How many sexual minorities are hidden? Projecting the size of the global closet with implications for policy and public health

Effectiveness of educational intervention for improving Monkeypox (Mpox) viral infection knowledge among MSM population

BACKGROUND

Mpox is a zoonotic disease caused by the mpox virus (MPXV), which has recently exhibited human-to-human transmission globally. Due to its hidden nature and high-risk behaviors, men who have sex with men (MSM) has become a focal point for mpox prevention and control. This study evaluates the impact of health interventions on mpox knowledge awareness among MSM.

METHODS

Through pre- and post-MIP surveys, we analyzed the awareness of mpox knowledge, preferences for acquiring mpox information, and preferred channels among MSM. Data collection occurred from August 2023 to March 2024, with a total of 1514 valid questionnaires collected. The Mpox Intervention Program (MIP) included the development and distribution of educational materials, Voluntary Counseling and testing (VCT) clinic consultations, and surveys.

RESULTS

Post-intervention, the total score for mpox knowledge awareness significantly increased from 58.50 to 68.47 (P <0.001), and the knowledge awareness rate rose from 48.66 % to 64.60 % (P <0.001). The intervention significantly improved participants' understanding of mpox incubation period, asymptomatic infections, transmission routes, and prevention measures (P <0.001). MSM preferred obtaining mpox knowledge through new media and internet social platforms, with no significant changes in preferences pre- and post-MIP.

CONCLUSION

The MIP effectively improved mpox knowledge awareness and cognitive levels among MSM. These findings provide scientific evidence for optimizing health education strategies and controlling the spread of mpox.

Neuropsychological assessment with lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) individuals: Practice, education, and training survey

Objective: We sought to describe the LGBTQ + related education, training, and clinical practice of independently licensed neuropsychologists in the United States and to identify factors that predict affirmative neuropsychological practices. We hypothesized that LGBTQ + identity, female gender, more recent training, and extent of LGBTQ + education/training would predict use of LGBTQ + practice guidelines. Method: A workgroup of clinical psychologists with experience in LGBTQ + psychology and neuropsychology developed a survey to identify personal and professional factors that predict affirmative neuropsychological testing practices. The survey was distributed through professional organizations and listservs between August and September 2021 with 118 responses meeting inclusionary criteria. Results: The majority of participants identified as heterosexual (70.3%) and cisgender (97.5%), and most (48-63%) received LGBTQ + training post-licensure. Between 19% and 32% of participants reported never completing LGBTQ + specific education. Consistent with our hypotheses, factors predicting affirmative clinical practice behaviors were LGBTQ + education/training, and personal background (sexual minority status, female/feminine gender, and years since degree). Other significant factors included prior experience with LGBTQ + patients and primary patient population (child vs. adult). Qualitative responses indicated varying values, attitudes, and knowledge regarding collection of LGBTQ + information and modification of clinical practice. Conclusions: Neuropsychologists underutilize affirming practices as evidenced by low rates of querying pronouns, knowing whether LGBTQ + health information is available at their institutions, and adjusting evaluation and feedback approaches. We provide specific training and education recommendations to increase knowledge and skills and to address beliefs about LGBTQ + health that can serve to promote affirmative neuropsychological practice.

Positive LGBT+ Identity, Interpersonal Discrimination, and Satisfaction with Life: A Cross-National Comparison Between LGBT+ People in the UK, Italy, and Turkey

The present study explored how identity authenticity and LGBT+ community connectedness may mediate the effects of interpersonal discrimination on life satisfaction in a sample of LGBT+ participants across three counties. We used a cross-sectional online survey to collect data and paper questionnaires. Participants were 723 LGBT+ people (56.6% females): 308 (42%) of participants were from the UK, 245 (34%) from Italy, and 170 (24%) from Turkey. Participants' age ranged from 18-60 years (M = 33.83, SD = 11.55). Analysis of variance and multigroup mediation models implemented through path analysis were performed. The associations of interpersonal discrimination with identity authenticity and connectedness to the LGBT+ community showed cross-country variations. The association between interpersonal discrimination and identity authenticity was stronger in Italy than in the UK but non-significant in Turkey. Interpersonal discrimination showed a negative association with connectedness to the LGBT+ community in Italy and the UK, with Italy exhibiting the strongest effect. Conversely, this association was positive in Turkey. Irrespective of the country, life satisfaction showed a negative association with interpersonal discrimination and positive associations with identity authenticity and connectedness to the LGBT+ community. This study provides valuable insights into the differences and similarities between the experiences of LGBT+ people in the UK, Italy, and Turkey. The social and policy implications that emerge from the study highlight the relevance of addressing structural stigma in different cultures and emphasize the need for targeted interventions and supportive policies at the supranational level to improve the quality of life of LGBT+ individuals.

Motor-evoked potentials as biomarkers for sexual arousal?

BACKGROUND

Motor cortex excitability may represent the neuronal endpoint of motivational processes and was shown to be modulated by both sexual arousal and deceptive behavior.

AIM

This is the first study to investigate the influence of lying and sex in heterosexual women and men based on motor-evoked potentials (MEPs) measured while viewing sexually arousing pictures.

