interventions evaluated. The only established suicide-specific intervention examined was Dialectical Behavior Therapy, and minority stress- and LGBTQ-specific interventions rarely targeted suicidal thoughts and behaviors (STBs). Nevertheless, most interventions reviewed demonstrated support for feasibility and/or acceptability. Only five studies tested suicide-related outcome differences between an LGBTQ+ group and a cisgender/heterosexual group. These studies did not find significant differences in STBs, but certain subgroups such as bisexual individuals may exhibit specific treatment disparities. Conclusion: Given the dearth of research, more research examining interventions that may reduce STBs among LGBTQ+ people is critically needed to address this public health issue.

Exploring the Role of Self-Defective Beliefs in the Relation Between Sexual Orientation and Nonsuicidal Self-Injury in Young Women

INTRODUCTION

People who identify as sexual minorities (SM) report higher rates of nonsuicidal self-injury (NSSI) than heterosexual individuals. One explanatory factor that may be important in this relation is self-defective beliefs. The present study examined the role of self-defective beliefs in the link between sexual orientation and NSSI.

METHOD

Participants were college-aged women (n = 145) with (n = 84) and without (n = 61) recent, recurrent NSSI, completed measures of NSSI and self-defective beliefs. Participants were recruited from a large college and surrounding area in the northeastern U.S.

RESULTS

suggest that SM participants were more likely to report a history of NSSI, frequent and versatile NSSI, and greater self-defective beliefs compared to heterosexual participants, but not more likely to report medically severe NSSI. Results from cross-sectional mediation analyses revealed that self-defective beliefs mediated the relation between SM identity and lifetime NSSI history and partially mediated the relations for NSSI medical severity and versatility, but not NSSI frequency.

CONCLUSIONS

Taken together, our findings suggest that self-defective beliefs are a salient cognitive concern associated with indicators of NSSI severity in college-aged SM women. Additional research is needed to determine whether these findings replicate in SM men, transgender, and gender diverse populations.

Bisexual minority stress as a risk factor for sexual violence-related posttraumatic stress disorder symptoms among bisexual+ women: A multilevel analysis

Bisexual+ (e.g., bisexual, pansexual, queer) women experience higher rates of sexual violence (SV) and posttraumatic stress disorder (PTSD) than heterosexual and lesbian women, as well as unique identity-related minority stress. We examined between- and within-person associations between bisexual minority stress and PTSD symptoms related to SV in a sample of young bisexual+ women (N = 133) who reported adult SV (Mage = 22.0 years, range: 18-25 years; 85.0% White; 99.3% cisgender). We analyzed data from four waves of data collection (baseline to 3-month follow-up) using multilevel models. Controlling for SV severity, there was a significant within-person effect of antibisexual stigma from lesbian/gay people on PTSD, β = .17, p = .010, suggesting that at waves when women experienced more stigma, they also reported higher PTSD symptom levels. At the between-person level, women who reported higher levels of antibisexual stigma from heterosexual people, β = .26, p = .043, and anticipated binegativity, β = .29, p = .005, on average across study waves also reported higher average levels of PTSD. Additionally, anticipated binegativity explained the association between average antibisexual stigma and PTSD, β = .15, p = .014, 95% CI [0.45, 4.61]. Bisexual minority stress may be associated with higher PTSD symptom severity following SV among young bisexual+ women, and the anticipation of binegativity may be a target mechanism in this association. Study findings highlight the importance of examining the joint contributions of SV and minority stress to identify novel targets for future research and practice to address PTSD symptoms.

Efficacy of videoconferencing-delivered cognitive behavioural therapy to reduce anxiety disorder severity in LGBTQ+ people: An exploratory trial protocol

OBJECTIVE

Cognitive behavior therapy (CBT) is a well-established treatment for anxiety disorders in the general population. However, the efficacy of CBT for lesbian, gay, bisexual, transgender, queer, questioning, and otherwise non-heterosexual or non-cisgender (LGBTQ+) people with anxiety disorders is still emerging in the literature. This protocol proposes an exploratory, two-group, randomized controlled trial comparing the efficacy of CBT for anxiety disorders against a waitlist control group.

METHODS

The trial will recruit 52 LGBTQ+ adults with a primary anxiety disorder diagnosis. The treatment will consist of videoconferencing-delivered CBT using the Unified Protocol (UP). The treatment will be provided in eight weekly individual sessions. Following treatment completion, the waitlist control participants will receive an LGBTQ+ adapted CBT intervention delivered via videoconferencing. The control group will receive the LGBTQ+ adapted UP in weekly sessions for eight weeks. Diagnostic status and symptom severity will be assessed at baseline, post-treatment, and three-month follow-up. Post-treatment qualitative exit interviews will collect participant perspectives on treatment acceptability.

RESULTS

Outcome measures will be compared across groups and benchmarked with existing literature to assess efficacy and feasibility, while qualitative analysis will explore intervention acceptability.

CONCLUSION

The results are anticipated to inform best-practice remote transdiagnostic treatment of anxiety disorders in LGBTQ+ people.

Sexual minority stressors and disordered eating behaviors in daily life: a daily diary study of sexual minority cisgender female couples

Young cisgender sexual minority women (e.g. lesbian, queer) in the U.S. are at risk for disordered eating behaviors (DEB). Minority stress theory proposes sexual minority stressors (SMS; e.g. discrimination) related to marginalized statuses are culturally specific stressors that may explain engagement in these behaviors. However, little is known about daily SMS-DEB associations. We conducted a 14-day daily diary study of 321 U.S.-based sexual minority cisgender women ages 19-35 who were in a relationship with a woman. SMS were assessed using an 8-item daily measure of distal SMS (e.g. heard anti-LGBT talk, verbal harassment), and DEB with single items capturing dietary restraint, overeating, loss of control eating, and emotional eating. Multi-level models revealed on days when women experienced SMS, they were more likely to report dietary restraint and emotional eating, but not overeating or loss of control eating. Women who generally reported more frequent SMS were more likely to report all four DEB. There were no significant couple-level SMS-DEB associations. These findings expand our understanding of how SMS is associated with DEB in the daily lives of cisgender sexual minority women. Future studies are needed to explore the temporal sequencing of the associations. Findings may also help to inform the design of culturally tailored interventions aimed at reducing DEB among sexual minority women.

COVID-19 Concerns, Coping and Perceived Peer Norms: Correlates of Increased Alcohol and Marijuana Use Among Sexual Minority Women

This study explored the impact of COVID-related concerns and other characteristics on alcohol and marijuana use among sexual minority women (SMW). Survey data from a racially/ethnically diverse sample of 338 SMW participants in the Chicago Health and Life Experiences of Women (CHLEW) study were used to examine correlates of three substance use outcomes: frequent intoxication (once a month or more), perceived increase in alcohol use, and perceived increase in marijuana use. Coping motives for alcohol use was positively associated with each of the substance use outcomes. Belief that peers (in terms of age, sexual identity, and gender) used alcohol often to cope was associated with higher odds of frequent intoxication. COVID-19 related financial concerns were positively associated with both frequent intoxication and increased marijuana use. Health and mental health concerns were associated with lower odds of frequent intoxication. Findings underscore the importance of enhancing coping skills, addressing perceived peer coping norms, and providing both economic and social support in intervention efforts.

Implementing LGBTQ-affirmative cognitive-behavioral therapy: implementation strategies across five clinical trials

BACKGROUND

LGBTQ-affirmative cognitive-behavioral therapy (CBT) is an evidence-based treatment for reducing transdiagnostic mental and behavioral health concerns among LGBTQ individuals. Preserving the effects of this intervention as it is translated into practice can maximize public health benefits. This study systematically identifies and evaluates implementation strategies for LGBTQ-affirmative CBT.

