Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members.

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW's mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW's health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study's findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW's diverse gender identities and expressions; (2) focusing on SMW's nonbinary stressors; (3) formulating SMW's gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW's lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

Developing the "Oppression-to-Incarceration Cycle" of Black American and First Nations Australian Trans Women: Applying the Intersectionality Research for Transgender Health Justice Framework.

Trans women are disproportionately incarcerated in the United States and Australia relative to the general population. Stark racial and ethnic disparities in incarceration rates mean that Black American and First Nations Australian trans women are overrepresented in incarceration relative to White and non-Indigenous cisgender and trans people. Informed by the Intersectionality Research for Transgender Health Justice (IRTHJ) framework, the current study drew upon lived experiences of Black American and First Nations Australian trans women to develop a conceptual model demonstrating how interlocking forces of oppression inform, maintain, and exacerbate pathways to incarceration and postrelease experiences. Using a flexible, iterative, and reflexive thematic analytic approach, we analyzed qualitative data from 12 semistructured interviews with formerly incarcerated trans women who had been incarcerated in sex-segregated male facilities. Three primary domains-pathways to incarceration, experiences during incarceration, and postrelease experiences-were used to develop the "oppression-to-incarceration cycle." This study represents a novel application of the IRTHJ framework that seeks to name intersecting power relations, disrupt the status quo, and center embodied knowledge in the lived realities of formerly incarcerated Black American and First Nations Australian trans women.

Availability of Accessible Representative Health Data to Examine Sexual and Gender Minority Disparities in Incarceration and Its Health Implications in the United States, 2010-2020.

Purpose: To facilitate identification of the impact of incarceration on the health of sexual and gender minority (SGM) populations, we sought to identify publicly accessible, representative health datasets that assessed SGM status and incarceration history from 2010 to 2020 and to examine SGM disparities in lifetime incarceration experiences. Methods: Datasets were identified and analyzed through a multistep process: (1) content search of 76 health datasets; (2) consultation with 14 subject matter experts; (3) a systematic review; and (4) a data analysis stage. Utilizing the identified health datasets, we produced representative estimates of sexual minority (SM) incarceration disparities. Results: Five publicly accessible databases were identified that assessed SM status and incarceration history; none assessed gender minority status and incarceration history. Across datasets, the weighted prevalence of lifetime incarceration among SM populations was substantially higher (range = 17.5%-26.3%) than among non-SM populations (range = 4.6%-21.2%). Conclusion: Few publicly accessible, representative health datasets collect standardized information regarding SM status and incarceration history, and none assess diverse gender identities and incarceration history. These data suggest that a disproportionate proportion of SM individuals may experience incarceration compared with non-SM individuals. Research assessing the health effects of incarceration on SGM populations remains limited; publicly accessible, representative health data are needed to address this gap.

Early Timing and Determinants of the Sexual Orientation Disparity in Internalizing Psychopathology: A Prospective Cohort Study from Ages 3 to 15.

Knowing the age at which the sexual orientation disparity in depression and anxiety symptoms first emerges and the early determinants of this disparity can suggest optimal timing and targets of supportive interventions. This prospective cohort study of children ages 3 to 15 (n = 417; 10.6% same-sex-attracted; 47.2% assigned female at birth) and their parents sought to determine the age at which the sexual orientation disparity in depression and anxiety symptoms first emerges and whether peer victimization and poor parental relationships mediate this disparity. Same-sex-attracted youth first demonstrated significantly higher depression symptoms at age 12 and anxiety symptoms at age 15 than exclusively other-sex-attracted youth. Age 12 peer victimization mediated the sexual orientation disparity in age 15 depression symptoms. Age 12 poor mother-child relationship mediated the sexual orientation disparity in age 15 anxiety symptoms. The findings are discussed in terms of implications for developmentally appropriate interventions against social stress during early development.

Psychological Distress, Suicidal Ideation, and Suicide Attempt Among Lesbian, Gay, and Bisexual Immigrants: Population-Based Findings from the Stockholm Public Health Cohort.

