Protective school climates and reduced risk for suicide ideation in sexual minority youths

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55210.

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

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

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

Outer-context determinants on the implementation of school-based interventions for LGBTQ+ adolescents

Background

Schools are critical venues for supporting LGBTQ+ youth well-being. Implementing LGBTQ-supportive practices can decrease experiences of stigmatization, discrimination, and victimization that lead to adverse mental health outcomes like anxiety, depression, and suicidality. However, schools are also subject to a wide range of outer-context pressures that may influence their priorities and implementation of LGBTQ-supportive practices. We assessed the role of emergent outer-context determinants in the context of a 5-year cluster randomized controlled trial to study the implementation of LGBTQ-supportive evidence-informed practices (EIPs) in New Mexico high schools.

Method

Using an iterative coding approach, we analyzed qualitative data from annual interviews with school professionals involved in EIP implementation efforts.

Results

The analysis yielded three categories of outer-context determinants that created challenges and opportunities for implementation: (a) social barriers related to heterocentrism, cisgenderism, and religious conservatism; (b) local, state, and national policy and political discourse; and (c) crisis events.

Conclusions

By exploring the implications of outer-context determinants for the uptake of LGBTQ-supportive practices, we demonstrate that these elements are dynamic-not simply reducible to barriers or facilitators-and that assessing outer-context determinants shaping implementation environments is crucial for addressing LGBTQ health equity.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

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

CONCLUSIONS

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

Affirming educational and workplace settings are associated with positive mental health and happiness outcomes for LGBTQA + youth in Australia

BACKGROUND

Affirming socio-cultural settings are essential for protecting the mental health and wellbeing of lesbian, bisexual or pansexual, trans and gender diverse, asexual and queer (LGBTQA +) youth. However, limited research has explored the role of affirming educational and workplace settings, as reported by LGBTQA + youth themselves, with respect to their mental health and wellbeing. Moreover, existing research maintains a focus on mitigating poor mental health outcomes, with little attention to positive wellbeing outcomes among LGBTQA + youth.

METHODS

Using data from the largest national survey of LGBTQA + youth aged 14-21 in Australia, multivariable regression analyses were conducted to explore associations between affirming educational and workplace settings and psychological distress and subjective wellbeing among 4,331 cisgender and 1,537 trans and gender diverse youth. Additionally, a series of multivariable regression analyses were conducted to explore individual sociodemographic traits that are associated with reporting affirming educational or workplace settings.

RESULTS

Both cisgender and trans or gender diverse participants who reported that their education institution or workplace were affirming of their LGBTQA + identity reported lower levels of psychological distress as well as higher levels of subjective happiness. Additionally, affirming environments were not experienced equally across all subsections of LGBTQA + youth, with reporting of an affirming educational or workplace setting differing most noticeably across gender, type of educational institution and residential location.

CONCLUSION

The findings demonstrate that affirming educational and workplace settings can result not only in better mental health, but also greater levels of subjective happiness among LGBTQA + youth. The outcomes illustrate the importance of ensuring all LGBTQA + youth are afforded the opportunity to thrive in environments where they feel validated and confident to express their identities. The findings further highlight a need to target education institutions and workplaces to ensure the implementation of policies and practices that promote not just inclusion of LGBTQA + youth but affirmation of their identities.

Social Isolation: An Unequally Distributed Health Hazard

Social isolation is a potent predictor of poor health, mortality, and dementia risk. A great deal of research across national contexts provides causal evidence for these linkages and identifies key explanatory mechanisms through which isolation affects health. Research on social isolation recognizes that some people are more likely than others to be isolated, but over the past several decades, researchers have focused primarily on the consequences of isolation for health rather than a systematic assessment of the social conditions that foster isolation over the life course. In this article, we review the available evidence on inequities in social isolation and develop a conceptual framework to guide future research on structural systems that fuel social isolation over the life course. Future work in this area has the potential to identify root causes of inequality in social isolation, as well as targeted policy levers to reduce isolation in vulnerable populations.

Protective Environmental Factors and Opioid Use Among Sexual Minority Youth

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

A 3D framework of implicit attitude change

According to early theories, implicit (automatic) social attitudes are difficult if not impossible to change. Although this view has recently been challenged by research relying on experimental, developmental, and cultural approaches, relevant work remains siloed across research communities. As such, the time is ripe to systematize and integrate disparate (and seemingly contradictory) findings and to identify gaps in existing knowledge. To this end, we introduce a 3D framework classifying research on implicit attitude change by levels of analysis (individual vs. collective), sources of change (experimental, ontogenetic, and cultural), and timescales (short term vs. long term). This 3D framework highlights where evidence for implicit attitude change is more versus less well established and pinpoints directions for future research, including at the intersection of fields.