METHODS

First, we identified and operationalized implementation strategies used across five trials of LGBTQ-affirmative CBT using the Pragmatic Implementation Reporting Tool. Second, we evaluated the relative importance of these strategies via a quantitative assessment (N = 31 unique trial implementers). Survey responses were analyzed descriptively within each trial. Across all trials, we organized strategies as (1) high priority, (2) moderate priority, and (3) optional (if resources are available) for implementing LGBTQ-affirmative CBT.

RESULTS

Within each trial, we identified 20 or more implementation strategies that were used, many of which overlapped across trials. We identified nine high priority strategies (e.g., working with clients to engage them in LGBTQ-affirmative CBT), nine moderate priority strategies (e.g., conducting ongoing training in LGBTQ-affirmative CBT), and nine optional/resource dependent strategies (e.g., showing visual indicators of LGBTQ affirmation within the physical spaces where LGBTQ-affirmative CBT is delivered).

CONCLUSIONS

LGBTQ-affirmative CBT is a complex intervention requiring a package of implementation strategies. Our findings provide guidance for implementers in settings with different levels of resources regarding the highest priority strategies that may be needed to preserve the effectiveness of LGBTQ-affirmative CBT as it is translated into real-world settings.

Associations Between Gender and Sexuality Characteristics of Cisgender Bisexual Women and Risk of Sexual Assault

Objective

Research consistently documents disproportionately high rates of sexual assault among bisexual women, one of the fastest growing sexual minority demographic groups in the United States. This study seeks to better understand how bisexual women's position as both women and sexual minority people may heighten their risk for sexual assault.

Method

Using data from 165 bisexual women in the Chicago Health and Life Experience of Women (CHLEW) study, we examine associations between the gender and sexuality characteristics of self-identifying cisgender bisexual women and sexual assault.

Results

We found that the risk of experiencing sexual assault, including rape, is associated with past experiences of bi-stigma, earlier age of recognizing bisexual identity, gender discrimination, and a less masculine gender presentation.

Conclusion

Our findings suggest that bisexual women are targeted in specific overlapping sexist, bi-phobic and stereotypical ways that may leave them particularly vulnerable to sexual assault. This study highlights the need for more research that investigates how bisexual women's high rates of sexual assault are shaped by oppressive systems and social forces related to their gender and sexuality.

Real-Time Exposure to Negative News Media and Suicidal Ideation Intensity Among LGBTQ+ Young Adults

Importance

With a recent surge in anti-lesbian, gay, bisexual, transgender, or queer (LGBTQ+) policies and associated news and media coverage, there is a need to study the association of LGBTQ+ focused news or media exposure and short-term changes in suicidal ideation (SI) among LGBTQ+ youth.

Objective

To examine within-person direct and indirect associations between exposure to general and LGBTQ+ negative news or media and SI intensity through expectations of rejection.

Design, Setting, and Participants

This intensive longitudinal cohort study used a smartphone-based ecological momentary assessment (EMA) protocol wherein participants responded to EMAs 3 times per day for 28 consecutive days. Young adults aged 18 to 24 years who self-identified as LGBTQ+, resided in Tennessee, and had past-year SI and at least mild depression (defined as a score ≥5 on the Patient Health Questionnaire-9) were eligible for inclusion. Participants were recruited through social media advertisements, LGBTQ+ community organizations, and mental and behavioral health clinics. Participants were recruited between March 30, 2023, and August 23, 2023, and data analyses were conducted from August 28, 2023, through April 20, 2024.

Exposures

At each EMA, participants reported on recent exposure to negative news or media. A 3-level categorical exposure variable denoted (1) no news or media exposure (reference); (2) exposure to general negative news or media; and (3) exposure to LGBTQ+ negative news or media. Each EMA also assessed expectations of rejection due to LGBTQ+ identity on a scale of 0 (not at all) through 10 (very much).

Main Outcomes and Measures

Three primary outcomes assessed current (ie, "right now") intensity of active SI, passive SI, and self-harm ideation, each measured on a scale from 0 (not at all) to 10 (very strong). Multilevel modeling approaches were used to account for the hierarchical structure of EMA data, with assessments (level 1) nested within people (level 2). Linear mixed models and multilevel mediation models were used to examine within-person associations between exposure to negative news or media and the 3 primary outcomes, as well as the mediating role of expectations of rejection.

Results

Of 31 total participants, 22 were assigned female sex at birth (71%), and 16 (52%) self-identified as transgender or gender diverse. The median (IQR) participant age was 21 (18-22) years, and a total of 2189 EMAs were completed, with a median (range) compliance of 90.5% (41.7%-100%). At the within-person level, recent exposure to LGBTQ+ negative news or media was significantly associated with increased active SI (estimate [b], 0.14; 95% CI, 0.04-0.25; P = .009), passive SI (b, 0.23; 95% CI, 0.04-0.41; P = .02), and self-harm ideation (b, 0.13; 95% CI, 0.02-0.23; P = .02). No statistically significant associations were detected for exposure to general negative news or media. In multilevel mediation models, heightened expectations of rejection explained some of the total effect of exposure to LGBTQ+ negative news or media on active SI (23%) and passive SI (37%).

Conclusions and Relevance

This intensive longitudinal cohort study found that SI intensity modestly increased in the hours immediately following exposure to LGBTQ+ negative news or media among LGBTQ+ young adults. These findings have timely implications for research and intervention, particularly within sociopolitical and geographic contexts where news or media coverage about LGBTQ+ topics is intensified.

Cyberaggression victimization on anxiety and depression in college students: the role of emotion regulation, social media, social support, and biological sex

Objective: To test a conceptual model by which emotion dysregulation mediates the association between cyberaggression victimization (CAV) and symptoms of depression and anxiety among college students. Participants: Undergraduate students (N = 459) aged 18 to 29 years. Methods: Participants responded to an online questionnaire assessing CAV and distress associated with these experiences. Participants reported on emotion dysregulation, social media use integration, social support, and depression and anxiety symptoms. Results: As expected, emotion dysregulation mediated the relationship between CAV and depressive and anxiety symptoms. Contrary to expectations, biological sex and social media integration did not moderate the relationship between CAV and emotion dysregulation. Social support reduced the negative effects of emotion dysregulation on depressive and anxiety symptoms. Conclusion: These findings point to the need for colleges to invest in prevention and intervention efforts to reduce exposure to CAV and the impact of those experiences on the health and well-being of students.

State of the Science: LGBTQ-Affirmative Psychotherapy

Sexual and gender minority (SGM) individuals experience significantly higher levels of depression, anxiety, and behavioral comorbidities (i.e., substance use, suicide) compared to heterosexual and cisgender individuals. LGBTQ-affirmative psychotherapy aims to ameliorate the adverse psychosocial processes, ultimately caused by stigma, that underlie this disparity. Over the past two decades, the mental health field has introduced professional guidelines and treatment protocols for LGBTQ-affirmative psychotherapy, and established their efficacy across distinct SGM populations, delivery modalities, and settings. This state of the science review outlines the history, current evidence, and future directions of LGBTQ-affirmative psychotherapy. It provides an historical account of clinically relevant research for SGM populations and outlines the factors that moved the field from pathologizing perspectives to affirmative approaches. It then discusses the current evidence for LGBTQ-affirmative psychotherapy, as well as studies identifying treatment moderators, including race/ethnicity and stigma exposure, as well as potential treatment mechanisms, including hypervigilance, shame, negative self-schemas, unassertiveness, and emotion dysregulation. SGM individuals can only benefit from LGBTQ-affirmative psychotherapy if protocols are widely available and used by therapists. To this end, the article presents current findings on implementation and dissemination, such as therapist training, and different treatment delivery modalities. Finally, the article outlines an agenda for future research to advance the field of LGBTQ-affirmative psychotherapy, including identifying treatment mechanisms, successfully implementing and disseminating treatment protocols, determining which contexts and client characteristics warrant adaptations to current protocols, and understanding how LGBTQ-affirmative psychotherapy can interact with structural and systemic conditions to exert the strongest possible impact on SGM mental health.

