Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.

The role of sleep duration in suicide risk among sexual and gender minority adolescents.

BACKGROUND: Short sleep duration is linked with suicide risk in adolescence. Sexual and gender minority (SGM) adolescents experience substantially increased risk for suicide compared to their non-SGM peers. METHODS: We investigated the role of sleep duration in SGM adolescent suicide risk using population-based, cross-sectional data from the 2022 Minnesota Student Survey (MSS; N = 85,610, Mage = 14.8). Adolescents reported average school-night sleep duration; those reporting <6 h were classified as having very short sleep duration. The MSS additionally assessed past-year suicidal ideation and suicide attempt. Mediation analyses assessed the role of sleep duration in explaining associations between SGM identity and suicide risk. Further, to examine intervention mechanisms, among SGM adolescents (n = 20,171, 23.6%), a logistic regression model assessed associations among demographic factors, perceived parental care, and very short sleep duration. RESULTS: As compared to non-SGM adolescents, SGM adolescents reported substantially higher prevalence of past-year suicidal ideation and suicide attempt and 2.6× higher prevalence of very short sleep duration (all p < 0.001). Mediation analyses demonstrated that very short sleep duration partially mediated the pathway between SGM identity and past-year suicidal ideation (15.5% mediated) and suicide attempt (17.2% mediated). Among SGM adolescents, a striking positive dose-response relationship was observed between level of perceived parental care and very short sleep duration. As perceived parental care decreased, so too did hours of sleep. DISCUSSION: Sleep duration is a crucial and understudied mechanism underlying suicide risk disparities affecting SGM adolescents. Family-based interventions may improve SGM adolescent sleep and reduce suicide risk.

Trends in paediatric firearm-related encounters during the COVID-19 pandemic by age group, race/ethnicity and schooling mode in Tennessee.

BACKGROUND: Increases in paediatric firearm-related injuries during the COVID-19 pandemic may be due to changes in where children and adolescents spent their time. This study examines changes in the frequency of paediatric firearm-related encounters as a function of schooling mode overall and by race/ethnicity and age group at a large trauma centre through 2021. METHODS: We use data from a large paediatric and adult trauma centre in Tennessee from January 2018 to December 2021 (N=211 encounters) and geographically linked schooling mode data. We use Poisson regressions to estimate smoothed monthly paediatric firearm-related encounters as a function of schooling mode overall and stratified by race and age. RESULTS: Compared with pre pandemic, we find a 42% increase in paediatric encounters per month during March 2020 to August 2020, when schools were closed, no significant increase during virtual/hybrid instruction, and a 23% increase in encounters after schools returned to in-person instruction. The effects of schooling mode are heterogeneous by patient race/ethnicity and age. Encounters increased among non-Hispanic black children across all periods relative to pre pandemic. Among non-Hispanic white children, encounters increased during the closure period and decreased on return to in-person instruction. Compared with pre pandemic, paediatric firearm-related encounters increased 205% for children aged 5-11 and 69% for adolescents aged 12-15 during the school closure period. CONCLUSION: COVID-19-related changes to school instruction mode in 2020 and 2021 are associated with changes in the frequency and composition of paediatric firearm-related encounters at a major trauma centre in Tennessee.

LGBTQ College student health and wellbeing at the onset of the pandemic: additional evidence and lessons learned from COVID-19.