Difficulties With Methodology in Social Science Research With Controversial Issues Regarding Human Sexuality

Social science is commonly used in debates about controversial issues, especially for those concerning human sexuality. However, caution must be exercised in interpreting such social science literature, because of a variety of methodological and theoretical weaknesses that are not uncommon. Families are complex structurally and over time; such data are not easily analyzed. Merely determining the number of, for example, sexual minority families has been a difficult task. While some new theories are popular with social scientists, for example, sexual minority theory, they are often used to the exclusion of other, equally valid theories and often are not well tested empirically. Some types of families remain relatively unexamined. Social scientists can be biased by their own values, which are reflected in weak use of theory and in a variety of methodological problems. Eight studies are presented as examples of probable confirmation bias, in which methods and theory were modified in unusual ways that may have affected the outcomes and conclusions. Suggestions for improving social science include greater attention to effect sizes rather than statistical significance per se, deliberately minimizing the politicization of science, developing a culture of humility with respect to social science, deliberately reducing common biases, and maintaining a deeper curiosity about social science than is often seen. Scientists must be open to seeing their best "sacred cow" ideas or theories disproven or modified with increases in research on such issues.

Summary

In controversial areas of social science, there can be numerous threats to the validity of science. Here, some of the more common risks for social science research and theory are examined, with several specific illustrations of how bias appears to have crept into social science, often as confirmation bias. Recommendations are made for reducing bias in future research.

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

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

Loneliness in Sexual Minority Individuals in the Southeastern United States: The Role of Minority Stress and Resilience

Health disparities in the sexual minority population may be exacerbated by the loneliness experienced due to minority stress. Using a minority stress framework, this study examined minority stress, protective variables, and mental health as correlates of loneliness in sexual minority individuals in a small metropolitan area in the southeastern United States. Participants (n = 273) were a subsample of sexual minority individuals from a broader sample of LGBTQ adults in the Central Savannah River area who completed a health needs assessment. Bivariate correlations were calculated to assess for degree of significant relationships between loneliness and barriers to health care, minority stress, and mental health. Hierarchical linear regression was conducted to examine the relative importance of the study variables' associations with loneliness. A multiple regression model found household income, assault victimization, depressive symptoms, and sense of community to be significant correlates of loneliness. Interventions to decrease loneliness in this population will need to consider these interconnected, multi-level influences.

The Development of Proud & Empowered: An Intervention for Promoting LGBTQ Adolescent Mental Health

Sexual and gender minority adolescents (SGMA) experience higher rates of internalizing psychopathology, including depression, anxiety, self-harm, and posttraumatic stress disorder. The primary explanation for these mental health disparities is minority stress theory, which suggests that discrimination, violence, and victimization are key drivers of chronic minority stress and place SGMA at higher risk of mental health concerns. To help address these concerns, the authors undertook a nearly 8-year process of developing Proud & Empowered, a school-based intervention to help SGMA cope with minority stress experiences. This manuscript details the intervention development process, including: (a) identifying the mechanisms of change (Stage 0), (b) building the intervention (Stage 1A, Part 1), (c) acceptability testing and program revision (Stage 1A, Part 2), (d) feasibility and pilot testing (Stage 1B, Part 1), (e) modification of the intervention to improve implementability (Stage 1B, Part 2), and (f) the final intervention.

Explaining behavioral health differences in urban and rural sexual minority adolescents: A longitudinal investigation of minority stress in a diverse national sample of sexual minority adolescents: A longitudinal investigation of minority stress in a diverse national sample of sexual minority adolescents

PURPOSE

Experiences of sexuality-based discrimination (ie, minority stressors) against youth who identify as nonheterosexual (ie, sexual minority) have been associated with increased symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD) for sexual minority adolescents (SMA; ages 14-17). However, little is known about the experiences of SMA living in rural communities across the United States. Thus, the present study sought to examine differences in mental health patterns between urban and rural dwelling SMA, and to see whether these differences are, at least in part, explained by experiences of lifetime minority stress.

METHODS

A nationwide sample of SMA residing in the United States (N = 2,558; aged 14-17, M = 15.90 years, SD = 0.98) was recruited through purposive social media and respondent-driven sampling methods to complete a cross-sectional survey online. Measures included those of minority stress, urbanicity, and symptoms of anxiety, depression, and PTSD. Parallel multiple mediation (PMM) analysis was employed to test whether urbanicity was associated with anxiety, depressive, and PTSD symptoms through reported lifetime minority stress.