Construct Validity and Measurement Invariance of the Difficulties in Emotion Regulation Scale - Short Form (DERS-SF): Further Evidence From Community and Student Samples

The current study aimed to evaluate the psychometric properties of the Difficulties in Emotion Regulation Scale-Short Form (DERS-SF) in Iran, including testing its measurement invariance across sexes, as well as community and student populations. Two samples were recruited: a community sample of 583 participants (58.7% female; Mage = 33.55) and a university student sample of 409 participants (67.2% female; Mage = 24.48). Besides the DERS-SF, participants completed a battery of instruments online, measuring mentalizing capacity and borderline personality features. Confirmatory factor analyses supported the tenability of the five-factor model, excluding the awareness subscale. Except for the awareness subscale, acceptable to excellent internal consistencies were found for the DERS-SF and its subscales. The awareness-excluded DERS-SF was significantly and strongly associated with relevant constructs (|rs| = .49 to .59). This study also found evidence for configural, metric, and scalar invariance of the DERS-SF across sexes and community and student populations. Our findings extended the evidence for the validity and reliability of the DERS-SF and its awareness-excluded version by administering it in Iranian samples and supporting its cross-cultural applicability.

The Role of Shame in Associations with PTSD and Depression Symptoms and Hazardous Drinking Among Bisexual Women Who Experienced Sexual Violence

Bisexual (i.e. those with attraction to multiple genders) women experience disparities in sexual violence and mental health outcomes, including PTSD, depression, and hazardous drinking, compared to lesbian and heterosexual women. Unique stigma due to bisexual identity (antibisexual stigma), negative reactions to sexual violence (SV) disclosure (e.g. victim blaming), and prior child sexual abuse (CSA) may all contribute to shame. We tested whether shame explained the associations of antibisexual stigma, negative reactions to SV disclosure, and CSA severity with PTSD symptoms, depression, and hazardous drinking among young bisexual women. Participants who self-identified as bisexual women, between the ages of 18-35, residing in the US were recruited via Amazon's Mechanical Turk (MTurk) and completed online questionnaires. Women who reported SV since age 18 that they disclosed to someone were included in the current study, yielding a sample of 156 bisexual women (Mage = 25.7; 98.1% cisgender, 86.5% White). Path analysis with bias-corrected bootstrapping was conducted. There were significant direct effects of negative reactions on hazardous drinking and CSA on PTSD, and direct effects of shame on PTSD and depression symptoms. Shame explained the associations of antibisexual stigma, negative reactions, and CSA with PTSD symptoms, depression symptoms, and hazardous drinking. Shame may explain why stigmatizing experiences related to bisexual identity, sexual violence, and CSA history relate to distress among bisexual women. Shame is an important treatment target among bisexual survivors of SV.

Technology-Facilitated Abuse Among College Students: Prevalence and Consequences, and Examinations by Gender and Sexual Identity

The purpose of this investigation is to document the prevalence and consequences of technology-facilitated abuse (TFA) among college students and examine whether gender identity and sexual identity are associated with TFA exposure and related academic and mental health consequences. Data were analyzed from a campus climate survey distributed in Spring 2022. Data from 1,543 college students were collected for TFA experiences, academic consequences, and TFA-related depression, anxiety, and traumatic stress. Multiple linear regression analyses were conducted to test for unique contributions of sexual identity, gender identity, and number of TFA experiences to the outcomes of academic consequences, depression, anxiety, and traumatic stress. The number of TFA experiences was a significant predictor across all models. The contributions of sexual identity and gender identity differed for each outcome. The results of this study align with prior research which has found sexual identity and gender identity to affect outcomes associated with TFA. In addition, TFA was more prevalent among sexual and gender minority students, and the consequences of TFA were more severe within this population. These results suggest that programming takes a dual approach in addressing TFA through reducing TFA exposure and mitigating the impacts of TFA on mental health and other outcomes.

Guided internet-based LGBTQ-affirmative cognitive-behavioral therapy: A randomized controlled trial among sexual minority men in China

OBJECTIVE

LGBTQ-affirmative cognitive-behavioral therapy (CBT) addresses minority stress to improve sexual minority individuals' mental and behavioral health. This treatment has never been tested in high-stigma contexts like China using online delivery.

METHOD

Chinese young sexual minority men (n = 120; ages 16-30; HIV-negative; reporting depression and/or anxiety symptoms and past-90-day HIV-transmission-risk behavior), were randomized to receive 10 sessions of culturally adapted asynchronous LGBTQ-affirmative internet-based CBT (ICBT) or weekly assessments only. The primary outcome included HIV-transmission-risk behavior (i.e., past-30-day condomless anal sex). Secondary outcomes included HIV social-cognitive mechanisms (e.g., condom use self-efficacy), mental health (e.g., depression), and behavioral health (e.g., alcohol use), as well as minority stress (e.g., acceptance concerns), and universal (e.g., emotion regulation) mechanisms at baseline and 4- and 8-month follow-up. Moderation analyses examined treatment efficacy as a function of baseline stigma experiences and session completion.

RESULTS

Compared to assessment only, LGBTQ-affirmative ICBT did not yield greater reductions in HIV-transmission-risk behavior or social-cognitive mechanisms. However, LGBTQ-affirmative ICBT yielded greater improvements in depression (d = -0.50, d = -0.63) and anxiety (d = -0.51, d = -0.49) at 4- and 8-month follow-up, respectively; alcohol use (d = -0.40) at 8-month follow-up; and certain minority stress (e.g., internalized stigma) and universal (i.e., emotion dysregulation) mechanisms compared to assessment only. LGBTQ-affirmative ICBT was more efficacious for reducing HIV-transmission-risk behavior for participants with lower internalized stigma (d = 0.42). Greater session completion predicted greater reductions in suicidality and rumination.

CONCLUSIONS

LGBTQ-affirmative ICBT demonstrates preliminary efficacy for Chinese young sexual minority men. Findings can inform future interventions for young sexual minority men in contexts with limited affirmative supports.

Effects of Racist Microaggressions and Sexual and Gender Minority Stress on Mental Health Among Latinx Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning + Young Adults

This study examines the effects of racist microaggressions and lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)-related minority stressors (i.e., identity concealment, family rejection, internalized LGBTQ-phobia, victimization, and racialized heterosexism/cisgenderism) on psychological distress among Latinx LGBTQ+ young people, specifically college students. Participants are a Latinx subset (n = 80) from a national online nonprobability cross-sectional survey of LGBTQ+ college students. The study aim was examined using linear/logistic regression. Findings indicated that racist microaggressions and family rejection were associated with psychological distress. In addition, racist microaggressions were the only stressor associated with clinically significant psychological distress that may warrant psychiatric/psychological treatment. Therefore, racist microaggressions and family rejection are unique stressors that may saliently affect mental health among Latinx LGBTQ+ students. There is a great need to integrate minority stress theory with other critically-oriented theories, such as intersectionality, in research and intervention to eliminate mental health inequities faced by Latinx LGBTQ+ young people.

Emotion regulation strategies and coping self-efficacy as moderators of daily associations between transgender and gender diverse (TGD) enacted stigma and affect among TGD young adults assigned female at birth

BACKGROUND

Ecological momentary assessment (EMA) studies have begun to establish links between sexual minority enacted stigma and anxious/depressed affect at the daily level. However, few of these studies have examined the effects of the unique stigma experienced by transgender and gender diverse (TGD) people. Further, the potential moderating roles of emotion regulation strategies (i.e., strategies used to up- or down-regulate emotions) and coping self-efficacy (i.e., individuals' perceptions of their ability to cope effectively with stressors) have been neglected in EMA research on enacted stigma.