In a large, population-based sample in Sweden, we sought to examine mental health disparities between lesbian, gay and bisexual (LGB) and heterosexual individuals with different immigration statuses. We conducted a population-based study including 1799 LGB and 69,324 heterosexual individuals, recruited in 2010 and 2014 as part of the Stockholm Public Health Cohort. Data were obtained from self-administered surveys that were linked to nationwide registers. We examined associations between mental health outcomes (i.e., psychological distress, suicidal ideation, and suicide attempt) and sexual orientation (LGB versus heterosexual), immigration status (immigrant versus Nordic-born), and their interaction. Sex-stratified weighted multivariable logistic regression analyses were used to calculate adjusted odds ratios with 95% confidence intervals. LGB individuals demonstrated substantially elevated odds of all mental health outcomes compared to heterosexuals; immigrants reported moderately elevated odds of psychological distress and suicide attempt, but not suicidal ideation, compared to Nordic-born individuals. Interaction terms between sexual orientation and immigration status were significant at p < 0.05 for psychological distress for both sexes and for suicidal ideation and attempt among women. Unexpectedly, models probing interactions generally demonstrated that Nordic-born LGB individuals demonstrated greater risk of psychological distress, suicidal ideation, and suicide attempt than did immigrant LGB individuals, especially among women. Supplemental analyses showed that Nordic-born bisexual women demonstrated the highest risk of all studied outcomes. Being LGB in Sweden is generally a stronger risk factor for poor mental health among Nordic-born than immigrant populations. These findings call for future intersectionality-focused research to delineate the unique cultural, social, and psychological factors associated with mental health and resilience among LGB immigrants.

Sexual and Gender Minority Status and Firearms in the Household: Findings From the 2017 Behavioral Risk Factor Surveillance System Surveys, California and Texas.

OBJECTIVES: Although lesbian, gay, bisexual, and transgender (LGBT) people have a higher prevalence of reporting a lifetime suicide attempt than non-LGBT people, suicide prevention research on access to lethal means (eg, firearms) among LGBT people is limited. Our study examined (1) the presence of firearms in the home and (2) among respondents with firearms in the home, the storage of firearms as stored unloaded, stored as loaded and locked, or stored as loaded and unlocked. METHODS: We used data from the 2017 Behavioral Risk Factor Surveillance System surveys from California and Texas (N = 11 694), which were the only states to include items about both sexual orientation and gender identity and the status of firearms in the home. We used logistic regression analysis to assess the association of sexual orientation and gender identity with having firearms in the home while accounting for sociodemographic characteristics and survey state. All analyses were weighted to account for the complex sampling design. RESULTS: Approximately 4.2% of the sample identified as lesbian, gay, and bisexual (LGB). About 18.2% of LGB people reported firearms in the home compared with 29.9% of their heterosexual peers. After adjusting for sex, age, race/ethnicity, educational attainment, and military veteran status, LGB respondents had significantly lower odds of reporting firearms in the home than their heterosexual peers (adjusted odds ratio = 0.47; 95% CI, 0.27-0.84). Among respondents with firearms in the home, firearm storage did not differ by sexual orientation. CONCLUSIONS: Further research is needed to examine whether lower odds of firearms in the home are protective against suicide deaths among LGB populations.

Health Disparities, Risk Behaviors and Healthcare Utilization Among Transgender Women in Los Angeles County: A Comparison from 1998-1999 to 2015-2016.

Data from two studies of transgender women in Los Angeles County that used the same methodology and survey assessment (Study 1: 1998-1999, N = 244; Study 2: 2015-2016, N = 271), compared structural determinants of health, HIV/STI prevalence, HIV risk behaviors, substance use, gender confirmation procedures, and perceived discrimination and harassment/abuse across a 17-year time period. Findings demonstrated that participants in the latter study reported significantly higher access to healthcare insurance and prescription hormones. However, participants in the latter study also reported lower levels of income; and, elevated prevalence of homelessness, HIV and lifetime STIs, receptive condomless anal intercourse with casual partner(s), and reported physical harassment/abuse. Given the timeframe of these results, these findings elucidate specific areas of transgender women's health and risk profiles that improved or worsened across 17 years. While healthcare access has improved, transgender women continue to face significant barriers to good health, indicating the need for increased attention to this population.

Structural Inequities and Social Networks Impact Hormone Use and Misuse Among Transgender Women in Los Angeles County.

In order to reduce gender dysphoria and combat stigma, transgender women often affirm their gender through social and medical transition, which may include cross-sex hormone therapy. This study examined associations between medically monitored hormone use and hormone misuse (non-prescribed hormone use including "fillers"), structural inequities (access to housing, health insurance, and income), and social network dynamics among 271 transgender women in Los Angeles. Hormone use status was coded trichotomously (hormone use, hormone misuse, no hormone use), and robust multinomial logistic regression as well as novel social network analysis was conducted to examine associations. Results demonstrated that younger, African-American/Black transgender women were most likely to engage in hormone misuse compared to transgender women who were older or non-African-American/Black. One-third of the sample reported sex work as a main source of income, and this group was more likely to misuse hormones than those with another primary source of income. Transgender women with access to stable housing and health insurance were most likely to engage in medically monitored hormone use. Social network analysis revealed that transgender women with a greater number of hormone-using network alters were most likely to misuse hormones, but that using the Internet to find transgender friends mitigated this association. Results demonstrate the multifaceted risk profile of transgender women who use and misuse hormones, including that social networks play an important role in hormone usage among transgender women.