FINDINGS

On average, SMA living in rural areas significantly reported more lifetime minority stress, depressive, and PTSD symptoms than SMA living in urban settings. Results from our PMM analysis indicated that heightened experiences of lifetime minority stress indirectly linked the effects of living in rural areas on anxiety (b = -0.288, 95% CI = [-0.491, -0.085]), depressive (b = -0.158, 95% CI = [-0.270, -0.047), and PTSD symptoms PTSD (b = -0.349, 95% CI = [-0.596, -0.105]). The model accounted for 16.8%, 18%, and 24.1% of the variability in anxiety symptoms, depressive symptoms, and PTSD symptoms, respectively.

CONCLUSIONS

SMA in our study who reside in rural areas reported elevated minority stress, depressive, and PTSD symptoms as compared to their urban dwelling peers. Our study found that lifetime experiences of minority stress fully mediated the relationship between urbanicity and both depressive and PTSD symptoms, and partially mediated the relationship between urbanicity and anxiety. These findings highlight the need to increase support for rural youth who are growing into adulthood and may find continuing challenges in their family, peer, and community relationships.

Addressing Health Disparities in LGBTQ Youth Through Professional Development of Middle School Staff

BACKGROUND

Significant health disparities exist for sexual minority youth (SMY). While supportive adults in schools have been shown to improve mental wellbeing and academic outcomes for students, most teachers do not receive training specific to lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) students.

METHODS

The project aimed at providing staff from a Hawaii middle school with "Safe Space" professional training to increase knowledge and comfort in supporting SMY. Pre- and post-training surveys were used to measure knowledge of LGBTQ issues and comfort in supporting LGBTQ students and a 2-week and 3-month survey assessed staff's application of newly learned material.

RESULTS

Sixty-four staff participated in the first of 2 training sessions with 59 completing both sessions. Results from the pre- and post-survey showed a 34.9% increase in knowledge of LGBTQ issues (effect size = 1.22) and a 5.5% increase in self-rated comfort level in supporting LGBTQ students (effect size = 0.22). A 3-month follow-up indicated that 52.9% of the respondents were actively applying knowledge learned within their school setting.

CONCLUSIONS

The project results demonstrate the value of the training not only in the short term but also staff's ability to apply the knowledge they learned. Given the success of implementation, expansion to other schools could facilitate ally-building attitudes and behaviors as a protective factor for SMY throughout the state.

Transgender-Specific Adolescent Mental Health Provider Availability is Substantially Lower in States with More Restrictive Policies

OBJECTIVE

Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states - especially at the macro-social level - have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states' transgender-specific policy climate.

METHOD

We quantified states' policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states' transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers - identified via Psychology Today - per transgender adolescent in all 50 states and the District of Columbia.

RESULTS

Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio = 0.65, 95% CI [0.52, 0.81], p = .00017), controlling for state-level conservatism, religiosity, and urbanicity. States' transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity.

CONCLUSIONS

Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.

Moderating Effect of Community and Individual Resilience on Structural Stigma and Suicidal Ideation among Sexual and Gender Minority Adults in the United States

BACKGROUND

Structural stigma in the form of discriminatory laws and policies impacts the mental health of sexual and gender minorities, especially with regard to suicidality. However, this relationship could be moderated by resilience. The past two years has brought anti-SGM legislation, particularly transgender sports bans, at the state level in the United States into focus. This study aims to understand if the relationship between familiarity with transgender sports bans (proposed or enacted) and suicidality was moderated by individual or community resilience.

METHODS

This was a cross-sectional study of survey data collected from a national sample of 1033 SGM adults in the United States between 28 January and 7 February 2022. Univariate and multivariate moderation analyses were used.

RESULTS

In the univariate analyses and the final model, community resilience moderated the relationship between structural stigma and suicidality (p = 0.0002); however, individual resilience did not (p = 0.0664).

CONCLUSION

Interventions to bolster community resilience may attenuate the negative mental health impacts of structural stigma and are warranted, along with concerted efforts to minimize structural stigma in the form of discriminatory laws and policies targeting people who are SGM.

Trends in Deaths by Suicide 2014-2019 Among Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, and Other Gender/Sexual Minority (LGBTQ+) Youth

PURPOSE

This study describes changes in proportions of lesbian, gay, bisexual, transgender, and other gender/sexual minorities (LGBTQ+) among total deaths by suicide in American 11-29 year olds between 2014 and 2019.