METHODS

Sixteen heterosexual couples were shown 360 trials consisting of pictures displaying both almost naked females and males and neutral control images. In a subsequent forced-choice question about wanting to see the respective pictures fully naked, they were instructed to either answer in agreement with or opposite to their sexual preference. Participants went through 2 blocks of answering truthfully and 2 blocks of lying, with these 4 blocks being shown in a randomized alternating order.

OUTCOMES

To measure cortical excitability, MEPs were used, evoked by single transcranial magnetic stimulation pulses between image presentation and response.

RESULTS

In normalized MEPs, women and men showed higher amplitudes for preferred over non-preferred sexual stimuli, but only on a descriptive level. Planned contrasts showed higher non-normalized MEPs for lying in all picture categories. Direct comparisons to a preliminary study showed overall lower effect sizes.

CLINICAL IMPLICATIONS

Both sexes tend to show higher MEPs in response to their sexually preferred stimuli. MEPs are not stable markers for willful volitionally controlled deception although lying does increase cortical excitability. The present experimental design does not seem valid enough to serve as a diagnostic marker for sexual preference or paraphilia and malingering.

STRENGTHS AND LIMITATIONS

This is the first study investigating whether sexual motivational stimuli modulate MEPs in women, while also examining the influence of lying for both sexes. The sample was too small for some found effects to be significant. Also, the experimental setup may have been less suited for female participants in comparison to male ones.

CONCLUSION

The operationalization of sexual motivation via MEPs seems to highly depend on different experimental factors including the sex of the participants, induced motivation, and lying.

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.

Psychosis risk for lesbian, gay, and bisexual individuals: systematic review and meta-analysis

The social defeat hypothesis posits that low status and repeated humiliation increase the risk for psychotic disorders (PDs) and psychotic experiences (PEs). The purpose of this paper was to provide a systematic review of studies on risk of PDs and PEs among lesbian, gay, or bisexual (LGB) people and a quantitative synthesis of any difference in risk. PubMed, PsycINFO, Embase, and Web of Science were searched from database inception until January 30, 2024. Two independent reviewers assessed the eligibility and quality of studies, extracted effect sizes, and noted the results of mediation analyses. Using a random effects model we computed pooled odds ratios (ORs). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The search identified seven studies of PDs and six of PEs. As for PDs, the unadjusted (2.13; 95% confidence interval 0.72-6.34) and covariate-adjusted pooled OR (2.24; 1.72-3.53) were not significantly increased for LGB individuals. After exclusion of a study of limited quality, both the unadjusted pooled OR (2.77; 1.21-6.32) and the covariate-adjusted pooled OR (2.67; 1.53-4.66) were significantly increased. The pooled ORs were increased for PEs: unadjusted, pooled OR = 1.97 (1.47-2.63), covariate-adjusted, pooled OR = 1.85 (1.50-2.28). Studies of PE that examined the mediating role of several variables reported that the contribution of drug abuse was small compared to that of psychosocial stressors. The results of a study in adolescents suggested a protective effect of parental support. These findings suggest an increased psychosis risk for LGB people and support the social defeat hypothesis.

Qualitative exploration of uterine cancer care for lesbian, gay, bisexual, trans and queer (LGBTQ+) patients in the UK: shifting from equality to equity

OBJECTIVE

Patients identifying as lesbian, gay, bisexual, transgender and/or queer/questioning (LGBTQ+) report significant disparities in cancer care and are disproportionally affected by a cancer diagnosis on a number of health-related indicators. This study aimed to explore uterine cancer (UC) care from the perspectives of LGBTQ+ patients and stakeholders, to identify this population's care needs, which have been underprioritised thus far.

METHODS AND ANALYSIS

Qualitative interview data were collected from three cohorts of participants: LGBTQ+ UC patients, partners of UC patients and stakeholders who provide advocacy and/or support within the UC care pathway, including healthcare professionals (HCPs). Semi-structured qualitative interviews were conducted and data were analysed using inductive reflexive thematic analysis.

RESULTS

Fifteen participants (three patients, one partner, eight HCPs and three cancer support charity representatives) were recruited. Data analysis identified themes which represented participants' reflections on the relevance and opportunities for identity disclosure during the diagnostic pathway; feelings and implications of not fitting into the gynaecological cancer environment and, opportunities and challenges surrounding HCP education, and protocolled sexual and gender identity data collection.

CONCLUSION

UC patients who identify as LGBTQ+ have specific care needs and considerations, particularly related to transvaginal procedures and survivorship. Opportunities for disclosure of patients' LGBTQ+ identity during the UC care pathway are essential for these needs to be recognised. Despite this, there are conflicting agendas between HCPs and stakeholders on the best approach to integrate disclosure processes. The current findings highlight the need for public health agendas and clinical services to address the needs of LGBTQ+ UC patients.