BACKGROUND: The coronavirus (COVID-19) pandemic has killed more than six million people and disrupted health care systems globally. In the United States alone, more than one million people have died from COVID-19 infections. At the start of the pandemic, nearly all aspects of our lives paused to prevent the spread of the novel coronavirus. Many institutions of higher education transitioned to remote learning and enacted social distancing measures. This study examined the health needs and vulnerabilities of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) college students at the start of the COVID-19 pandemic in the United States. METHODS: We fielded a rapid-response online survey between April and June of 2020. We recruited 578 LGBTQ-identifying college students aged 18 years and older by reaching out to LGBTQ-serving organizations on 254 college campuses and via targeted social media advertising. RESULTS: Approximately 40% of LGBTQ college students surveyed were dissatisfied with life at the start of the COVID-19 pandemic, and almost all (90%) were concerned that COVID-19 would threaten their mental health. Moreover, about 40% of LGBTQ college students reported unmet mental health needs, and 28% were worried about seeking care during the pandemic because of their LGBTQ identity. One out of four LGBTQ college students had to go back in the closet because of the pandemic, and approximately 40% were concerned about their finances or personal safety during the COVID-19 pandemic. Some of these adverse outcomes were prominent among younger students, Hispanic/Latinx students, and students with unsupportive families or colleges. CONCLUSIONS: Our study adds novel findings to the large body of research demonstrating that LGBTQ college students experienced distress and elevated mental health needs early in the pandemic. Future research should examine the long-term consequences of the pandemic among LGBTQ and other minoritized college students. Public health policymakers, health care providers, and college and university officials should provide LGBTQ students affirming emotional supports and services to ensure their success as the COVID-19 pandemic transitions to endemic.

Effects of the Affordable Care Act Dependent Coverage Mandate on Health Insurance Coverage for Individuals in Same-Sex Couples.

A large body of research documents that the 2010 dependent coverage mandate of the U.S. Affordable Care Act was responsible for significantly increasing health insurance coverage among young adults. No prior research has examined whether sexual minority young adults also benefitted from the dependent coverage mandate despite previous studies showing lower health insurance coverage among sexual minorities. Our estimates from the American Community Survey, using difference-in-differences and event study models, show that men in same-sex couples aged 21-25 experienced a significantly greater increase in the likelihood of having any health insurance after 2010 than older, 27- to 31-year-old men in same-sex couples. This increase is concentrated among employer-sponsored insurance, and it is robust to permutations of periods and age groups. Effects for women in same-sex couples and men in different-sex couples are smaller than the associated effects for men in same-sex couples. These findings confirm the broad effects of expanded dependent coverage and suggest that eliminating the federal dependent mandate could reduce health insurance coverage among young adult sexual minorities in same-sex couples.

Disparities in Health Insurance Coverage and Access to Care for Children By Mother's Sexual Orientation.

OBJECTIVE: Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health insurance status, access to care, and health services utilization for children by mother's sexual orientation. METHODS: We used data on children with lesbian mothers (n = 195), bisexual mothers (n = 299), and heterosexual mothers (n = 23,772) in the 2013-2017 National Health Interview Survey. Logistic regression models were used to compare health insurance status, access to care, and health services utilization while adjusting for demographic and socioeconomic characteristics of the child, mother, and household. RESULTS: After controlling for sociodemographic factors, there were no statistically significant differences in health insurance coverage, access to care, or health services utilization between children of lesbian mothers and children of heterosexual mothers. Compared to children with heterosexual mothers, children with bisexual mothers were more likely to have public health insurance (OR 2.33; 95% CI 1.07-7.68), delayed medical care due to cost (OR 2.33; 95% CI 1.12-4.86), unmet medical care due to cost (OR 2.86; 95% CI 1.07-7.68), and a visit to the emergency room (OR 1.74; 95% CI 1.27-2.39) in the prior year after controlling for child-level characteristics. Some of these differences were attenuated after controlling for maternal demographics and household characteristics. CONCLUSIONS FOR PRACTICE: Children with bisexual mothers experience barriers to routine medical care. Addressing socioeconomic dimensions of health care access and targeted outreach to bisexual parents will help promote health equity for children growing up in sexual minority households.

Using peer ethnography to address health disparities among young urban Black and Latino men who have sex with men.

OBJECTIVES: We examined the effectiveness of peer ethnography to gain insider views on substance use and sex among a diverse range of high-risk substance-using Black and Latino young men who have sex with men. METHODS: We recruited 9 peer ethnographers aged 21 to 24 years from youth programs for the lesbian, gay, bisexual, and transgender community in Los Angeles, California, and trained them in ethnography, study protocol, and human participant protection. Peer ethnographers collected 137 single-spaced pages of field notes in 2009 and 2010 derived from observation of 150 members of the target population. RESULTS: Peer ethnography revealed local language and phrasing and provided a window into new and different social contexts. Peers provided valuable information on current trends in substance use, revealing themes that needed to be addressed in further research, such as the use of substances during sex to "clock coin" (exchange sex for money and substances). These data enabled us to refine our recruitment strategies and ask more culturally relevant questions in a later phase of the study. CONCLUSIONS: The peer ethnography method can provide a sound basis for further research phases in multistage studies on numerous other social issues and with other hard-to-reach populations.