METHODS

The current study aimed to extend this literature by examining the moderating roles of six emotion regulation strategies (i.e., reflection, reappraisal, rumination, expressive suppression, distraction, social sharing) and coping self-efficacy on concurrent and prospective associations between TGD enacted stigma and affect using EMA data from 115 sexual minority gender diverse individuals assigned female at birth.

RESULTS

Results indicated that coping self-efficacy buffered prospective associations between TGD enacted stigma and anxious/depressed affect, while rumination exacerbated these effects. Some unexpected buffering effects were identified in concurrent associations between enacted stigma and negative affect, with suppression and distraction temporarily tempering this association. However, suppression also prospectively predicted increases in negative affect, suggesting that any benefit of this emotion regulation strategy is temporary.

CONCLUSIONS

Findings highlight emotion regulation strategies that may be effective in reducing negative affect, identify coping self-efficacy as a promising buffer of effects of enacted stigma, and confirm emotion regulation strategies that may exacerbate effects of enacted stigma.

Perceptions of a Cardiovascular Risk Reduction Intervention for Sexual Minority Adults

Sexual minority (SM) adults have a higher prevalence of risk factors for cardiovascular disease (CVD), largely attributable to increased exposure to minority stressors. There are no evidence-based CVD risk reduction interventions tailored to the needs of SM adults. We conducted a qualitative descriptive study to explore SM adults' perceptions and preferences for a culturally tailored, minority stress-informed intervention for CVD risk reduction. SM adults without CVD were interviewed and presented with a 10-week proposed intervention that combined elements of existing interventions for minority stress and CVD risk reduction. Participants were asked about preferences regarding intervention delivery methods, setting, and duration. Interviews were deductively coded into cognitive, behavioral, and socio-environmental themes informed by the Social Cognitive Theory. Themes were also inductively coded based on participant responses. The sample included 22 SM adults with a mean age of 52 (±7.16) years; approximately 55% were female-identified and 59% were non-Latinx White. Cognitive themes included recognition of stress associated with minoritized identities and self-efficacy for behavior change. Behavioral themes included stress management skills and maintaining a healthy lifestyle (e.g., exercise). Socio-environmental themes included barriers (e.g., time commitment) and facilitators (e.g., financial incentives) for participating in the proposed intervention. All participants were interested in an intervention that would improve their cardiovascular health. A majority indicated they preferred a 12-week, virtual, synchronous, group intervention. All participants endorsed the proposed intervention with particular emphasis on stress-reduction components. This study provides important knowledge that should be considered in designing tailored interventions for CVD risk reduction among SM adults.

A Systematic Review of Evidence-Based Cognitive and/or Behavioural Interventions Targeting Mental Health in LGBTQ+ Populations

Background

Despite a minority stress-related higher risk to develop mental health difficulties, and problematic access to and treatment from healthcare providers, research into LGBTQ+ mental health support is limited. The aims of this systematic review were to explore evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in LGBTQ+ populations, before providing recommendations for future clinical and research directions.

Method

Six databases were searched in February-March 2022 and risk of bias evaluated using the Cochrane RoB 2/ROBINS-I tools. A narrative synthesis following the PICOS framework and the review questions was used to examine the results.

Results

Sixteen studies met inclusion criteria, including various interventions and adaptations, mental health difficulties, and other emotion- and minority stress-related processes/constructs. Risk of bias was judged as high, and critical/serious, respectively, in all studies. Outcomes included improvements in symptoms of depression (most statistically/clinically significant effects/large effect sizes), and anxiety, emotion regulation, and internalised homophobia in the pre-post studies.

Conclusion

Cognitive/behavioural interventions and adaptations for LGBTQ+ populations feature a range of therapeutic modalities and levels of adaptation, with largely positive effects, in the context of limited and heterogenous literature and risk of bias concerns, as well as limitations related to publication bias and inclusion criteria of the current work. Suggestions for future clinical and research directions include a focus on generic therapeutic competencies and metacompetencies, and affirmative, potentially more holistic approaches, as well as more consistency in methodology, more focus on underserved LGBTQ+ populations and intersectionality, and more detailed investigations into mechanisms of change.

Strategies for Coping with Minority Stress among Queer Young Adults: Usage Frequency, Associations with Demographics, and Mental Health

Queer young adults report significantly higher levels of anxiety and depression than their heterosexual counterparts, which is linked to sexual minority stress. Therefore, it is important to understand the coping strategies employed by this population to navigate minority stress and how coping strategies may impact mental health outcomes. Drawing from a U.S. national diverse sample of 387 queer young adults (ages 18-39 years), we analyzed descriptive results of 11 behavioral strategies to cope with minority stress and used ordered logistic and linear regression to examine the following objectives: the frequency of the use of each coping strategy, and the associations between each strategy and demographic characteristics as well as depression and anxiety. Results revealed that avoidance and talking with friends were the most frequently utilized coping strategies, while prayer/religious activities and counseling/psychotherapy/support groups were infrequently used. We examined utilization preferences of coping strategies across demographic factors (e.g., assigned sex at birth and sexual orientation). The use of counseling/psychotherapy/support group was positively associated with mental health symptoms, while exercise and mindfulness/mediation were associated with lower mental health symptoms. Our findings provide insights for mental health researchers and professionals in selecting appropriate coping strategies for queer young adults in prevention and intervention efforts.

Religious Identity Dissonance: Examining the Path of Religious Factors to Depression in Sexual Minority Men in the USA

Little is known about the religious factors that contribute to religious identity dissonance (ID) for sexual minority men. Our aim was to model the path of religious factors to depression symptoms through ID and internalized stigma (IS). US sexual minority men (N = 168) participated in a survey about religious factors and mental health. Serial mediation of religious factors through ID and IS to depression symptoms was assessed using Hayes PROCESS macro. Results indicate that two religious factors significantly increase depression through ID and IS. Negative parental religious messages about LGBTQ people play a meaningful role in ID and increasing depression.

Therapist Multicultural Orientation: Client Perceptions of Cultural Humility, LGB Identity, and the Working Alliance

Little attention has been given to how therapist cultural humility may benefit lesbian, gay, and bisexual (LGB) clients. Thus, the current study examined whether therapist cultural humility predicted stronger client-therapist working alliances in a sample of 333 LGB individuals. LGB identity centrality (IC; the extent to which a person's LGB identity is central to their overall identity) and LGB identity affirmation (IA; the extent to which an LGB person associates their sexual orientation with positive thoughts or feelings) were considered as moderators. Therapist cultural humility predicted stronger working alliances between LGB clients and their therapist; however, this association was not moderated by IC or IA. The present results suggest that LGB clients who rated their therapists as culturally humble toward their sexual orientation also reported stronger working alliances with their therapist, regardless of IC or IA. Lastly, exploratory analyses revealed that lower therapist cultural humility ratings were associated with greater sexual orientation acceptance concerns, internalized homonegativity, difficulties coming out, and sexual orientation concealment. The clinical implications of these findings are discussed. Future research should consider the benefits of therapist cultural humility for other gender and sexually diverse persons.