METHODS

Data came from the Centers for Disease Control and Prevention's (CDC) National Violent Death Reporting System (NVDRS). All cases classified as deaths by suicide since 2014 that had valid data for sexual orientation or transgender identity were included from states that started participating in NVDRS before 2016. The latest year of data available was 2019. Valid n = 4,086, including 673 LGBTQ+ cases. Analyses used "reverse regression" with gender/sexual orientation as the dependent variable, essentially estimating contributions of timing of fatal self-injury and other variables to relative risk of a case being LGBTQ+.

RESULTS

The proportion of decedents who were LGBTQ+ increased between 2014 and 2019. Post-hoc analyses suggested an inflection point or break in the trend at November 9, 2016. The proportion of decedents who were LGBTQ+ increased from 13% before to 20% after that date, driven largely by increases from 2.0% to 6.5% among transgender youth and from 0.5% to 1.7% among those described in medical examiner and law enforcement reports as "struggling" or questioning. Asian bisexual females and gay males were especially overrepresented.

CONCLUSIONS

Previous research found that the policy environment affects LGBTQ+ youths' mental health; this study generalizes those findings to actual deaths by suicide. LGBTQ+ youth at risk should be assessed for anxiety, trauma, and perceived physical threat from the political and rhetorical environment.

Factors Associated with Non-Binary Gender Identity in Psychiatric Inpatients with Suicidal Ideation Assigned Female at Birth: A Case-Control Study

The study aimed to investigate factors associated with non-binary gender identity in Russian female psychiatric inpatients with suicidal ideation. This case-control study included 38 female inpatients with non-binary gender identity and a control group-76 cisgender women matched for age (age range 19-35 years, M age, 21.5 years); both groups were psychiatric inpatients with suicidal thoughts. All patients underwent the Self-Injurious Thoughts and Behaviors Interview and completed the brief Reasons for Living Inventory. We also used the WHO Quality of Life Questionnaire (WHOQOL-100) and the Life Style Index (LSI). Non-binary gender identity in inpatients with suicidal ideation was associated with lower educational level, higher unemployment rate, being more socially reticent in preschool, and lifetime sexual experience with both male and female partners. In addition, they were younger at the time of the first suicidal ideation, suicide plan development, and attempt. Non-binary inpatients had lower scores in freedom, physical safety, and security facets of WHOQOL-100 and a higher level of intellectualization on LSI. People with non-binary gender identity face educational, employment, and communication issues. They also have distinct suicidal thoughts and behavioral profiles. These issues and differences mean unique approaches to suicide prevention for a population of inpatients with non-binary gender identity are needed.

LGBTQ+ Students' Peer Victimization and Mental Health before and during the COVID-19 Pandemic

Given the well-established health disparities between lesbian, gay, bisexual, transgender, queer, and gender-expansive (LGBTQ+) and cisgender, straight youth, scholars predicted the COVID-19 pandemic would disproportionately impact LGBTQ+ students. Yet, few studies have described changes in LGBTQ+ students' school experiences and well-being during the pandemic. Using survey data from 40,904 middle and high school students, we examined changes from before (2018) to during (2021) the pandemic in peer victimization, anxiety, and suicide attempts. We conducted bivariate and multivariate regression analyses to assess changes between the two time points among LGBTQ+ and cisgender, straight students. We found LGBTQ+ students experienced more peer victimization, anxiety, and suicide attempts at both points, before and during the pandemic, than cisgender, straight youth. However, LGBTQ+ students reported increased anxiety, decreased peer victimization, and decreased suicide attempts in 2021, during the pandemic, compared to pre-pandemic 2018 reports. These findings suggest pandemic-related school disruptions may have provided LGBTQ+ students some relief from the harmful effects of poor, in-person school climates.

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.

Adolescent, parent, and provider perspectives on school-related influences of mental health in adolescents with suicide-related thoughts and behaviors

Previous research supports a link between school-related factors, such as bullying and school connectedness, and suicidal thoughts and behaviors. To deepen understanding of how school experiences may function as both protective and risk factors for youth struggling with suicidal thoughts and behaviors, this qualitative study explored multiple perspectives. Specifically, in-depth interviews were conducted with adolescents previously hospitalized for a suicidal crisis (n = 19), their parents (n = 19), and the professionals they may interact with in schools and hospitals (i.e., school professionals [n = 19] and hospital providers [n = 7]). Data were analyzed using applied thematic analysis revealing three main themes related to perceptions of how school experiences can positively or negatively impact mental health, including (a) school activities, (b) school social experiences, and (c) school interventions. An emergent theme related to the complexity of suicide-related risk identified the ways in which school experiences may intersect with other environmental, biological, and psychological factors. Findings underscore the need for school-based approaches to address the unique academic, social, and emotional needs of students with suicide-related risk that complement the supports and services provided in their home and community.