Do supportive work environments matter for minority aging? Work stress and subjective cognitive impairment among middle-age and older lesbian, gay, bisexual, transgender, and queer adults.

Research has documented how people's experiences at work affect their cognitive health outcomes, but how these processes unfold for minority groups, particularly lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations, is unclear. This study builds on the nascent literature by employing generalized structural equation models to test how experiencing major problems at work and working with LGBTQ+ supportive coworkers affect subjective cognitive impairment among middle-age and older LGBTQ+ adults. We also test for mediated and indirect effects of support and problems at work operating via vascular disease, sleep problems, and depression symptoms. Experiencing major problems at work is associated with a higher likelihood of reporting cognitive symptoms consistent with mild cognitive impairment, but this relationship is mediated by depression symptoms and sleep problems. Having LGBTQ+ supportive coworkers does not have direct effects on mild cognitive impairment, but does operate indirectly by decreasing problems at work and, in turn, decreases the likelihood of reporting cognitive symptoms consistent with mild cognitive impairment. Overall, we find that workplace stressors contribute to cognitive health directly and through mediated and indirect pathways and that supportive contexts reduce exposure to problems at work. We conclude with suggested possibilities to reorganize workplaces to improve long-term cognitive health outcomes for older adults, especially those who are LGBTQ+-identified.

Association of Sexual Orientation with Exposure to Suicide and Related Emotional Distress among US Adults.

OBJECTIVE: Suicide bereavement is a significant public health concern. Using nationally representative survey data, we quantify sexual orientation differences in frequency of suicide exposure and suicide exposure-related emotional distress among US adults. METHODS: We used cross-sectional data from the 2016 General Social Survey (GSS) and included sexual minority (i.e., lesbian, gay, bisexual; (n = 74, 5.3%) and heterosexual (n = 1,207, 94.7%) adults. The GSS asked several questions related to suicide exposure including number of lifetime suicide exposures, emotional distress related to suicide exposure, time elapsed since suicide exposure, and relationship(s) and perceived closeness to the person(s) who died. We use descriptive statistics to describe differences in suicide exposure characteristics across sexual orientation. Among those who were exposed to at least one suicide (n = 698, 51.1%), a weighted multivariable logistic regression model examined the association between sexual orientation and suicide exposure-related emotional distress adjusting for confounders. RESULTS: Sexual minorities reported a similar number of lifetime suicide exposures and were not significantly different from heterosexuals on other suicide exposure characteristics. However, sexual minority, compared to heterosexual, respondents experienced 3.14 greater odds of severe emotional distress related to suicide exposure (95% CI = 1.42-6.94, p = .005). CONCLUSION: Perhaps due to stigmatizing mourning experiences, sexual minority adults are particularly vulnerable to severe suicide exposure-related emotional distress. Future research to understand the scope of sexual minority-specific bereavement support services and public policies (e.g., bereavement leave) as well as intervention development to support sexual minority adults' coping in the wake of suicide exposure is warranted. HIGHLIGHTSApproximately half of sexual minority US adults report a lifetime suicide exposureSexual minority adults experience more severe suicide exposure-related emotional distressPostvention care should be tailored to meet the needs of sexual minority adults.

Political network composition predicts vaccination attitudes.

Political polarization is growing rapidly in the United States and has been linked to politicized public health issues including vaccination. Political homogeneity among one's interpersonal relationships may predict polarization levels and partisan bias. In this study, we analyzed if political network structure predicted partisan beliefs about the COVID-19 vaccine, beliefs about vaccines in general, and COVID-19 vaccine uptake. Personal networks were measured by whom the respondent discussed "important matters" with to obtain a list of individuals who are close to the respondent. The number of associates listed who share the political identity or vaccine status with the respondent was calculated as a measure of homogeneity. We find that having more Republicans and unvaccinated individuals in one's network predicted lower vaccine confidence whereas having more Democrats and vaccinated individuals in one's network predicted higher vaccine confidence. Exploratory network analyses revealed that non-kin others are especially impactful on vaccine attitudes when those network connections are also Republican and unvaccinated.