Reckoning With Our Past and Righting Our Future: Report From the Behavior Therapy Task Force on Sexual Orientation and Gender Identity/Expression Change Efforts (SOGIECEs)

Sexual orientation and gender identity/expression change efforts (SOGIECEs) are discredited practices that are associated with serious negative effects and incompatible with modern standards for clinical practice. Despite evidence linking SOGIECEs with serious iatrogenic effects, and despite support for LGBTQ+-affirmative care alternatives, SOGIECE practices persist. In the 1970s and 1980s, Behavior Therapy published articles testing and/or endorsing SOGIECEs, thereby contributing to their overall development, acceptance, and use. The Behavior Therapy Task Force on SOGIECEs was assembled to conduct a rigorous review of the SOGIECE articles published in Behavior Therapy and to decide whether, and what, formal action(s) should be taken on these articles. This report provides a detailed review of the historic SOGIECE literature published in Behavior Therapy and outlines the Task Force's deliberative and democratic processes resulting in actions to: (1) add prominent advisory information to k = 24 SOGIECE papers in the form of digital "black box" disclaimers that caution readers that the SOGIECE practices tested or described in these papers are inconsistent with modern standards, (2) offset organizational financial benefits from the publication of these papers, and (3) promote LGBTQ+-affirmative practices. SOGIECEs are not the only concerning practices across the field's history, and the pages of today's scientific journals include practices that will be at odds with tomorrow's moral standards and ethical guidelines. This report calls for precautionary measures and editorial safeguards to minimize the future likelihood and impact of problematic published scholarship, including the need to fully include those with relevant lived experiences in all aspects of clinical science and peer review.

History and Iatrogenic Effects of Conversion Therapy

Research indicates that sexual orientation change efforts (SOCEs) are not effective and furthermore commonly lead to iatrogenic effects such as depression, anxiety, and even suicide. Negative attitudes toward homosexuality derive from most formal religions and are incarnated in medical and psychological theories that support and encourage SOCEs. Oppression of sexual minorities makes it unlikely that change requests by patients are voluntary. Recently there has been a dramatic change as the field moves from reparative to affirmative approaches. Here, we review the history of SOCEs, their consequences, current affirmative treatments, and future directions in the field as they pertain to the well-being of the queer community. From an institutional community psychology perspective, we argue that even if true conversion were possible, such efforts are unethical and should not be pursued even if requested. As is the case with all psychological/psychiatric interventions, the issue is not "can" but "ought."

Sexual Orientation and Gender Identity Reporting in Highly Cited Current Alcohol Research

Purpose: This study aimed to measure the frequency of high-quality and transparent sexual orientation and gender identity (SOGI) data collection and reporting in highly cited current alcohol use research, using the extant literature to identify community-informed priorities for the measurement of these variables. Methods: A single search to identify alcohol use literature was conducted on PubMed with results restricted to primary research articles published between 2015 and 2022. The 200 most highly cited studies from each year were identified and their titles and abstracts reviewed against inclusion criteria after deduplication. After full-text review, study characteristics and data indicating quality of SOGI reporting were extracted. The fidelity of the results was verified with a random sample before analyses. Results: The final sample comprised 580 records. Few studies reported gender identity (n = 194; 33.4%) and, of these, 7.2% reported the associated gender identity measure. A two-stage approach to measure gender was adopted in 3 studies, one study used an open-ended question with a free-text response option, and 13 studies recorded nonbinary gender identities (reported by 0.9% of the whole sample). Nineteen (3.3%) studies reported sexual orientation and more than half of these provided the sexual orientation measure. Eight of the 20 studies that reported sexual orientation and/or gender identity measures were classified as sexual and gender minority specialist research. Conclusions: Culturally competent SOGI reporting is lacking in highly cited current alcohol research. SOGI measures should be disclosed in future research and should provide free-text response options.

A Descriptive Review and Meta-Regression Study of Demographic and Study Context Factors in US Clinical Trials of Cognitive Behavioral Interventions for Alcohol or Other Drug Use

Objectives. Cognitive-Behaviorally Based Interventions (CBIs) are evidence-based treatments for alcohol and other drug (AOD) use with potential variable effectiveness by population sub-groups. This study used evidence synthesis to examine treatment effect by demographic and study context factors in clinical trials of CBI for AOD. Methods. Studies were systematically identified, and their characteristics and outcome data were extracted and summarized. Standardized mean differences were calculated for within- and between-condition effects on substance use outcomes. Demographic and study context moderators were identified during data acquisition and several sensitivity analyses were conducted. Results. The sample included K = 29 trials and a total of 15 study-level moderators were examined. Information on participants' age, biological sex, and race were reported in at least 26 trials, but information on gender identity, sexual orientation, and ethnicity were reported infrequently or in non-inclusive ways. The mean between-condition effect size was small and moderately heterogenous (d = 0.158, 95% CI = 0.079, 0.238, I2 = 46%) and the mean within-condition effect size was large and showed high heterogeneity (dz = 1.147, 95% CI = 0.811, 1.482, - I2 = 96%). The specific drug targeted in the study and whether biological assay-based outcomes were used moderated between-condition CBI efficacy and the inclusion of co-occurring mental health conditions and study publication date moderated within-condition CBI effects. Conclusions. Results provide preliminary data on study context factors associated with effect estimates in United States based clinical trials of CBI for AOD.

LGBQ-affirming clinical recommendations for compulsive sexual behavior disorder

Background and aims

Since the inclusion of Compulsive Sexual Behavior Disorder (CSBD) in the International Classification of Diseases (11th ed.), there has been little effort placed into developing clinical recommendations for lesbian, gay, bisexual, and queer (LGBQ) clients with this condition. Thus, we develop preliminary clinical recommendations for mental health professionals working with LGBQ clients who may be struggling with CSBD.

Methods

The present paper synthesizes the CSBD literature with advances in LGBQ-affirming care to develop assessment and treatment recommendations. These recommendations are discussed within the context of minority stress theory, which provides an empirically supported explanation for how anti-LGBQ stigma may contribute to the development of mental health conditions in LGBQ populations.

Results

Assessment recommendations are designed to assist mental health professionals in distinguishing aspects of an LGBQ client's sociocultural context from CSBD symptomology, given recent concerns that these constructs may be wrongly conflated and result in misdiagnosis. The treatment recommendations consist of broadly applicable, evidence-based principles that can be leveraged by mental health professionals of various theoretical orientations to provide LGBQ-affirming treatment for CSBD.

Discussion and Conclusions

The present article provides theoretically and empirically supported recommendations for mental health professionals who want to provide LGBQ-affirming care for CSBD. Given the preliminary nature of these recommendations, future research is needed to investigate their clinical applicability and efficacy.

Unveiling the neuro-cognitive paradigm: a new approach to the treatment of anxiety: a comprehensive review

This study aimed to explore the neuro-cognitive paradigm in anxiety diseases by integrating neurobiological and cognitive perspectives. The ideal was to enhance our understanding of the complex interplay between neural and cognitive processes in anxiety and its counteraccusations for treatment. A comprehensive review of the literature was conducted, examining studies that delved into the neurobiological supplements and cognitive impulses in anxiety. The findings revealed the involvement of brain regions similar to the amygdala, prefrontal cortex, and hippocampus in anxiety diseases, along with dysregulation in neurotransmitter systems. Cognitive impulses, including attentional bias towards trouble, interpretation bias, and memory impulses, were constantly observed in individuals with anxiety. The results stressed the bidirectional relationship between neurobiology and cognition, demonstrating that neurobiological factors impact cognitive processes, and cognitive factors modulate neural exertion. Integrated interventions targeting both neurobiological and cognitive factors showed a pledge in treating anxiety diseases. The study linked gaps in the literature and emphasized the significance of considering artistic factors and developing individualized treatment approaches. Overall, this study contributes to a comprehensive understanding of anxiety diseases and informs unborn exploration and clinical practice.

Rural and urban differences in disparities in substance use and substance use disorders affecting sexual minority populations

BACKGROUND

Sexual minority populations are at elevated risk for substance use (SU) and substance use disorders (SUD) compared to heterosexual populations. These disparities are theorized to be amplified for rural sexual minority populations due to their increased exposure to minority stress and reduced access to sexual minority communities. However, there is a lack of research examining differences in SU disparities affecting sexual minority populations by urbanicity, and little research has examined differences in SUD treatment utilization by sexual minority status or urbanicity.