Rethinking minority stress: A social safety perspective on the health effects of stigma in sexually-diverse and gender-diverse populations

For over two decades, the minority stress model has guided research on the health of sexually-diverse individuals (those who are not exclusively heterosexual) and gender-diverse individuals (those whose gender identity/expression differs from their birth-assigned sex/gender). According to this model, the cumulative stress caused by stigma and social marginalization fosters stress-related health problems. Yet studies linking minority stress to physical health outcomes have yielded mixed results, suggesting that something is missing from our understanding of stigma and health. Social safety may be the missing piece. Social safety refers to reliable social connection, inclusion, and protection, which are core human needs that are imperiled by stigma. The absence of social safety is just as health-consequential for stigmatized individuals as the presence of minority stress, because the chronic threat-vigilance fostered by insufficient safety has negative long-term effects on cognitive, emotional, and immunological functioning, even when exposure to minority stress is low. We argue that insufficient social safety is a primary cause of stigma-related health disparities and a key target for intervention.

Neighborhood cohesion and psychological distress across race and sexual orientation

Introduction

Method

Result

Conclusion

•

Lesbian, gay, and bisexual (LGB) people are more likely to meet the criteria for psychological distress than non-LGB people.

•

Neighborhood cohesion (NC) has differing impact on psychological distress by race and sexual orientation.

•

NC provides greater protection against moderate distress for non-LGB groups and severe psychological distress for LGB groups.

Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

Suicide rates among ethnoracially minoritized youth (i.e., youth of color) peak before the age of 30, and striking disparities in access to mental health services have been identified in this age group. However, suicide prevention strategies have yet to fully address structural racism as a mechanism in producing disparities in risk, protective factors, and access to quality effective intervention for youth of color. Such an approach is critical to provide more culturally responsive mental health care. Through an adapted socio-ecological model, the authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors contextualize the impact of structural racism in three key settings where youth suicide prevention occurs: mental health services, schools, and the interface between crisis care and law enforcement. The authors posit that critical attention must be paid to the intersection of mutually reinforcing, interdependent systems rather than to systems in isolation. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youths and families.

Safety and Predictors of Sexual Minority Youth Carrying Weapons

Prior research has revealed sexual minority youth are more likely to carry weapons both outside of and within school. However, to date, no study has examined the degree to which bullying and harassment is associated with weapon carrying among sexual minority youth. We utilized the Youth Risk Behavior Survey to examine the prevalence and likelihood of carrying weapons by sexual identity, adjusting for adverse experiences. From the Youth Risk Behavior Survey 2009-2015, we examined self-report of adverse experiences (e.g., being bullied, skipping school due to fear for personal safety) and performed Logistic regressions to estimate the odds of carrying a weapon and were adjusted to include demographics and adverse experiences. When surveyed by sexual identity, 14.0% of heterosexual, 21.8% of gay/lesbian, 18.5% of bisexual, and 17.4% of "not sure" students reported carrying a weapon in the past 30 days. Odds of carrying a weapon were significantly increased for youth who skipped school due to feeling unsafe at school, had ever been threatened with a weapon in the past year, and had ever been in a physical fight. Compared to heterosexual female peers, sexual minority women had increased odds of carrying a weapon. Pediatricians should recognize that experiencing bullying and feeling unsafe are associated with weapon carrying, particularly among sexual minorities. Pediatricians and professionals who work with youth should recognize that reported experiences of bullying may not be the most salient indicator of risk for weapon carrying among all youth, and that other fears of or experiences with bullying are crucial to screen for among sexual minorities in particular.

Diversity and Inclusion: Impacts on Psychological Wellbeing Among Lesbian, Gay, Bisexual, Transgender, and Queer Communities

