Inequities in the distribution of adverse childhood experiences and their association with health among transgender people of color.

BACKGROUND: Racism and cisgenderism expose transgender people of color to adversity across the life course. However, little is known about the prevalence of adverse childhood experiences (ACEs) in this population or their association with health in comparison to other groups. OBJECTIVE: Guided by the structural trauma framework, we examined race/ethnicity/gender group differences in the prevalence of ACEs and their association with adult mental and physical health. PARTICIPANTS AND SETTING: 2019-2021 Behavioral Risk Factor Surveillance Survey. METHODS: Transgender participants (n = 551) were matched with two cisgender men (n = 1102) and two cisgender women (n = 1102) on key covariates. We compared age-adjusted predicted probabilities of nine ACEs by race/ethnicity/gender group. We then fit adjusted logistic regression models predicting poor mental and physical health by each ACE and compared marginal effects between groups. RESULTS: Transgender people of color had higher age-adjusted probabilities of six ACEs than at least one other group; for example, household incarceration was 0.16 (95 % CI: 0.11-0.22) compared to 0.09 (95 % CI: 0.06-0.13) for cisgender men of color (p = 0.032). The relationship between five ACEs and poor mental health was greater for transgender people of color than at least one other group. For instance, the marginal effect of household alcoholism on poor mental health was 0.28 (95 % CI: 0.11-0.45) compared to 0.07 (0.01-0.14) for White cisgender men (p = 0.031). There were no statistically significant differences regarding effects on poor physical health. CONCLUSIONS: ACEs inequitably impact transgender people of color, reflecting the need to restructure the interlocking systems that drive adversity among transgender children of color and exacerbate ACEs' health effects among adults.

Community-Led Response to Address Economic Vulnerability due to COVID-19 with, for, and by Transgender Women of Color: A Qualitative Pilot Evaluation.

Purpose: Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color. Methods: We conducted a pilot program evaluation (n=8). Results: Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as "somewhat to extremely easy." Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities. Conclusion: Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color.

Structural Needs, Substance Use, and Mental Health Among Transgender and Nonbinary Young Adults in the San Francisco Bay Area: Findings from the Phoenix Study.

Transgender and nonbinary (trans) young adults report high rates of substance use and adverse mental health outcomes; however, few studies have examined how social, economic, and legal factors may contribute to health inequities in this population. Guided by the structural vulnerability framework, this study sought to explore structural needs and whether these needs were associated with substance use and mental health outcomes among trans young adults. Between 2019 and 2021, 215 trans young adults aged 18-29 from San Francisco Bay Area were recruited into a longitudinal study. Baseline data were used to examine bivariate and multivariable associations between structural needs and substance use and mental health outcomes. There were bivariate differences in the number of structural needs by education, income source, incarceration history, and ethnicity, and the number of unmet structural needs was associated with education and income source. After adjusting for sociodemographics, the number of structural needs was associated with daily marijuana use (AOR 1.29, 95% CI: 1.10-1.49) and suicidal ideation (AOR 1.24, 95% CI: 1.06-1.45), and the number of unmet structural needs was associated with daily marijuana use (AOR 1.30, 95% CI: 1. 10-1.55) and depressive symptoms (ß 2.00, 95% CI: 1.00-3.00). Additionally, both numbers of structural needs and unmet structural needs mediated the relationship between income source (traditional employment vs. other income only) and depressive symptoms (TIE ß 2.51, 95% CI: 0.99-4.04; ß 1.37, 95% CI: 0.23-2.52, respectively). Findings highlight a need for multisector efforts to address structural vulnerabilities among trans young adults.

Exploring the Potential for Smoke-Free Laws to Reduce Smoking Disparities by Sexual Orientation in the USA.