METHODS

We utilized data from 2015 to 2019 National Survey on Drug Use and Health to examine disparities in SU, SUD, SUD treatment utilization, and unmet SUD treatment need between sexual minority and heterosexual populations and test whether such disparities vary by urbanicity.

RESULTS

Results indicate that disparities in SU and SUD affecting sexual minority populations generalize across urbanicities. A subset of disparities differed by urbanicity, and the direction of these differences varied, with some disparities being stronger in urban than rural populations and vice versa. Despite elevated treatment utilization among some sexual minority groups, disparities in unmet SUD treatment need were prevalent across urbanicities and sexual identity groups.

CONCLUSIONS

Study findings highlight the ubiquity of disparities in SU, SUD, and unmet SUD treatment need affecting rural and urban sexual minority populations, while also demonstrating nuanced differences in disparities by urbanicity. The persistence of disparities in unmet SUD treatment need emphasizes the need for future research to identify factors contributing to this disparity and for policies that alleviate these disparities.

Daily and Momentary Associations Between Gender Minority Stress and Resilience With Alcohol Outcomes

BACKGROUND AND PURPOSE

Minority stressors have been linked with alcohol use among transgender and gender diverse (TGD); however, no ecological momentary assessment studies have examined daily links between minority stress and alcohol use specifically among TGD. This study examined gender minority stressors and resilience as predictors of same-day or momentary alcohol-related outcomes. Feasibility and acceptability of procedures were evaluated.

METHODS

Twenty-five TGD adults (mean age = 32.60, SD = 10.82; 88% White) were recruited Canada-wide and participated remotely. They completed 21 days of ecological momentary assessment with daily morning and random surveys (assessing alcohol outcomes, risk processes, gender minority stressors, resilience), and an exit interview eliciting feedback.

RESULTS

Gender minority stress had significant and positive within-person relationships with same-day alcohol use (incidence risk ratio (IRR) = 1.12, 95% confidence interval [CI] [1.02, 1.23]), alcohol-related harms (IRR = 1.14, 95% CI [1.02, 1.28]), and coping motives (IRR = 1.06, 95% CI [1.03, 1.08]), as well as momentary (past 30-min) alcohol craving (IRR = 1.32, 95% CI [1.18, 1.47]), coping motives (IRR = 1.35, 95% CI [1.21, 1.51]), and negative affect (IRR = 1.28, 95% CI [1.20, 1.36]). Gender minority stress indirectly predicted same-day drinking via coping motives (ab = 0.04, 95% CI [0.02, 0.08]). Resilience was positively associated with same-day alcohol use (IRR = 1.25, 95% CI [1.03, 1.51]) but not harms.

CONCLUSIONS

TGD adults may use alcohol to cope with gender minority stress, which can increase the risk for alcohol-related harms. Interventions are needed to eliminate gender minority stressors and support adaptive coping strategies.

Childhood sexual abuse, adult sexual assault, revictimization, and coping among sexual minority women

BACKGROUND

Compared with heterosexual women, sexual minority women experience higher rates and greater severity of sexual victimization. Little is known about how childhood sexual abuse (CSA), adult sexual assault (ASA), and revictimization impact coping in this population. Few studies have examined the effects of recency, developmental stage, and revictimization on coping.

OBJECTIVE

To improve psychosocial outcomes following sexual victimization, it is important to understand whether different patterns of exposure differentially impact coping over time. To do so, we investigated associations between CSA, ASA, and revictimization (both CSA and ASA) and adult sexual minority women's coping strategies.

PARTICIPANTS AND SETTING

Data are from a longitudinal community-based sample of 513 sexual minority women of diverse ages and races/ethnicities.

METHODS

Participants reported CSA (

RESULTS

High-risk (i.e., genital penetration) CSA and recent ASA were associated with more avoidant coping (compared to no CSA or no ASA). No interaction between CSA and ASA was found, but history of both CSA and ASA had a stronger effect on avoidant coping than no victimization or CSA only.

CONCLUSIONS

Although sexual revictimization had a stronger impact on coping than CSA or ASA only, we did not find a synergistic effect (i.e., CSA and ASA may have had stacked independent effects). History of ASA was more strongly associated with coping than CSA. Recency of sexual victimization appears especially salient to coping among sexual minority women.

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Key Words

• Adult sexual assault
• Childhood sexual abuse
• Coping
• Revictimization
• Sexual minority women

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MESH Headings

• Adult
• Female
• Child
• Humans
• Adolescent
• Child Abuse, Sexual/psychology
• Sexual Behavior/psychology
• Crime Victims/psychology
• Coping Skills
• Ethnicity

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Grants

• F32 AA029957 NIAAA NIH HHS
• K01 AA028239 NIAAA NIH HHS
• L60 AA029575 NIAAA NIH HHS
• R01 AA013328 NIAAA NIH HHS

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Affiliation(s)

Mariah Xu Columbia University, School of Nursing, United States of America.
Thomas Corbeil Columbia University, Department of Psychiatry, United States of America
Lauren Bochicchio Columbia University, School of Nursing, United States of America
Jillian R Scheer Syracuse University, Department of Psychology, United States of America
Melanie Wall Columbia University, Department of Psychiatry, United States of America
Tonda L Hughes Columbia University, School of Nursing, United States of America

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The Role of Shame in the Sexual-Orientation Disparity in Mental Health: A Prospective Population-Based Study of Multimodal Emotional Reactions to Stigma

Despite the prominence of shame in stigma theories, its role in explaining population-level mental health disparities between the stigmatized and non-stigmatized has not been investigated. We assessed shame explicitly (via self-report) and implicitly (via a behavioral task) in a prospective, representative cohort of sexual minority and heterosexual young adults in Sweden (baseline n=2,222). Compared to heterosexuals, sexual minorities evidenced higher explicit and implicit shame, which explained sexual orientation disparities in depression, social anxiety, and suicidal thoughts. Among sexual minorities, there was an indirect effect of shame in the association between interpersonal stigma (i.e., past-year family rejection and childhood bullying) and later experiences of adverse mental health; an indirect effect did not exist for the related construct, internalized stigma. Results suggest extending existing stigma theories to consider emotions like shame as characteristic reactions to stigma and guide the search for treatment targets focused on reducing the mental health sequelae of stigma.

Male homoparenting and its challenges: an integrative literature review

This study aims to elucidate the challenges faced in the exercise of male homoparenting, through an integrative literature review. Following PRISMA guidelines, empirical studies from the last 22 years were analyzed, independently collected by four researchers using the PubMed and APA PsychNet databases, with the descriptors "Homosexuality, Male" and "Father". The results reveal the unique and complex reality faced by homosexual men in the parental context. While some studies highlight significant challenges, such as stigmas and social prejudices, others do not observe such difficulties. The decision to become a father among homosexual men is influenced by factors specific to their reality, in a context where parenthood is not widely accepted. The findings of this study emphasize the need to understand the complex interactions among individual, social, and cultural factors in male homoparenting. In summary, this study highlights the need for inclusive and diversity-sensitive approaches to support family well-being.