Association of Affirming Care with Chronic Disease and Preventive Care Outcomes among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults.

INTRODUCTION: Experiences of discrimination and bias in healthcare contribute to health disparities for lesbian, gay, bisexual, transgender, and queer populations. To avoid discrimination, many go to great lengths to find healthcare providers who they trust and who are knowledgeable about their health needs. This study examines whether access to an affirming provider improves health outcomes for lesbian, gay, bisexual, transgender, and queer populations across a range of preventive health and chronic disease management outcomes. METHODS: This cross-sectional study uses Poisson regression models to examine original survey data (n=1,120) from Wave 1 of the Vanderbilt University Social Networks, Aging, and Policy Study, a panel study examining older (aged 50-76 years) lesbian, gay, bisexual, transgender, and queer adults' health and aging, collected between April 2020 and September 2021. RESULTS: Overall, access to an affirming provider is associated with greater uptake of preventive health screenings and improved management of mental health conditions. Participants with an affirming provider are more likely to have ever and recently received several types of preventive care than participants reporting a usual source of care that is not affirming, including past year provider visit, influenza vaccination, colorectal cancer screening, and HIV test. Access to an affirming provider is also associated with better management of mental health conditions. CONCLUSIONS: Inclusive care is essential for reducing health disparities among lesbian, gay, bisexual, transgender, and queer populations. Health systems can reduce disparities by expanding continuing education opportunities; adopting nondiscrimination policies for patients and employees; and ensuring that necessary care is covered by health insurance.

Sexual Behavior Change Among Gay and Bisexual Men During the First COVID-19 Pandemic Wave in the United States.

Background: After decades of navigating HIV and other sexually transmitted infections, gay and bisexual men are responding to new and uncertain risks presented by the coronavirus (COVID-19) pandemic by adapting their sexual behavior. Methods: This paper uses data from a national sample of 728 gay and bisexual men collected from April 10 to May 10, 2020, to examine changes to sexual behavior in response to the first wave of the pandemic in the USA. We also assess whether behavior modifications are associated with exposure to statewide public health measures, including Stay-at-Home orders. Results: Sexual minority men report significant changes to their sexual behavior and partner selection during the first wave. Nine out of 10 men reported having either one sexual partner or no sexual partner in the last 30 days at the time of interview, a decrease compared to just before the pandemic for nearly half of men surveyed. Reporting no sexual partners in the last 30 days was significantly predicted by increased exposure to a Stay-at-Home order. Sexual minority men also reduced interactions with casual partners, increased no-contact sexual behaviors (e.g., masturbation and virtual sex), and engaged in new strategies to reduce their risks of infection from partners. HIV-positive men were particularly likely to adopt strategies including avoiding casual partners and avoiding public transportation to meet sexual partners. Conclusion: Sexual minority men's behavior changes during the first wave may have reduced the impact of the coronavirus pandemic on their communities. Despite substantial changes in sexual behavior for most men in our sample during the initial first wave, we identify some concerns around the sustainability of certain behavioral changes over time and nondisclosure of COVID-19 symptoms to partners.

'Their type of drugs': perceptions of substance use, sex and social boundaries among young African American and Latino gay and bisexual men.

Studies of sexuality have increasingly shifted their attention towards understanding the social contexts that inform and organise sexual behaviour. Building on this work, we examine how substance use and sex are socially organised and meaningful activities for young African American and Latino gay and bisexual men who use substances with sex. Drawing on 30 qualitative interviews in Los Angeles and New York, we identify the ways in which social boundaries inform substance use among these young men. We find that many of them view the gay and racial/ethnic communities they belong to as differentiated by patterns of substance use. Further, they see these communities as actively constructing group boundaries through substance use, sanctioning the use of particular substances while simultaneously discouraging the use or discussion of others. For these young men, racial/ethnic and gay communities provide salient contexts in which the use of certain substances and not others is socially meaningful. Findings demonstrate the important and heretofore unrecognised ways that perceived social boundaries inform these young men's use of substances. As both protective and marginalising influences, perceptions of communities and social identities have real consequences for the sexual health of young African American and Latino gay and bisexual men.