Pressure From Within: Gay-Community Stress and Body Dissatisfaction Among Sexual-Minority Men

Although intraminority gay community stress has been theorized to affect sexual minority men's body dissatisfaction, this association has not been evaluated quantitatively. In two samples of sexual minority men-one sample recruited from a population-based study of U.S. adults (n=424; Mage =54.29), the other a sample meeting diagnostic criteria for depressive, anxiety, or trauma-/stressor-related disorders (n=251; M age =26.52)-this study investigated associations between gay community stress and body dissatisfaction. In both samples, gay community stress was significantly associated with sexual minority men's greater body dissatisfaction in models that controlled for demographic and minority stress variables. In terms of specific domains of gay community stress, perceptions of the gay community's focus on sex, social status, and social competition were significant correlates of greater body dissatisfaction. Future research can determine the impact of routinely addressing gay community stress in body image and eating disorder treatments for this population.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

The Intersection of Mental Health and Sexual and Gender Minority Identities for Older Adults Living with Human Immunodeficiency Virus: A Narrative Review

The transition of HIV into a chronic illness has brought to the forefront the pressing need to address the complex web of social determinants of HIV outcomes. A structured literature search and narrative review of studies describing intervention strategies for mental health among sexual/gender minority (SGM) older adults living with HIV (OALWH) published in the last decade identified 2 studies for inclusion. This narrative review identifies age-sensitive and culturally adapted therapies, mindfulness and meditation-based stress reduction, group therapy, digital mental health resources, and psilocybin-assisted group therapy as emerging intervention models tailored to meet the unique needs of SGM OALWH.

Adverse Childhood Experiences and Health Outcomes Among Sexual and Gender Minorities: A Systematic Review

Current research indicates a strong association between adverse childhood experiences (ACEs) and adverse health outcomes. Participants in frequently cited ACE research are predominantly heterosexual and cis gendered; the extent to which ACEs affect health outcomes among sexual and gender minorities (SGMs) is unclear. This systematic review examined the frequency of, and relationship between, ACEs and negative health outcomes among SGM. CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Scopus, and PubMed databases were searched with no date restriction. After eliminating duplicates, titles and abstracts were reviewed resulting in 22 articles to be critiqued using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. A total of 22 studies met final inclusion criteria. The frequency of reporting at least one ACE among SGMs ranged from 51.4 to 91.6%, while the frequency of reporting four or more ACEs ranged from 18.1 to 60.7%. SGMs reported a higher frequency of ACEs than non-SGM. ACEs were associated with poorer mental and physical health outcomes, as well as increased risky behavior among SGMs. SGMs report a high frequency of ACEs, but current studies did not include data regarding ongoing stigma and adversities that may further contribute to their negative health outcomes. Further research is needed to fully understand the impact of adversities experienced due to the sexual and/or gender orientation of this minority group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00576-4.

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.

Implementing LGBTQ Culturally Appropriate Affirmation Training in the Southern United States: An Evidence-Based Practice Project

BACKGROUND

The lesbian, gay, bisexual, transgender, or queer (LGBTQ) community is diverse, and members have a shared need for culturally competent health care (CCH). Best practices show that culturally appropriate affirmation training (CAAT) bridges the sociocultural knowledge gap between patient and provider, resulting in increased access to CCH.

METHOD

The pre-/posttest project design used validated tools to measure group changes in knowledge, attitude, and skills before and after delivery of LGBTQ CAAT. The sample included staff interacting with or making decisions on behalf of patients (n = 11) at a nonprofit clinic in the southern United States.

RESULTS

A Wilcoxon signed-rank test showed an increase in health care team scores for knowledge, attitude, and skills (knowledge, p = .006, r = -.59; attitude, p = .123, r = -.33; skills, p = .005, r = -.60). Qualitative analysis (thematic analysis) (a) showed that participants explored sensitive subjects in a nonjudgmental way; (b) connected the dots between minority stress, bias, and patient-provider trust; and (c) showed increased staff confidence in providing care to LGBTQ patients.

CONCLUSION

As staff undergo LGBTQ CAAT, access to CCH will increase, health outcomes will improve, and LGBTQ health disparities will decrease. [J Contin Educ Nurs. 2024;55(3):121-129.].

U.S. Pediatric Residents' Preparedness, Attitudes, and Knowledge in LGBTQ+ Health Care

INTRODUCTION

The objective of this study was to evaluate pediatric residents' lesbian, gay, bisexual, transgender, queer, and all sexual and gender diverse (LGBTQ+) care.

METHOD

In June 2022, U.S. pediatric residents completed an anonymous online survey including the Lesbian, Gay, Bisexual, and Transgender-Development of Clinical Skills Scale (LGBT-DOCSS).

RESULTS

Pediatric residents (n = 78) reported low-to-moderate annual amounts of LGBT curricular hours (3.32 ± 3.17) and LGBT patients (13.84 ± 15.11) as well as low-to-moderate clinical preparedness and knowledge and high positive attitudes. They were significantly less likely to report receiving adequate training and supervision, having experience, and feeling competent in transgender care compared with lesbian, gay, and bisexual care. In general, pediatric residents who reported more LGBT education and LGBT patients also reported higher LGBT-DOCSS scores.

DISCUSSION

Pediatric residents in this study had substantial shortcomings in LGBTQ+ care. Pediatric programs must increase LGBTQ+ education and LGBTQ+ patient exposure.