For scholars, practitioners, and legislators concerned about sexual minority adolescents, one of the main goals is to create more positive and inclusive learning environments for this minority group. Numerous factors, such as repeated patterns of homophobic bullying by classmates and others in school, have been a significant barrier to achieving this goal. In addition, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents encounter substantial inequality across a broad spectrum of wellbeing and education consequences. Compared with their heterosexual counterparts, LGBTQ adolescents experience more anxiety, depression, suicidal thoughts, antisocial behavior, poorer academic performance, less school attachment and protection, and a weaker desire to finish their studies. Such discrepancies based on gender and sexuality were linked to more maltreatment encountered by LGBTQ adolescents. It is crucial to recognize the backgrounds and expectations of LGBTQ adolescents to offer them the best resources. To overcome the inequality and obstacles faced by these LGBTQ adolescents, it is essential to examine tools and techniques that can be utilized. This study examined the literature that explains why society fails to provide enough support to LGBTQ students. Specifically, mechanisms explaining how LGBTQ adolescents interact with others in the learning environment and how such discrepancies arise will be examined. Following that, violence and prejudice, which are fundamental causes of psychological problems among LGBTQ adolescents, will be explored. This review paper thus provides supportive strategies for schools to develop more inclusive learning environments for LGBTQ adolescents.

The roles of school in supporting LGBTQ+ youth: A systematic review and ecological framework for understanding risk for suicide-related thoughts and behaviors

The extant literature on suicide-related thoughts and behaviors (STB) has highlighted increased patterns of risk among specific minoritized populations, including lesbian, gay, bisexual, transgender, questioning, intersex, two spirit, and queer (LGBTQ+) youth. Compared to their heterosexual and cisgender peers, LGBTQ+ youth are at increased risk for having STB. Identity-specific stressors such as homonegativity and anti-queerness are among the unique factors posited to contribute to this risk and inhibit factors that protect against suicide. The school setting has been a focal point for suicide prevention and intervention and may also play a key role in linking students to care; however, schools also hold the potential to provide supports and experiences that may buffer against risk factors for STB in LGBTQ+ students. This systematic literature review presents findings from 44 studies examining school-related correlates of STB in LGBTQ+ students, informing an ecological approach to suicide prevention for school settings. Findings underscore the importance of school context for preventing STB in LGBTQ+ youth. Approaches that prioritize safety and acceptance of LGBTQ+ youth should span multiple layers of a student's ecology, including district and state level policies and school programs and interventions, such as Gender and Sexuality Alliances and universal bullying prevention programs. Beyond their role as a primary access point for behavioral health services, schools offer a unique opportunity to support suicide prevention by combating minority stressors through promoting positive social relationships and a safe community for LGBTQ+ students.

Adolescent Bullying Victimization at Secondary School and Adult Suicidality and Depressive Symptoms Among 2152 Lesbian, Gay, and Bisexual Adults in South Korea

This study examined the association between adolescent bullying victimization (ABV) and adult mental health among lesbian, gay, and bisexual (LGB) individuals in South Korea (hereafter Korea). We conducted a cross-sectional survey of 2152 Korean LGB adults in 2016. Based on experiences of and reasons for ABV, participants were categorized into 4 groups: “never bullied,” “bullied due to sexual orientation and gender expression (SOGE),” “bullied due to other reasons,” and “bullied, reason unspecified.” Compared with participants who have never been bullied during adolescence, those who have been “bullied due to SOGE” were 1.56 times (95% confidence interval [CI] = 1.36-1.80), 1.53 times (95% CI = 1.30-1.81), and 3.59 times (95% CI = 2.05-6.28) more likely to report depressive symptoms, suicidal ideation, and suicide attempts, respectively. Statistically significant associations with all 3 mental health indicators were also observed among those who have been “bullied due to other reasons”: depressive symptoms (adjusted prevalence ratio [aPR] = 1.72, 95% CI = 1.55-1.92), suicidal ideation (aPR = 1.48, 95% CI = 1.29-1.70), and suicide attempts (aPR = 3.15, 95% CI = 1.84-5.38). This study suggests that ABV may increase depressive symptoms and suicidality in adulthood among LGB individuals.

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

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

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

Background and objectives

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

Methods

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

Results

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

Conclusions

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

•

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

•

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

•

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

Reducing behavioral health symptoms by addressing minority stressors in LGBTQ adolescents: a randomized controlled trial of Proud & Empowered

Background

Minority stress may lead to poorer mental health for sexual and gender minority adolescents, yet no interventions have been tested through an RCT to address these concerns.

Methods

We report on an RCT of an intervention—Proud & Empowered—with four high schools. Measures assess the intervention’s impact on mental health symptoms.

Results

Compared to the control, participants in the treatment condition reported significant differences in minority stress, anxiety, and depressive symptoms. Moderation analyses showed that the intervention significantly moderated the relationship between minority stress and PTSD (b = -1.28, p = .032), depression (b = -0.79, p = .023), and suicidality (b = 0.14, p = .012) symptoms; those in the intervention condition had mitigated relationships between measures of stress and health outcomes compared to those in the control condition.