Network loss following the 2016 Presidential Election among LGBTQ+ adults.

Growing levels of political polarization in the United States have been associated with political homogeneity in the personal networks of American adults. The 2016 Presidential Election in the United States was a polarizing event that may have caused further loss of connections to alters who had different politics. Kinship may protect against loss of politically different ties. Additionally, loss of ties with different political views may be particularly pronounced among LGBTQ+ people as they are more likely to be impacted by public policy decisions compared to their heterosexual counterparts. We analyzed two waves of the University of California, Berkeley Social Networks Study's (UCNets) Main Sample and LGBTQ+ Oversample of older adults that occurred in 2015 and 2017, which provided an opportunity to assess alter loss after the 2016 Presidential Election. When evaluating all adults, we found that politically different alters were more likely to reflect kin ties than partner or friend ties. We also found that politically different kin are less likely to be dropped suggesting that kinship acts as a moderating effect of different political views on alter loss. LGBTQ+ respondents were more likely to drop kin alters with different political views than their cisgender heterosexual counterparts. We discuss the implications these results have for political polarization interventions as well as the social networks impact politics can have on LGBTQ+ individuals.

LGBTQ+ Affirming Care May Increase Awareness and Understanding of Undetectable = Untransmittable among Midlife and Older Gay and Bisexual Men in the US South.

One of the most significant innovations in HIV prevention is the use of HIV treatment to prevent HIV transmission. This information has been disseminated as the "Undetectable = Untransmittable" (U = U) message. Despite evidence of effectiveness, U = U awareness, belief, and understanding remains limited in some communities. In this study, we examine whether having an LGBTQ affirming healthcare provider increases U = U awareness, belief, and understanding among midlife and older gay and bisexual men in the US south, an understudied and underserved population and region where new HIV infections are increasing. We used data from the Vanderbilt University Social Networks Aging and Policy Study (VUSNAPS) on sexual minority men aged 50 to 76 from four southern US states collected in 2020-2021. We found that only one in four men reported prior awareness of U = U, but awareness was higher among men who have an LGBTQ affirming provider. Among HIV negative men, those with an affirming provider were more likely to believe and understand U = U, have more accurate risk perception, and have ever tested for HIV. Improving access to LGBTQ affirming healthcare may improve U = U awareness, belief, and understanding, which could help to curb HIV transmission in the US south.

The effect of partner sex: nondisclosure of HIV status to male and female partners among men who have sex with men and women (MSMW).

A common concern within HIV prevention is that HIV positive MSMW do not disclose their HIV status to female partners who are thus at increased risk for HIV infection. The present study uses unique data to examine whether MSMW disclose more often to male rather than female partners. Data were collected on most recent male and/or female primary partner and four most recent casual partners from 150 MSMW (50 African American, 50 Latino, 50 White). MSMW reported on 590 partners (31% female; 69% male). Disclosure was coded as disclosure before sex, disclosure after sex, or nondisclosure. A series of multinomial logistic regressions with partners clustered within respondents were conducted to evaluate effects of respondent characteristics and partner characteristics on timing of disclosure. In bivariate and multivariate analyses there were no significant differences in odds of disclosure to male and female partners before or after sex. Although MSMW were substantially less likely to disclose to HIV negative partners before sex compared to HIV positive partners regardless of sex, when we fully interacted the multivariate model by partner sex, the odds of disclosure to HIV negative male partners compared to HIV positive male partners before sex were significantly higher than the odds of disclosure to HIV negative female partners compared to HIV positive female partners. Patterns of mutual nondisclosure and nonreciprocal disclosure were observed with both primary and casual partners. The paper makes additional methodological contributions to the measurement and analysis of disclosure.

Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships.