Kept in the Closet: Structural Stigma and the Timing of Sexual Minority Developmental Milestones Across 28 European Countries

Structural stigma's role in lesbian, gay, and bisexual (LGB) people's attainment of identity development milestones remains unknown. In a sample of 111,498 LGB people (ages 15 to 65+) living across 28 European countries, associations were investigated between structural stigma measured using an objective index of discriminatory country-level laws and policies affecting LGB people and the timing and pacing of LGB self-awareness, coming out, and closet duration, and subgroup differences in these associations. On average, self-awareness occurred at age 14.8 years old (SD = 5.1), coming out occurred at 18.5 years old (SD = 5.7), and the closet was 3.9 years long (SD = 4.9); thereby highlighting adolescence as a key period for sexual identity development and disclosure. Greater structural stigma was associated with higher odds of never coming out, later age of coming out, and longer closet duration. Gender identity, transgender identity, and sexual identity moderated associations between structural stigma and these developmental milestones. Reducing structural stigma can plausibly promote sexual identity development among LGB populations, especially during adolescence when identity related milestones are often attained.

Neglected gaps in improving the health, wellbeing, and care for sexual and gender minority young people living in low- and lower-middle- income countries: a scoping review

BACKGROUND

There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10-24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs?

METHODS

We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O'Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations.

RESULTS

Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10-24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13).

CONCLUSION

The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

A Developmental Model of the Sexual Minority Closet: Structural Sensitization, Psychological Adaptations, and Post-closet Growth

Across the lifespan, most sexual minority individuals experience the closet-a typically prolonged period in which no significant others know their sexual identity. This paper positions the closet as distinct from stigma concealment given its typical duration in years and absolute removal from sources of support for an often-central identity typically during a developmentally sensitive period. The Developmental Model of the Closet proposed here delineates the vicarious learning that takes place before sexual orientation awareness to shape one's eventual experience of the closet; the stressors that take place after one has become aware of their sexual orientation but has not yet disclosed it, which often takes place during adolescence; and potential lifespan-persistent mental health effects of the closet, as moderated by the structural, interpersonal, cultural, and temporal context of disclosure. The paper outlines the ways in which the model both draws upon and is distinct from earlier models of sexual minority identity formation and proposes several testable hypotheses and future research directions, including tests of multilevel interventions.

Lesbian Gay Bisexual Transgender and Queer Health-Care Experiences in a Military Population

ABTRACTThis study aimed to understand the experiences of lesbian, gay, bisexual, transgender, and queer of former military service members. Data for this analysis was collected from the two open-ended survey questions as part of a larger online survey. The analysis was performed using the web-based data analysis application Dedoose. Eighty-eight qualitative responses were used. Analysis of the responses revealed five main themes: (1) identity, (2) negative experiences, (3) impact of experiences, (4) policy, and (5) positive experiences. These findings can influence future military research by focusing on the effects of the Don't Ask Don't Tell policy, negative and positive experiences, and the impact of those experiences.

Comment l’évolution de l’opinion publique et des réformes législatives influence-t-elle la satisfaction de vie des minorités sexuelles ?

INTRODUCTION

Structural stigma in the form of legal discrimination and population acceptance of same-sex relationships vary greatly across European countries. Previous cross-sectional research has linked such county variation in stigma with life-satisfaction among sexual minorities, but the consequences of the past decade's improvement in legal recognition and social acceptance of same-sex relationships are unknown. In the current study, we, therefore, examined the change in life-satisfaction among sexual minorities between 2012 and 2019 in France, Sweden, and Poland - three countries for which the legal situation and social acceptance of sexual minorities have changed in different directions during the past decade.

METHOD

Between April and July 2012, and again between May and July 2019, the European Union Agency for Fundamental Rights conducted web-based surveys to monitor the fundamental rights situation affecting lesbian, gay, and bisexual (LGB) individuals, living in 28 European countries. For the current study, we analyzed data from all LGB respondents in France, Sweden, and Poland, with no history of migration in 2012 (n = 12,357) and 2019 (n = 21,858).

RESULTS

Regression models adjusted for age, gender, education, and relationship status, showed a strong and significant improvement in life-satisfaction among sexual minorities in France between 2012 and 2019 (β = 0.397, 95 % CI: 0.337, 0.457, p &lt; .001), a country that had experienced improvements in legal recognition (e.g., same-sex marriage legislation in 2013) and improved social acceptance during the same period. In Sweden, which had a high degree of legal recognition and social acceptance in place already in 2012, we found a small increase life-satisfaction among sexual minorities between 2012 and 2019 (β = 0.188, 95 % CI: 0.042, 0.333, p = .012). In Poland, who had experienced deteriorating social acceptance between 2012 and 2019, we found a declined in life-satisfaction among sexual minorities (β = - 0.289, 95 % CI: - 0.385, - 0.193, p &lt; .001).

CONCLUSIONS

Although life satisfaction has increased during the past decade among sexual minorities living in Europe, there are significant variations across countries largely due to the structural stigma and degree of legal recognition of same-sex relationships of those countries. The findings highlight the importance of further efforts to reduce structural stigma by improving legal recognition and social acceptance of same-sex relationships to promote equitable life satisfaction.