Conclusions

Results suggest that Proud & Empowered help reduce mental health symptoms and exposure to minority stressors and build coping strategies.

Trial Registration

The intervention was registered on clinicaltrials.gov on August 1, 2019 under Trial #NCT04041414.

OKAPI, an Emotional Education and Classroom Climate Improvement Program Based on Cooperative Learning: Design, Implementation, and Evaluation

A positive school climate can directly influence the relationships and social interactions among students while also contributing to the development of socio-emotional skills. Simultaneously, the school climate depends on these said skills. Despite this close relationship, emotional education and school climate improvement programmes have traditionally been studied separately. This study describes and evaluates the effectiveness of a new programme, OKAPI (Organisation, Cooperation, Positive Environment, Participation and Emotional Intelligence), for the development of socio-emotional skills and the improvement of classroom climate for primary school students using a cooperative learning methodology. The total sample comprised 86 students aged 9–11 years. A quasi-experimental design with pre-test and post-test measures with a control group was used. The results show that the program’s implementation is effective both for the improvement of the classroom climate and the acquisition of training in the field of emotional intelligence, as well as for the development of cooperative competences. Among the fundamental pillars of the OKAPI programme are its simplicity and transversality, so that teachers are responsible for its application and monitoring; thus, the programme becomes an agent of change in their educational practice.

Protective Factors for LGBTI+ Youth Wellbeing: A Scoping Review Underpinned by Recognition Theory

Considerable research has been undertaken regarding the mental health inequalities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of societal and individual prejudice, stigma and discrimination. Far less research has focussed on protective factors that promote wellbeing for this population. A scoping review was conducted using a six-stage methodological framework, and is reported in accordance with the PRISMA-ScR statement. This explored the extent, range and nature of the peer-reviewed, published, academic literature on what is known about the protective factors that promote LGBTI+ youth wellbeing. Six databases were systematically searched applying Population–Concept–Context key inclusion criteria, complemented by contact with authors to identify additional sources, reference checks and hand searches. Ninety-six individual research records were identified and analysed, drawing from Honneth’s Recognition Theory. Interpersonal relations with parents (n = 40), peers (n = 32) and providers (n = 22) were associated with indicators of enhanced wellbeing, as were LGBTI+ community relations (n = 32). Importantly, online (n = 10), faith (n = 10) and cultural (n = 5) communities were potentially protective. Content and thematic analysis highlighted the importance of Gay–Straight Alliances (GSAs) (n = 23) offering powerful protective opportunities through intersecting interpersonal, community and legal forms of recognition. GSAs enhance allyship by peers and providers (n = 21), facilitate access to LGBTI+ community networks (n = 11) and co-exist alongside inclusive policies (n = 12), curricular (n = 5) and extracurricular activities (n = 1). This scoping review underscores the need to move beyond the predominant focus on risk factors for LGBTI+ youth, which subsequently inform protectionist approaches. It concludes with an appeal to develop mechanisms to apply recognitive justice to policy, practice and, importantly, future research directions. This emphasises the salience of enhanced understandings of inclusion, which is rights-based, universally available and of potential benefit to all.

Teen, Queer, and Asian: Lesbian, Gay, Bisexual, Transgender, Queer, Plus Asian American Students' Experiences in Schools

BACKGROUND

The experiences of youth with intersecting LGBTQ+ and Asian American (AA) identities have been largely unexplored. This study explored these experiences of LGBTQ+ AA California youth with mental health, school climate, and school victimization.

METHODS

Drawing from the 2016-2017 California Healthy Kids Survey (N = 326,124), this study utilized secondary data analyses to examine mental health, school climate, and school victimization among students of specific AA ethnicities (eg, Cambodian, Hmong, Vietnamese) and LGBTQ+ identities. The participants in this study included 7th, 9th, and 11th graders from California public schools, with subsamples of lesbian or gay students (N = 13,291), bisexual students (N = 30,127), and transgender students (N = 7916).

RESULTS

The results indicated that Asian Indian, Cambodian, Hmong, Japanese, Korean, Laotian, and Other Asian LGBTQ+ students experienced more negative school climate and victimization compared to their Chinese, Filipino, Vietnamese, and white LGBTQ+ peers. For instance, 41.1% of Cambodian transgender students reported they were beaten up compared to 27.1% of white transgender students. Mental health differences between LGBTQ+ AA and LGBTQ+ white students were also found.

CONCLUSIONS

This study's findings can inform school administrators and teachers how to best support LGBTQ+ AA populations.