Treatment advocacy (TA) programs have been implemented by AIDS service organizations (ASOs) and primary care clinics across the USA to help engage clients with HIV into care and support their adherence to antiretroviral therapy (ART). TA aims to empower people with HIV through education and client-centered counseling regarding HIV, ART, and other health issues; advocate on behalf of patients with providers; and make referrals to healthcare services and clinical trials. However, relatively little is known about the impact TA has on clients' healthcare experiences. The present study's objectives included exploring how TA services help clients engage in HIV care, initiate ART, and adhere to HIV medications. We conducted 25 semi-structured qualitative open-ended interviews with clients living with HIV/AIDS recruited from AIDS Project Los Angeles (APLA); four HIV medical providers; and two TA staff at APLA. Of the 25 clients interviewed, 92% were male and 8% were female. The average age was 43 years (SD=9). About 60% were African-American, 20% were White, 12% were other or multiracial, 4% were Latino, and 4% were Asian/Pacific Islander. Five interconnected themes consistently emerged across clients, TAs, and providers. TAs helped clients understand treatments and supported adherence within a holistic context. Further, TAs acted as a bridge to providers and helped clients build self-advocacy skills. Our data show that TA services go beyond traditional areas of education and treatment adherence. TA services within an ASO also provide a safe place to discuss initial HIV diagnoses and other health issues in a more comprehensive manner. TA services complemented medical and other social services by preparing clients with HIV to be better consumers of healthcare services. Future quantitative research examining the effectiveness of TA on improving clients' engagement in care and adherence is a critical next step.

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence.

ABSTRACT: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

Structural competency and the future of firearm research.

In this critical literature review we develop a five-part agenda for pandemic-era research into mass shootings and multiple-victim homicides that promotes understanding the psychologies of individual shooters within larger structures and systems. We show how the momentous events set in motion by the COVID-19 virus, and the structural drivers of inequity and racism that its spread exposed, challenge mental health research on gun trauma to better account for broader terrains of race and place, as well as the tensions, politics, and assumptions that surround guns in the U.S. more broadly. Doing so will broaden mental-health interventions into epidemics of U.S. gun trauma, and challenge mental health research better recognize structural biases inherent in its own purview. We frame the agenda through the rubric of structural competency, an emerging framework that systematically trains health care professionals and others to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases. Developing a structural framework around research into U.S. gun violence addresses the risks, traumas, meanings, and consequences that firearms represent for all communities-and highlights the importance of a renewed focus on mental health and safety for communities of color. Recognizing how gun violence reflects and encapsulates structures helps mental health experts address common sense gun policies within broader contexts-by fighting against structural racism or racially inflected gun policies for instance, or against economic policies that undermine access to mental health care more broadly.

Methods for recruiting men of color who have sex with men in prevention-for-positives interventions.

Men who have sex with men (MSM), especially MSM of color, are disproportionately impacted by HIV/AIDS compared to heterosexuals and Caucasians. Nonetheless, fewer sexual and ethnic minorities participate in prevention interventions for people with HIV. We consider recruitment for Positive Connections, a randomized controlled trial comparing unsafe sex prevention interventions primarily for HIV-positive (HIV+) MSM in six US epicenters. One community-based organization (CBO) in each city recruited adult MSM, particularly men of color and HIV+. Recruitment methods included on-line and print advertising, outreach events, health professionals, and social networks. Data on demographics, HIV status, and recruitment method were collected at registration. We tested for differences in registration proportions and attendance rates by recruitment strategy, stratified on race/ethnicity and serostatus. Of the 1,119 registrants, 889 attended the intervention. The sample comprised 41% African American, 18% Latino/Hispanic, and 77% HIV+. Friend referral was reported by the greatest proportion of registrants, particularly among African American (33%) and HIV+ men (25%). Print advertising yielded the largest proportions of non-Hispanic white (27%) and HIV-negative registrants (25%). Registrants recruited on-line were the least likely to attend (45% versus 69% average); this effect was strongest among Latino/Hispanic (27% attendance) and non-Hispanic white men (36%). Retention during the follow-up period did not differ by serostatus, race/ethnicity, or recruitment method. Differential attendance and retention according to recruitment strategy, serostatus, and racial/ethnic group can inform planning for intervention sample size goals.