On the Relationship Between Online Heterosexist Discrimination and Mental Health and Substance Use Among LGBTQ+ Young Adults

LGBTQ+ individuals experience disproportionately higher rates of mental health and substance use difficulties. Discrimination is a significant factor in explaining these disparities. Meyer's (2003) minority stress theory (MST) indicates that proximal group-specific processes mediate the relationship between discrimination and health outcomes, with the effects moderated by other social factors. However, online discrimination has been understudied among LGBTQ+  people. Focusing on LGBTQ+  young adults experiencing online heterosexist discrimination (OHD), the current study aimed to investigate the effect of OHD on mental health outcomes and explore whether the effect was mediated by proximal factors of internalized heterosexism, online concealment, and acceptance concerns and moderated by social support. Path analysis was used to examine the effects. A total of 383 LGBTQ+  young adults (18-35) from an introductory psychology subject pool, two online crowdsourcing platforms, and the community completed a questionnaire assessing these constructs. OHD was associated with increased psychological distress and cannabis use. Two proximal stressors (acceptance concerns and sexual orientation concealment) mediated the relationship between OHD and psychological distress. Sexual orientation concealment also mediated the relationship between OHD and cannabis use. There was no evidence that online social support from LGBTQ+ peers moderated any of the relationships. MST is a viable guiding framework for exploring OHD. Acceptance concerns and online concealment are important constructs to consider and may be potential treatment targets for individuals experiencing psychological distress or engaging in cannabis use due to OHD.

Promoting Resilience to Improve Disordered Eating (PRIDE): A case series of an eating disorder treatment for sexual minority individuals

OBJECTIVE

Despite the increased risk for eating disorders (EDs) among sexual minority (SM) individuals, no ED treatments exist specifically for this population. SM stress and appearance-based pressures may initiate and/or maintain ED symptoms in SM individuals; thus, incorporating strategies to reduce SM stressors into existing treatments may help address SM individuals' increased ED risk. This mixed-methods study evaluated the feasibility, acceptability, and preliminary efficacy of Promoting Resilience to Improve Disordered Eating (PRIDE)-a novel ED treatment for SM individuals.

METHODS

N = 14 SM individuals with an ED diagnosis received 14 weekly sessions integrating Enhanced Cognitive Behavioral Therapy for EDs (CBT-E) with techniques and principles of SM-affirmative CBT developed to address SM stressors. Participants completed qualitative interviews and assessments of ED symptoms and SM stress reactions at baseline (pretreatment), posttreatment, and 1-month follow-up.

RESULTS

Supporting feasibility, 12 of the 14 (85.7%) enrolled participants completed treatment, and qualitative and quantitative data supported PRIDE's acceptability (quantitative rating = 3.73/4). By 1-month follow-up, 75% of the sample was fully remitted from an ED diagnosis. Preliminary efficacy results suggested large and significant improvements in ED symptoms, clinical impairment, and body dissatisfaction, significant medium-large improvements in internalized stigma and nonsignificant small-medium effects of sexual orientation concealment.

DISCUSSION

Initial results support the feasibility, acceptability, and initial efficacy of PRIDE, an ED treatment developed to address SM stressors. Future research should evaluate PRIDE in a larger sample, compare it to an active control condition, and explore whether reductions in SM stress reactions explain reductions in ED symptoms.

PUBLIC SIGNIFICANCE

This study evaluated a treatment for SM individuals with EDs that integrated empirically supported ED treatment with SM-affirmative treatment in a case series. Results support that this treatment was well-accepted by participants and was associated with improvements in ED symptoms and minority stress outcomes.

A systematic review and research agenda of internalized sexual stigma in sexual minority individuals: Evidence from longitudinal and intervention studies

Internalized sexual stigma is a well-established risk factor for poor mental health among sexual minority individuals. However, there has been no synthesis of the literature pertaining to risk and protective factors that influence the development of internalized sexual stigma over time. This systematic review presents findings from 31 studies addressing this question (n = 9192); 23 studies examined psychosocial and sociodemographic predictors of internalized sexual stigma among sexual minority individuals, and eight studies tested the effects of psychological interventions on internalized sexual stigma. Longitudinal studies highlight the stability of internalized sexual stigma over time, and the role of stigma and discrimination, proximal minority stressors (e.g., outness, concealment), and psychological factors (e.g., depressive and anxious symptoms, coping styles, and demoralization) in predicting subsequent internalized sexual stigma. Demographic factors appear to play only a limited role in predicting subsequent internalized sexual stigma. Finally, most intervention studies found no significant effects in reducing internalized sexual stigma, with three exceptions finding significant intervention effects among young sexual minority individuals. We conclude by outlining a theory-driven model of internalized stigma and a research agenda to test more nuanced models of internalized stigma that include multifactorial risk indices.

The cumulative effects of stigma-related stress: Chronic stigma-related stress exposure exacerbates daily associations between enacted stigma and anxious/depressed affect

PURPOSE

Sexual and gender minority individuals are at elevated risk for mood and anxiety disorders compared to heterosexual and cisgender individuals. Ecological momentary assessments studies have implicated experiences of enacted stigma (i.e., biased treatment) by linking these experiences with elevations in anxious and depressed affect. The current study utilizes a theory from the broader stress and affect literature to determine whether chronic enacted stigma exposure amplifies individuals' negative affective reactions to experiences of enacted stigma at the daily level.

METHODS

We used data from a 30-day ecological momentary assessment study with 429 sexual minority women and gender diverse sexual minorities assigned female at birth (SMWGD) living in the US in 2020-21 to determine whether concurrent and prospective event-level associations between enacted stigma, anxious/depressed affect, and perceived coping efficacy were moderated by chronic enacted stigma exposure.

RESULTS

Results demonstrate that individuals with moderate to high chronic stigma exposure experience larger increases in anxious/depressed affect and larger decreases in perceived coping efficacy following daily experiences of enacted stigma. Further, these effects of daily stigma on anxious/depressed affect persist for longer among individuals with high chronic stigma exposure. Interestingly, chronic stigma exposure did not moderate associations between daily general stressors (i.e., those unrelated to identity) and affect or perceived coping efficacy, suggesting that these effects are specific to stigma-related stressors.

CONCLUSIONS

These results help to advance our understanding of both long-term and daily effects of exposure to enacted stigma, highlighting the potentially profound cumulative effects of stigma exposure and the need to intervene in this cycle.

Prospective examination of mechanisms linking minority stress and anxious/depressed affect at the event level: The roles of emotion regulation strategies and proximal minority stressors

BACKGROUND

While studies have linked sexual minority stress with anxious/depressed affect, few studies have prospectively examined how mechanistic processes linking minority stress and anxious/depressed affect unfold in near-real time. Furthermore, studies of mechanisms have focused exclusively on rumination and proximal minority stressors (e.g., internalized stigma). This limits our understanding of other potential mechanisms, such as decreases in the use of reappraisal and reflection, strategies associated with reducing anxious/depressed affect.

METHOD

We used data from a 30-day ecological momentary assessment study with 429 sexual minority women and gender diverse sexual minorities assigned female at birth to determine whether concurrent and prospective event-level associations between minority stress and anxious/depressed affect were mediated by changes in six emotion regulation strategies, perceived coping efficacy, and proximal stressors.

RESULTS

In partially lagged analyses, when individuals experienced enacted or internalized stigma, they reported increased rumination and expressive suppression on the same day, which predicted increases in anxious/depressed affect into the next day. Decreases in reappraisal also mediated partially lagged associations between internalized stigma and anxious/depressed affect. Fully lagged mediation was only demonstrated for rumination as a mechanism linking internalized stigma with anxious/depressed affect. We found concurrent evidence for other mechanisms (i.e., perceived coping efficacy, reflection, internalized stigma, and rejection sensitivity).