+Fièr : une application mobile pour aider les jeunes issus de la communauté LGBTQ+ et leur famille

Les personnes LGBTQ+ sont 1,5 à 4 fois plus à risque que les personnes hétérosexuelles de souffrir de troubles de santé mentale (p. ex. dépression, anxiété, comportements suicidaires).

Objectif L’objectif est de décrire le processus de développement d’une application mobile pour les jeunes LGBTQ+ et leur famille. L’article fait partie d’un programme de recherche ayant comme but général de doter les jeunes LGBTQ+ et leur famille d’outils technologiques leur permettant de développer et soutenir des stratégies d’adaptation face à la stigmatisation. En effet, ceux-ci sont confrontés à des stresseurs uniques, à la fois dans la sphère publique (p. ex. victimisation) et personnelle (p. ex. développement identitaire et le processus de coming out).

Méthode Nous adapterons l’application mobile +Fort © développée par l’équipe dirigée par de la docteure Isabelle Ouellet-Morin, conçue pour soutenir les jeunes vivant de l’intimidation à réduire ces expériences, et nous créerons +Fièr/+ Proud, qui fera l’objet d’un codesign et d’une étude pilote auprès de participants LGBTQ+ âgés de 13 à 25 ans.

Retombées À terme, notre espoir est que les jeunes LGBTQ+, à l’échelle nationale et internationale, puissent explorer et développer des stratégies d’adaptation soutenant leur mieux-être, apprendre à l’aide d’outils personnalisés, partager leurs expériences uniques et informer leurs proches des défis auxquels ils font face et se battent en silence.

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

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

Confirming the Reliability and Validity of the Sexual Minority Adolescent Stress Inventory in a National Sample of Sexual Minority Adolescents

Objective: Sexual minority adolescents (SMA) experience numerous behavioral health disparities, including depression, anxiety, substance use, non-suicidal self-injury, and suicidality. The primary framework to understand these disparities is minority stress theory, which frames this disproportionate burden as the result of discrimination, violence, and victimization in a homophobic culture. Empirical examinations of minority stress among SMA have been limited by lack of diverse samples or validated measures. This study engaged a national community sample of SMA to confirm reliability and validity of the Sexual Minority Adolescent Stress Inventory (SMASI). Method: A national sample of 2,310 SMA aged 14-17 was recruited in the United States through a hybrid social media and respondent-driven sampling approach. Item response theory and confirmatory factor analysis established the psychometric properties of the SMASI in this sample; minority stress was modeled as a latent variable in several regression models to verify criterion and divergent validity. Results: In this national sample (M age = 15.9; 64% female and 60% White), the factor structure of the SMASI and its 11 subscales was confirmed and shown to be invariant by demographic characteristics. Minority stress as measured by the SMASI was significantly associated with all mental and behavioral health outcomes. Conclusions: This study provides evidence that SMASI is a reliable, valid, and important tool for better understanding minority stress and subsequent health and mental health consequences among SMA.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Impact of Positive School Climate on Suicidality and Mental Health Among LGBTQ Adolescents: A Systematic Review

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) adolescents are more likely to report suicidality and worse mental health than their heterosexual peers. We conducted a systematic review to examine the relationship between positive school climate and suicidality and mental health among LGBTQ adolescents. We searched the literature using PubMed, PsycINFO, and CINAHL. Six studies met inclusion criteria, and all had low to moderate risks of bias. Results indicate that LGBTQ students in schools with more positive school climates were at lower risk of suicidality and reported fewer depressive symptoms compared to students in less positive school climates. Being at the forefront of health in schools, school nurses have the opportunity to advocate for changes in school environments that promote positive mental health for all youth, including LGBTQ adolescents.

Differences in Adolescent Experiences of Polyvictimization and Suicide Risk by Sexual Minority Status

Sexual minority adolescents (SMA) report more suicide risk behaviors than heterosexual adolescents. Polyvictimization (co-occurrence of multiple types of victimization) may be an important, underresearched correlate of this disparity. With the 2017 national Youth Risk Behavior Survey (N = 13,179), national estimates of polyvictimization and suicide risk were assessed among high school students by sexual minority status (SM vs. heterosexual), and multivariate relationships between sexual minority status, polyvictimization, and suicide risk were tested. Additionally, risk profiles of those who experienced polyvictimization (2 + types of victimization; n = 1,932) were compared across sexual minority status. Results confirm that SMA are more likely to experience polyvictimization than heterosexual adolescents (31.8% v. 12.9%, respectively); however, also indicate that polyvictimization does not fully explain elevated suicide risk among SMA.