A conditional embrace-Swedish LGBTQ+ spaces through the eyes of ethnic minority non-heterosexual individuals

Introduction

In research on sexuality, marginalized sub-groups within sexual minorities have often been overlooked. From the vantage point of Sweden, internationally ranked as an exemplary progressive nation in equality issues and LGBTQ+ rights, and with an increasingly diversified population, the lived experiences of ethnic minority non-heterosexual people are still very much lacking in voice and visibility. The present study aimed to examine experiences within Swedish non-heterosexual spaces, held by ethnic minority non-heterosexual individuals.

Method

A thematic analysis of in-depth interviews with 22 Swedish non-heterosexual individuals, 13 cis-men and nine cis-women, with diverse first- and second-generation immigration backgrounds, was conducted.

Results

Two main themes were identified. The first theme, "Constantly contested identities," is composed of the sub-themes "Ingrained, intersecting ideals" and "Prejudiced spaces," and the second theme, "Effects and counteractions," of the sub-themes "Never fully human" and "Representation and separatism." The results, presented starting from a more theoretical level, moving to situated knowledge, and finally to psychological and practical implications, demonstrate that ethnic minority non-heterosexual people experience problematic and intersecting ideals, with related discrimination, in various Swedish non-heterosexual settings. Experiences of alienation, exotification, and tokenism were common among the participants and had negative psychological effects, including multiple-minority stress and a constant outsider feeling. Representation and participation in separatist forums were utilized as primary strategies to counteract the negative effects.

Discussion

The findings shed light on previously under-researched ideals and actions within Swedish LGBTQ+ spaces, and raises questions about how positive belonging can be achieved for multiple-minorities. Further research and continued critical discussions about ethnic minority non-heterosexual people's plight within non-heterosexual settings in Sweden, and beyond, is advocated.

Are Sibship Characteristics Predictive of Same Sex Marriage? An Examination of Fraternal Birth Order and Female Fecundity Effects in Population-level Administrative Data from the Netherlands

Despite historical increases in the number of individuals engaging in same-sex relations and entering same-sex unions, the causes of sexual orientation remain an open question. Two biological processes that have received some degree of empirical validation are the fraternal birth-order effect (FBOE) and the female-fecundity effect (FFE). Respectively, these processes posit that having a greater number of older brothers and being part of larger sibships independently increase the odds of male homosexuality. Nevertheless, previous studies have relied on suboptimal data and methods, including underpowered and selected samples, and models that fail to fully disentangle the two processes. In addition, they have rarely analyzed samples of women. We address these limitations using high-quality, population-level linked register data from the Netherlands (n = 9,073,496). Applying a novel multivariable approach, we jointly examine the FBOE and FFE by comparing the sibship characteristics of men (n = 26,542) and women (n = 33,534) who entered a same-sex union against those who did not (n = 4,607,785 men and 4,405,635 women). Our analyses yield robust evidence of an FBOE on both male and female homosexuality, but no support for the FFE. Additionally, we find that individuals' birth order affects the probability of entering a same-sex union, regardless of the sex of older siblings.

Creating a Welcoming Surgery Residency Training Program for LGBTQ Trainees

General Surgery residencies have been perceived as unwelcoming to lesbian, gay, bisexual, transgender, and queer (LGBTQ) applicants. Historically, applicants have been reluctant to reveal their LGBTQ status when interviewing for residency positions and LGBTQ surgery residents are more likely to consider leaving their residency. Despite the increased acceptance in society and calls for diversity by governing bodies, there is a perception that the field of surgery is lagging behind. In this article, we summarize the recent literature concerning LGBTQ status in surgery residencies and the impact it has on students and trainees. We then review the recent calls to action to remedy the identified shortcomings. We then share what has been done by our surgery residency, which has been successful in recruiting LGBTQ-identifying residents and summarize recommendation for moving forward.

IRP commission: sexual minorities and mental health: global perspectives

Sexual orientation is a key determinant of the identity of human beings. It has also been seen as a social determinant of health. People whose sexual orientation is non-heterosexual or sexual minorities or sexually diverse are included in the broad umbrella term LGBT (Lesbian, Gay, Bisexual, and Transgender) which is a commonly used acronym in activism, social policy, and subsequently cultural literature. For this reason, this Commission focuses primarily on sexual orientation i.e. lesbian, gay and bisexual (LGB) groups. We have used terms non-heterosexual, sexual minorities or sexual variation interchangeably. We have not considered asexual individuals as research in the field is too limited. We are cognisant of the fact that topics relating to mental health and sexual orientation discussed in this Commission will intersect with other issues of personal, cultural and social identity, and will thus be relevant to individuals including many transgender individuals. The inclusion of mental health issues relevant to gender-diverse individuals as well as gender identity is important and deserves its own separate detailed discussion. The exact number of sexually diverse individuals in a population is often difficult to estimate but is likely to be somewhere around 5% of the population. Rates of various psychiatry disorders and suicidal ideation and acts of suicide in LGB populations are higher than general population and these have been attributed to minority stress hypothesis. Elimination of inequality in law can lead to reduction in psychiatric morbidity in these groups. However, these are all diverse groups but even within each group there is diversity and each individual has a distinct and unique experiences, upbringing, responses to their own sexual orientation, and generating varying responses from families, peers and friends as well as communities (including healthcare professionals). The mental healthcare needs of sexual minority individuals vary and these variations must be taken into account in design, development and delivery of healthcare and policies. Improving access to services will help engagement and outcomes and also reduce stigma. The commission recommends that there is no role for so-called conversion therapies and other recommendations are made for clinicians, researchers and policymakers.