BACKGROUND: We examined associations between smoke-free laws and smoking outcomes in a nationally representative sample of US adults, including exploring whether these associations differed for heterosexual and sexual minority (SM) adults. METHODS: We constructed county-level variables representing the percent of the population covered by state-, county-, or city-level smoke-free laws in workplaces and hospitality venues. We combined this information with restricted individual-level adult data with masked county identifiers from the National Health Interview Survey (NHIS), 2013-2018. We used modified Poisson regression to explore associations between each type of smoke-free law and the prevalence ratio (PR) of current smoking, and we used linear regression to explore associations with smoking intensity (mean cigarettes per day). We assessed interactions between smoke-free laws and SM status on the additive scale to determine whether associations were different for SM and heterosexual adults. RESULTS: In adjusted models without interaction terms, smoke-free laws in hospitality venues were associated with lower prevalence of current smoking (PR = 0.93, 95% confidence interval (CI) = 0.89, 0.98). Both types of smoke-free laws were associated with lower mean cigarettes per day (workplace law change in mean = - 0.50, 95% CI = - 0.89, - 0.12; hospitality law change in mean = - 0.72, 95% CI = - 1.14,-0.30). We did not observe any statistically significant interactions by SM status, though statistical power was limited. CONCLUSIONS: We did not find evidence that smoke-free laws were differentially associated with smoking outcomes for heterosexual and SM adults. Additional studies are needed to further explore the potential for tobacco control policies to address the elevated risk of smoking in SM communities.

Structural vulnerability as a conceptual framework for transgender health research: findings from a community needs assessment of transgender women of colour in Detroit.

The concept of structural vulnerability explains how systems of oppression drive health inequities by reducing access to survival resources (e.g. food, housing) for marginalised populations. Indicators of structural vulnerability such as housing instability, violent victimisation and poverty are often interconnected and result from intersectional oppression. We sought to demonstrate the utility of the structural vulnerability framework for transgender health research by examining patterns of structural vulnerability indicators among transgender women of colour in Detroit. We conducted latent class analysis and tested associations between classes and mental health and substance use outcomes. Membership to the Lowest Vulnerability class was negatively associated with post-traumatic stress disorder (PTSD) (aOR = 0.10, 95% CI: 0.02-0.59). High Economic Vulnerability membership was associated with daily marijuana use (aOR = 4.61, 95% CI: 1.31-16.16). Complex Multi-Vulnerability membership was associated with PTSD (aOR = 9.75, 95% CI: 2.55-37.29), anxiety (aOR = 4.12, 95% CI: 1.22-13.97), suicidality (aOR = 6.20, 95% CI: 1.39-27.70), and club drug use (aOR = 4.75, 95% CI: 1.31-17.29). Substantively different findings emerged when testing relationships between each indicator and each outcome, highlighting the value of theoretically grounded quantitative approaches to understanding health inequities. Community-driven interventions and policy changes that reduce structural vulnerability may improve mental health and substance use outcomes among structurally vulnerable trans women of colour.

Televised Anti-Tobacco Media and Smoking Outcomes Among Heterosexual and Sexual Minority Adults in the United States.

BACKGROUND: The prevalence of smoking is higher among sexual minority (SM) individuals compared with heterosexuals. The impact of televised anti-tobacco mass media campaigns on smoking outcomes among SMs is not known. AIMS: We examined whether televised anti-tobacco advertising was differentially associated with current smoking and smoking intensity for SM and heterosexual adults. METHOD: We combined county-level anti-tobacco advertising data (gross rating points) with restricted, geocoded individual-level National Health Interview Survey data on smoking (2013-2015). We estimated associations between advertising and smoking outcomes, including potential effect modification by SM status. RESULTS: Greater anti-tobacco advertising exposure was associated with lower smoking prevalence (prevalence ratio [PR] = 0.97; 95% confidence interval [CI] = [0.94, 1.00]). Although the direction of the association differed for heterosexual and SM adults, differences were not statistically significant. No significant associations were observed with regard to smoking intensity. CONCLUSION: Associations between anti-tobacco advertising and smoking were not significantly different for heterosexual and SM adults.

Re-validation and cultural adaptation of the brief, standardized assessment tool for measuring HIV-related stigma in healthcare settings in Almaty, Kazakhstan.