CONCLUSIONS

Results provided support for the roles of rumination and expressive suppression as mechanisms of linking minority stress and anxious/depressed affect. The concurrent evidence for other mechanisms suggests that future research with more temporal resolution is necessary to determine the temporality and directionality of these associations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Discrimination, gender dysphoria, drinking to cope, and alcohol harms in the UK trans and non-binary community

Transgender (trans) and non-binary people may be at increased risk of alcohol harms, but little is known about motives for drinking in this community. This study explored the relationship between risk of alcohol dependence, experience of alcohol harms, drinking motives, dysphoria, and discrimination within a United Kingdom sample of trans and non-binary people with a lifetime history of alcohol use. A cross-sectional survey was co-produced with community stakeholders and administered to a purposive sample of trans and non-binary people from 1 February until 31 March 2022. A total of 462 respondents were included-159 identified as non-binary and/or genderqueer (identities outside the man/woman binary), 135 solely as women, 63 solely as men, 15 as another gender identity, 90 selected multiple identities. Higher levels of reported discrimination were associated with higher risk of dependence and more reported harms from drinking. Coping motives, enhancement motives, and drinking to manage dysphoria were associated with higher Alcohol Use Disorders Identification Test scores. Social, coping, and enhancement motives alongside discrimination and drinking to have sex were associated with harms. The relationship between discrimination and risk of dependence was mediated by coping motives and drinking to manage dysphoria. Further to these associations, we suggest that reducing discrimination against trans and non-binary communities might reduce alcohol harms in this population. Interventions should target enhancement motives, coping motives and gender dysphoria. Social and enhancement functions of alcohol could be replaced by alcohol free supportive social spaces.

Evaluation of a codesigned group cognitive-behavioural therapy intervention for trans young people (TAG TEAM): protocol for a feasibility trial and a subsequent pilot RCT

INTRODUCTION

Trans young people are at a higher risk of mental health difficulties such as depression, anxiety and suicidality than their cisgender peers, due in part to their experiences of minority stress. This protocol describes a feasibility trial and subsequent pilot randomised controlled trial (RCT) of a codesigned group cognitive-behavioural therapy intervention for trans young people, named Trans Adolescent Group ThErapy for Alleviating Minority stress (TAG TEAM).

METHODS AND ANALYSIS

To evaluate TAG TEAM, we will conduct a feasibility trial followed by a pilot RCT with trans young people aged 14-16 years who have been referred to the Royal Children's Hospital Gender Service in Melbourne, Australia. In the feasibility trial, we aim to enrol 32 participants who will be randomised at a 1:1 ratio to either in-person or online intervention arms. Participants will be assessed at baseline and post-treatment, with a nested qualitative evaluation post-treatment. Primary outcomes are the feasibility and acceptability of the intervention and the study design and associated procedures, including comparison of the in-person and online delivery modes. In the subsequent pilot RCT, we aim to enrol 64 participants who will be randomised at a 1:1 ratio to an intervention or waitlist control arm, with delivery mode determined by the feasibility trial. Participants will complete assessments at baseline, post-treatment and 3-month follow-up. Primary outcomes are the feasibility and acceptability of the RCT study design. In both the feasibility trial and pilot RCT, participants will complete assessments related to mood, anxiety, suicidality, quality of life, minority stress, family support and social transition. Quantitative data will be analysed using descriptive statistics. Qualitative data will be analysed using thematic and interpretive analysis.

ETHICS AND DISSEMINATION

The Royal Children's Hospital Human Research Ethics Committee has approved this study (#91162). Informed consent will be obtained in writing from all participants and a legal guardian. Findings will inform the development of a full-scale RCT to evaluate the efficacy of TAG TEAM and will be disseminated through conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12623000302651, ACTRN12623000318684.

Efficacy of psychosocial interventions to reduce affective symptoms in sexual and gender minorities: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals are more likely than cisgender heterosexuals to experience mental, physical, and sexual health issues. A promising contemporary strategy to address the issue of affective symptoms in sexual and gender minorities (SGM) is psychosocial intervention.

OBJECTIVE

To systematically evaluate the effect of psychosocial interventions on the improvement of affective symptoms in SGM, and to provide a reference for the implementation of effective psychological interventions for SGM with affective symptoms.

METHODS

Between the date of database construction until December 10, 2022, a computerized search of the English-language literature published both nationally and worldwide was done. 8 literature databases and 3 additional gray databases were searched. We gathered randomized controlled trials that used psychological interventions for SGM. To evaluate risk bias in included papers in accordance with Cochrane cooperation criteria, we used Review Manager 5.4 software. In conjunction with post-test and follow-up data, mean differences were standardized using Stata 12.0 software. Subgroup analysis was used to investigate the cause of heterogeneity. The study was conducted strictly in accordance with PRISMA guidelines, and it was registered on the PROSPERO platform (CRD42023408610).

RESULTS

This review covered 18 research, and 14 studies were included in the meta-analysis. A total of 1194 study cases, including 706 cases from the control group and 488 cases from the experimental group, were included in these investigations. Compared to the control group, the psychosocial intervention group had significantly lower levels of depression (standardized mean difference (SMD) = -0.17;95% CI = [-0.30, -0.04]; p = 0.012) and anxiety (SMD = -0.22; 95% CI = [-0.41, -0.04]; p = 0.01), but no significant differences were found for distress (SMD = -0.19; 95% CI = [-0.45,0.07]; p = 0.021).

CONCLUSION

According to this study, psychosocial interventions helped lessen the symptoms of depression and anxiety in SGM but had no significant effect on their psychological distress. To assess the impact of psychological intervention on SGM, more randomized controlled trials with larger sample sizes and numerous follow-up times should be done.

A patient-centered model of mental health care for trauma and minority stress in transgender and gender diverse people: A bottom-up network analysis

Transgender and gender diverse (TGD) individuals are disproportionately exposed to traumatic and high-impact minority stressors which can produce an array of transdiagnostic symptoms. Some clinical presentations align well with established evidence-based treatments, but others may require patient-centered modifications or combined approaches to address treatment needs. In this study, we employed a novel, bottom-up approach to derive insights into preferred intervention strategies for a broad range of trauma- and TGD-minority stress-related expressions of clinical distress. Participants (18 TGD individuals, 16 providers) completed a q-sort task by first sorting cards featuring traumatic experiences and/or minority stressors and transdiagnostic psychiatric symptoms into groups based on perceived similarity. Next, participants sorted interventions they believed to be most relevant for addressing these concerns/symptoms. We overlayed networks of stressors and symptoms with intervention networks to evaluate preferred intervention strategies. TGD networks revealed transdiagnostic clustering of intervention strategies and uniquely positioned the expectancy of future harm as a traumatic stressor. Provider networks were more granular in structure; both groups surprisingly emphasized the role of self-defense as intervention. While both networks had high overlap, their discrepancies highlight patient perspectives that practical, material, and structural changes should occur alongside traditional clinical interventions.

Emotion regulation and OCD among sexual minority people: Identifying treatment targets

Sexual minority individuals experience higher rates of psychopathology, such that sexual minority people are nine times more likely to receive a diagnosis or treatment for obsessive-compulsive disorder (OCD) compared to heterosexual people. Poor emotion regulation capacity is a risk factor for OCD, but little is known about sexual orientation differences in dimensions of emotion regulation and how dimensions of emotion regulation relate to OCD severity among sexual minority people. The aims of the current study include 1) comparing sexual minority to heterosexual people on OCD severity and emotion regulation capacity upon admission to treatment for OCD, and 2) examining emotion regulation in relation to OCD severity among sexual minority people. Participants (N = 470) were adults in partial hospital/residential treatment with an average stay of 59.7 days (SD = 25.3), including 22 % sexual minority people. Sexual minority people reported a lower emotion regulation capacity. Among the largest three subgroups (heterosexual, bi+, and gay/lesbian), bi+ individuals reported a lower emotion regulation capacity compared to heterosexual but not gay/lesbian people. Results suggest there are sexual orientation differences in emotion regulation capacity, and that bi+ people have the most difficulty with ER. There is a need for OCD treatment to directly target emotion regulation strategies and be affirming of sexual minority identities.