Sexual minority service user perspectives on mental health treatment barriers to care and service improvements

Sexual minorities (individuals with a lesbian, gay, bisexual, queer, or other non-heterosexual identity) are at elevated risk of developing common mental health disorders relative to heterosexual people, yet have less favourable mental health service experiences and poorer treatment outcomes. We investigated the experiences of sexual minority service users accessing mental health services for common mental health problems (e.g. depression or anxiety) in the UK. We recruited 26 sexual minority adults with experiences of being referred to Improving Access to Psychological Therapies (IAPT) or primary care counselling services. Semi-structured interviews explored participants' experiences of service use and views on service development. Interviews were analysed using thematic analysis. Barriers to effective relationships with practitioners included service users' fears surrounding disclosure, and practitioners' lack of understanding and/or neglect of discussions around sexuality. Regarding service development, participants highlighted the value of seeing practitioners with shared identities and experiences, visible signs of inclusivity, sexual minority training, tailored supports, and technological adjuncts. Our findings offer insights into possible contributory factors to treatment inequalities, and highlight potential methods for improving service provision for sexual minorities.

Chained multimediator model of sexual orientation disclosure, sexual minority stigma, sexual minority identity, social support, and resilience among ymsms

Introduction

This study aimed to investigate sexual orientation disclosure and mental health among young men who have sex with men (YMSMs). To this end, we constructed a chained multimediator model of sexual minority stigma, sexual minority identity, social support, and resilience, with the moderator of sexual orientation disclosure.

Methods

We conducted a cross-sectional survey of 345 YMSMs in Nanning, China. Bivariate analysis was used to evaluate factors associated with sexual orientation disclosure. Sexual minority stigma was used to predict identity, with social support as the step 1 mediator and resilience as the step 2 mediator. Sexual minority identity was analyzed using a chained moderated mediation model; sexual orientation disclosure was included as a moderator in all models to control its confounding effect.

Results

The average age of YMSMs was 20.0 ± 1.3 years. Bivariate analysis indicated that YMSMs who disclosed sexual orientation may have experienced less stigma (15.49 ± 3.02 vs 16.21 ± 2.74), obtained more social support (65.98 ± 11.18 vs 63.19 ± 11.13), had strong psychological resilience (37.40 ± 8.57 vs 35.39 ± 7.73), and had a more positive self-identity (104.12 ± 21.10 vs 95.35 ± 16.67); differences between subgroups were statistically significant (p < 0.05). Sexual minority stigma, perceived stigma, and enacted stigma were significantly associated with social support and resilience. The association between sexual minority stigma and sexual minority identity was significantly mediated by social support (indirect effect [95% CI] =  − 3.307 [− 4.782, − 1.907]). Resilience significantly mediated the same association for identity (− 2.544 [− 4.052, − 1.114]). The chained relationship from sexual minority stigma to social support, resilience, and identity was also significant, with an indirect effect of − 0.404 [− 0.621, − 0.249].

Conclusion

Among YMSMs in China, sexual minority stigma affects sexual minority identity through social support and resilience. Given the psychological effects of stigma, social support and resilience must be considered to better promote positive self-identity and mental health among YMSMs.

Absence of Behavioral Harm Following Non-efficacious Sexual Orientation Change Efforts: A Retrospective Study of United States Sexual Minority Adults, 2016-2018

BACKGROUND

Do sexual minority persons who have undergone unsuccessful sexual orientation change efforts (SOCE) suffer subsequent psychological or social harm from the attempt? Previous studies have conflated present and past, even pre-SOCE, harm in addressing this question. This study attempts, for the first time, to isolate and examine the question of current psychosocial harm for former SOCE participants among sexual minorities in representative population data.

METHOD

Using nationally representative data (n = 1,518) across three cohorts of sexual minorities (centered in 1969, 1987, and 2003) in the United States (U.S.), persons exposed to SOCE were compared with the remainder not exposed to SOCE on two measures of internal distress-psychological distress (Kessler scale) and current mental health-and seven measures of behavioral harm: substance abuse (DUDIT); alcohol dependence (AUDIT-C); self-harm; suicide ideation; suicide planning; suicide intentions; and suicide attempts.

RESULTS

The SOCE group was statistically indistinguishable from the non-SOCE group on any measure of harm. For behavioral harm, risk ratios were 0.97-1.02. Harm was equivalent for the two groups despite the SOCE group having experienced higher lifetime and current minority stress, greater childhood adversity, and lower socioeconomic status. Logistic regression models that adjusted for these differences suggest that SOCE exposure reduced the effect of minority stress and childhood adversity for suicide attempts, although this effect did not fully account for the equivalence between the SOCE and non-SOCE groups.