The HIV epidemic continues to grow in Kazakhstan and HIV stigma remains a major barrier to HIV prevention and treatment in the country. HIV stigma in healthcare setting may also discourage people living with HIV (PLHIV) from getting the care needed. Therefore, studying the attitudes of healthcare workers towards PLHIV is important and requires well-constructed measurement tools adapted to the specific cultural context. In our study, we aimed to adapt and re-validate a brief questionnaire on HIV stigma among healthcare workers in Almaty, Kazakhstan. We held focus group discussions to obtain input on an existing questionnaire and surveyed 448 primary healthcare providers to psychometrically evaluate the scale. The final HIV-stigma scale consisted of 15 items, 6 of them measuring negative opinions about PLHIV and the rest assessing stigmatizing health facility policies towards PLHIV. Both HIV-stigma subscales demons6trated adequate psychometric properties (with Cronbach's alpha α = 0.57 for the first and α = 0.86 for the second subscale, and with factor loadings >0.35 within each subscale). High numbers of respondents holding negative attitudes towards PLHIV, detected in this sample (87%; n = 380), may suggest the need for immediate actions addressing HIV stigma in healthcare in Kazakhstan.

US Black-White Differences in Mortality Risk Among Transgender and Cisgender People in Private Insurance, 2011-2019.

Objectives. To compare survival by gender and race among transgender and cisgender people enrolled in private insurance in the United States between 2011 and 2019. Methods. We examined Optum's Clinformatics Data Mart Database. We identified transgender enrollees using claims related to gender-affirming care. Our analytic sample included those we identified as transgender and a 10% random sample of cisgender enrollees. We limited our sample to those 18 years or older who were non-Hispanic Black or White. We identified 18 033 transgender and more than 4 million cisgender enrollees. We fit Kaplan-Meier survival curves and calculated standardized mortality ratios while adjusting for census region. Results. Black transfeminine and nonbinary people assigned male sex at birth were 2.73 times more likely to die than other Black transgender people and 2.38 and 3.34 times more likely than Black cisgender men and women, respectively; similar results were found when White transfeminine and nonbinary people assigned male sex at birth were compared with White cisgender cohorts. Conclusions. Our findings highlight glaring inequities in mortality risks among Black transfeminine and nonbinary people assigned male sex at birth and underscore the need to monitor mortality risks in transgender populations and address the social conditions that increase these risks. (Am J Public Health. 2022;112(10):1507-1514. https://doi.org/10.2105/AJPH.2022.306963).

Social Networks and Sexual and Gender Minority Disparities in Alcohol Use and Consequences Among First-Year College Students.

Purpose: In this work, we investigate the association between social relationships and alcohol use and the related consequences of sexual and gender minority (SGM) college students, and we highlight the importance of SGM social networks as a potential protective factor among SGM college students. Methods: The study used data from 1340 students (47.2% White and non-Hispanic, 55.4% assigned female at birth, 16.3% SGM), which were collected during the 2016 fall semester of the first year of college at one university. The study collected information about alcohol use and related consequences and about the social networks of participants through a peer nomination survey. Results: Regardless of SGM status, students who nominated at least one SGM peer reported significantly lower drinks per week (ß = -0.69, p = 0.04) and heavy drinking frequency (ß = -0.38, p = 0.02) after adjusting for relevant covariates including peer drinking. SGM participants showed a significantly stronger negative association between having an SGM peer and heavy drinking frequency and alcohol-related consequences than their cisgender heterosexual counterparts (ß = -0.90, p = 0.04; ß = -1.32, p = 0.03). Conclusion: These findings highlight the importance of SGM social networks as a potential protective factor for reducing alcohol use and related consequences among SGM college students. College campuses should identify ways to support connections among SGM students. Clinical trials registration number is NCT02895984.

Differences in All-Cause Mortality Among Transgender and Non-Transgender People Enrolled in Private Insurance.

Few studies have analyzed mortality rates among transgender (trans) populations in the United States and compared them to the rates of non-trans populations. Using private insurance data from 2011 to 2019, we estimated age-specific all-cause mortality rates among a subset of trans people enrolled in private insurance and compared them to a 10% randomly selected non-trans cohort. Overall, we found that trans people were nearly twice as likely to die over the period as their non-trans counterparts. When stratifying by gender, we found key disparities within trans populations, with people on the trans feminine to nonbinary spectrum being at the greatest risk of mortality compared to non-trans males and females. While we found that people on the trans masculine to nonbinary spectrum were at a similar risk of overall mortality compared to non-trans females, their overall mortality rate was statistically smaller than that of non-trans males. These findings provide evidence that some trans and non-trans populations experience substantially different mortality conditions across the life course and necessitate further study.