Factors Associated with Medical Doctors' Intentions to Discriminate Against Transgender Patients in Kuala Lumpur, Malaysia.

PURPOSE: Transgender people are frequent targets of discrimination. Discrimination against transgender people in the context of healthcare can lead to poor health outcomes and facilitate the growth of health disparities. This study explores factors associated with medical doctors' intentions to discriminate against transgender people in Malaysia. METHODS: A total of 436 physicians at two major university medical centers in Kuala Lumpur, Malaysia, completed an online survey. Sociodemographic characteristics, stigma-related constructs, and intentions to discriminate against transgender people were measured. Bivariate and multivariate linear regression were used to evaluate independent covariates of discrimination intent. RESULTS: Medical doctors who felt more fearful of transgender people and more personal shame associated with transgender people expressed greater intention to discriminate against transgender people, whereas doctors who endorsed the belief that transgender people deserve good care reported lower discrimination intent. Stigma-related constructs accounted for 42% of the variance and 8% was accounted for by sociodemographic characteristics. CONCLUSIONS: Constructs associated with transgender stigma play an important role in medical doctors' intentions to discriminate against transgender patients. Development of interventions to improve medical doctors' knowledge about and attitudes toward transgender people are necessary to reduce discriminatory intent in healthcare settings.

"What's the right thing to do?" Correctional healthcare providers' knowledge, attitudes and experiences caring for transgender inmates.

RATIONAL: Incarcerated transgender individuals may need to access physical and mental health services to meet their general and gender-affirming (e.g., hormones, surgery) medical needs while incarcerated. OBJECTIVE: This study sought to examine correctional healthcare providers' knowledge of, attitudes toward, and experiences providing care to transgender inmates. METHOD: In 2016, 20 correctional healthcare providers (e.g., physicians, social workers, psychologists, mental health counselors) from New England participated in in-depth, semi-structured interviews examining their experiences caring for transgender inmates. The interview guide drew on healthcare-related interviews with recently incarcerated transgender women and key informant interviews with correctional healthcare providers and administrators. Data were analyzed using a modified grounded theory framework and thematic analysis. RESULTS: Findings revealed that transgender inmates do not consistently receive adequate or gender-affirming care while incarcerated. Factors at the structural level (i.e., lack of training, restrictive healthcare policies, limited budget, and an unsupportive prison culture); interpersonal level (i.e., custody staff bias); and individual level (i.e., lack of transgender cultural and clinical competence) impede correctional healthcare providers' ability to provide gender-affirming care to transgender patients. These factors result in negative health consequences for incarcerated transgender patients. CONCLUSIONS: Results call for transgender-specific healthcare policy changes and the implementation of transgender competency trainings for both correctional healthcare providers and custody staff (e.g., officers, lieutenants, wardens).

Geographic and Individual Differences in Healthcare Access for U.S. Transgender Adults: A Multilevel Analysis.

PURPOSE: To identify geographic and individual-level factors associated with healthcare access among transgender people in the United States. METHODS: Multilevel analyses were conducted to investigate lifetime healthcare refusal using national data from 5831 U.S. transgender adults. Hierarchical generalized linear models examined associations between individual (age, gender, race, income, insurance, and healthcare avoidance) and state-level factors (percent voting Republican, percent same-sex couple households, income inequality, and transgender protective laws) and lifetime refusal of care. RESULTS: Results show that individual-level factors (being older; trans feminine; Native American, multiracial, or other racial/ethnic minority; having low income; and avoiding care due to discrimination) are positively associated with care refusal (all P-values <0.05). Adjusting for individual-level factors, variation was observed across U.S. states, with a greater proportion of states in the Southern and Western United States with transgender residents at increased odds of experiencing care refusal, relative to other regions of the United States. When adjusting for state-level factors, the percentage of the state population voting Republican was positively associated with care refusal among the transgender adults sampled (P < 0.01). CONCLUSION: Transgender adults surveyed reported differential access to healthcare by geographic region. Identifying geographic and individual-level factors associated with healthcare barriers allows for the development of targeted educational and policy interventions to improve healthcare access for transgender people most in need of services.