CONCLUSION

Despite higher exposure to factors predicting behavioral harm-minority stress, childhood adversity, and lower socioeconomic background-sexual minority persons who had undergone failed SOCE therapy did not suffer higher psychological or social harm. Concerns to restrict or ban SOCE due to elevated harm are unfounded. Further study is needed to clarify the reasons for the absence of harm from SOCE.

Absence of Behavioral Harm Following Non-efficacious Sexual Orientation Change Efforts: A Retrospective Study of United States Sexual Minority Adults, 2016-2018

BACKGROUND

Do sexual minority persons who have undergone unsuccessful sexual orientation change efforts (SOCE) suffer subsequent psychological or social harm from the attempt? Previous studies have conflated present and past, even pre-SOCE, harm in addressing this question. This study attempts, for the first time, to isolate and examine the question of current psychosocial harm for former SOCE participants among sexual minorities in representative population data.

METHOD

Using nationally representative data (n = 1,518) across three cohorts of sexual minorities (centered in 1969, 1987, and 2003) in the United States (U.S.), persons exposed to SOCE were compared with the remainder not exposed to SOCE on two measures of internal distress-psychological distress (Kessler scale) and current mental health-and seven measures of behavioral harm: substance abuse (DUDIT); alcohol dependence (AUDIT-C); self-harm; suicide ideation; suicide planning; suicide intentions; and suicide attempts.

RESULTS

The SOCE group was statistically indistinguishable from the non-SOCE group on any measure of harm. For behavioral harm, risk ratios were 0.97-1.02. Harm was equivalent for the two groups despite the SOCE group having experienced higher lifetime and current minority stress, greater childhood adversity, and lower socioeconomic status. Logistic regression models that adjusted for these differences suggest that SOCE exposure reduced the effect of minority stress and childhood adversity for suicide attempts, although this effect did not fully account for the equivalence between the SOCE and non-SOCE groups.

CONCLUSION

Despite higher exposure to factors predicting behavioral harm-minority stress, childhood adversity, and lower socioeconomic background-sexual minority persons who had undergone failed SOCE therapy did not suffer higher psychological or social harm. Concerns to restrict or ban SOCE due to elevated harm are unfounded. Further study is needed to clarify the reasons for the absence of harm from SOCE.

Lifecourse-varying structural stigma, minority stress reactions and mental health among sexual minority male migrants

Background

Increasing evidence suggests that structural stigma (e.g. discriminatory laws, policies and population attitudes) can give rise to minority stress reactions (i.e. rejection sensitivity, internalized homophobia and identity concealment) to compromise sexual minorities’ mental health. Yet, many sexual minorities encounter divergent structural stigma climates over the life course, with potential implications for their experience of minority stress reactions and mental health. We take advantage of sexual minority male migrants’ lifecourse-varying exposures to structural stigma contexts to examine this possibility.

Methods

A sample of 247 sexual minority men who had migrated from 71 countries to the low-structural-stigma context of Sweden completed a survey regarding migration experiences, minority stress reactions and mental health. This survey was linked to objective indices of structural stigma present in these men’s countries of origin, diverse in terms of structural stigma.

Results

Country-of-origin structural stigma was significantly associated with poor mental health and this association was mediated by rejection sensitivity and internalized homophobia, but only among those who arrived to Sweden at an older age and more recently.

Conclusions

Prolonged exposure to high levels of structural stigma can give rise to stressful cognitive, affective and behavioural coping patterns to jeopardize sexual minority men’s mental health; yet, these consequences of structural stigma may wane with increased duration of exposure to more supportive structural contexts.

Impact of structural ageism on greater violence against older persons: a cross-national study of 56 countries

OBJECTIVE

To determine the association between country-level structural ageism and prevalence of violence against older persons.

DESIGN

Country-level ecological study.

SETTING

Structural ageism data were drawn from the nationally representative World Values Survey 2010-2014 (WVS), global databases from the WHO, United Nations and the World Bank. Violence data were based on the Global Burden of Diseases (GBD) study 2017.

PARTICIPANTS

Analysis of 56 countries that represented 63.1% of the world's ageing population aged 60 and over across all six of WHO regions.

EXPOSURE

Structural ageism, following established structural stigma measures, consisted of two components: (1) discriminatory national policies related to older persons' economic, social, civil and political rights, based on the four core components of human rights protection in Madrid International Plan of Action on Aging and (2) prejudicial social norms against older persons, measured by negative attitudes toward older persons in 56 national polls in WVS aggregated to country-level. These components were z scored and combined such that higher score indicated greater structural ageism.

MAIN OUTCOMES AND MEASURES

Prevalence rates of violence per 100 000 persons aged 70 and over in each country was based on extensive epidemiological surveillance data, survey, clinical data and insurance claims in GBD and compiled by the Institute of Health Metrics and Evaluation, University of Washington.

RESULTS

There was a wide variation in levels of structural ageism across countries. As predicted, structural ageism was significantly associated with the prevalence rates of violence in multivariate models (β=205.7, SE=96.3, p=0.03), after adjusting for relevant covariates. Sensitivity analyses supported the robustness of our findings. That is, structural ageism did not predict other types of violence and other types of prejudice did not predict violence against older persons.

CONCLUSIONS

This study provides the first evidence of the association between higher structural ageism and greater violence against older persons across countries.

The Legal Vulnerability Model for Same-Sex Parent Families: A Mixed Methods Systematic Review and Theoretical Integration

Globally, parents and children in same-sex parent families are impacted by many laws related to the parental sexual orientation. These laws vary considerably from one country to another, ranging from full legal recognition to criminalization. The psychological consequences of living in an ambiguous or hostile legal climate likely interfere with parental health, family functioning, and child development. However, a systematic evidence synthesis of the pertinent literature and its placement within a broader psychological model are currently lacking. The aims of this review were thus (1) to systematically review qualitative and quantitative evidence on the impact of sexual orientation laws on same-sex parent families in key domains and (2) to place these findings within a broader model informed by minority stress and family theories. Our review was preregistered and conducted in line with PRISMA guidelines. We searched for qualitative, quantitative, and mixed methods studies on the impact of sexual orientation laws on target outcomes (parental health, family functioning, child outcomes) via systematic database search (PubMed, Scopus, Web of Science) and forward-backward searches. Fifty-five studies published between 1999 and 2020 were eligible for inclusion and were synthesized using a data-based convergent synthesis design. Thirteen descriptive and three overarching analytical themes were identified through thematic synthesis. Linking our findings with minority stress and family theories, we propose a novel legal vulnerability model for same-sex parent families. The model posits that legal vulnerability constitutes an increased risk for parental and child health as well as family functioning through individual and shared pathways between family members. Additionally, the model introduces counteractions that families engage in on the personal, familial, and systemic level to mitigate the impact of legal vulnerability, as well as moderators on the contextual, familial, couple, and individual level that modulate this impact. Implications for research and clinical practice are discussed.

A pilot cultural adaptation of LGB-affirmative CBT for young Chinese sexual minority men's mental and sexual health

Young men who have sex with men (YMSM) represent one of the most at-risk groups for HIV infection and experience sexual minority stress especially in high-stigma settings, which affects their psychological health and increases likelihood of HIV-risk behaviors. The HIV epidemic in China is increasing rapidly among YMSM. However, no evidence-based intervention has specifically targeted Chinese YMSM's minority stress to improve their mental and sexual health. Adaptation of evidence-based interventions to promote the mental and sexual health of YMSM is one promising way to achieve the global target of HIV epidemic control. The current adaptation study followed the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing model. YMSM (n = 41) and key stakeholders (n = 16) in China provided feedback into the selected intervention, a cognitive-behavioral therapy called Effective Skills to Empower Effective Men, originally developed with efficacy in the United States. An open pilot (n = 8) was also then conducted. Qualitative and quantitative data collected from each adaptation phase were analyzed to form the adapted intervention: "Yi Si Tang ()." Adaptations addressed a cultural context prioritizing family needs, limited support from the health system, as well as YMSM delivery preferences. YMSM and key stakeholders deemed the intervention acceptable and preliminarily feasible for the Chinese context. The pre-post comparison of mental and sexual health outcomes indicated improvement in mental health and sexual health of Chinese YMSM. Outcomes of the small initial pilot suggest future promise for this first-of-its-kind intervention for Chinese YMSM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

[Public funding of health research on LGTBIQ+population in Spain]

OBJECTIVE

To describe the public funding of research on LGTBIQ+health in Spain.

METHOD

We conducted an observational and descriptive study. We sought research projects dealing with LGTBIQ+health funded by the research projects grant from the Instituto Carlos III from 2013 to 2019. We consulted the webpage and the FIS portal and we identified projects that included LGTB community, totally or partially. We estimated the absolute and relative frequencies of LGTBIQ+projects in relation to total funded projects; and we described the LGTBIQ+funded projects by year of funding, topics, LGTBIQ+subpopulation, or funding.

RESULTS

Only 0,4% (n=16) of 4404 funded projects included -totally or partially- LGTBIQ+community, which represents only 0,3% of the funding. LGTBIQ+projects mainly focused on men who have sex with men (n=14) and the human immunodeficiency viruses (HIV) (n=11). The number of funded LGTBIQ+projects decreased from 2013 (n=6) to 2019 (n=0).

CONCLUSIONS

Research projects on LGTBIQ+health are scarce in Spain. Current funding for research on LGTBIQ+health is insufficient to care for population other than HIV and men within LGTBIQ+. There is a compelling necessity to promote the LGTBIQ+health research to mitigate health disparities, to offer inclusive health services, and to improve healthcare of about 3 million LGTBIQ+people living in Spain.

"Measurement and analytic vulnerabilities in the study of structural stigma"

Two general concerns remain following this updated and corrected study of structural stigma's effect on the premature mortality of sexual minorities. First, there seem to be better and worse ways to measure structural stigma. Scholars should be invested in best-possible measures. Second, remaining questions about measures and expectations suggest more attention be paid to an optimal modeling approach to predicting health outcomes among sexual minorities, one that neither underspecifies nor overspecifies models, but aims instead at better understanding stigma processes in population-based samples, not just searching for its effects.