State-Level Policy Stigma and Non-Prescribed Hormones Use among Trans Populations in the United States: A Mediational Analysis of Insurance and Anticipated Stigma.

BACKGROUND: Medical gender affirmation (i.e., hormone use) is one-way transgender (trans) people affirm their gender and has been associated with health benefits. However, trans people face stigmatization when accessing gender-affirming healthcare, which leads some to use non-prescribed hormones (NPHs) that increase their risk for poor health. PURPOSE: We examined whether healthcare policy stigma, as measured by state-level trans-specific policies, was associated with NPHs use and tested mediational paths that might explain these associations. Because stigmatizing healthcare policies prevent trans people from participation in healthcare systems and allow for discrimination by healthcare providers, we hypothesized that healthcare policy stigma would be associated with NPHs use by operating through three main pathways: skipping care due to anticipated stigma in healthcare settings, skipping care due to cost, and being uninsured. METHODS: We conducted analyses using data from the 2015 U.S. Transgender Survey. The analytic sample included trans adults using hormones (N = 11,994). We fit a multinomial structural equation model to examine associations. RESULTS: Among trans adults using hormones, we found that healthcare policy stigma was positively associated with NPHs use and operated through insurance coverage and anticipating stigma in healthcare settings. The effect sizes on key predictor variables varied significantly between those who use supplemental NPHs and those who only use NPHs suggesting the need to treat NPHs use as distinct from those who use supplemental NPHs. CONCLUSIONS: Our work highlights the importance of healthcare policy stigma in understanding health inequities among trans people in the USA, specifically NPHs use.

A Scoping Review Examining Social and Legal Gender Affirmation and Health Among Transgender Populations.

Purpose: Transgender (trans) populations experience health inequities. Gender affirmation refers to psychological, social, legal, and medical validation of one's gender and is a key social determinant of trans health. The majority of research has focused on medical affirmation; however, less is known about the role of social and legal affirmation in shaping trans health. This review aimed to (1) examine how social and legal gender affirmation have been defined and operationalized and (2) evaluate the association between these forms of gender affirmation and health outcomes among trans populations in the United States. Methods: We conducted a systematic search of LGBT Life, PsycInfo, and PubMed using search strings targeting transgender populations and gender affirmation. This review includes 24 of those articles as well as 1 article retrieved through hand searching. We used a modified version of the National Institute of Health Quality Assessment Tool to evaluate study quality. Results: All studies relied on cross-sectional data. Studies measured and operationalized social and legal gender affirmation inconsistently, and some measures conflated social gender affirmation with other constructs. Health outcomes related to mental health, HIV, smoking, and health care utilization, and studies reported mixed results regarding both social and legal gender affirmation. The majority of studies had serious methodological limitations. Conclusion: Despite conceptual and methodological limitations, social and legal gender affirmation were related to several health outcomes. Study findings can be used to develop valid and reliable measures of these constructs to support future multilevel interventions that improve the health of trans communities.

Smoke-Free Laws and Disparities in Secondhand Smoke Exposure Among Nonsmoking Adults in the United States, 1999-2014.

INTRODUCTION: Little is known about the relationship between smoke-free laws and persistent disparities in secondhand smoke (SHS) exposure among nonsmoking adults in the United States. AIMS AND METHODS: We constructed time-varying smoke-free law measures representing whether or not at least 50% of each US county's population was covered by smoke-free laws in workplaces and hospitality venues (restaurants/bars). We merged these data with restricted data on cotinine-derived SHS exposure among nonsmokers from the National Health and Nutrition Examination Survey, 1999-2014 (N = 25 444). Using logistic regression, we estimated associations between smoke-free law coverage and SHS exposure among all nonsmokers, and within age strata (25-39, 40-59, 60+). We explored differential associations by gender, race/ethnicity, education, and poverty-income ratio (PIR) by testing the significance of interactions terms for the full sample and within age strata. RESULTS: In adjusted models, hospitality coverage was associated with lower odds of SHS exposure in the full sample (odds ratio [OR] = 0.62; 95% confidence interval [CI] = 0.51-0.76), and within each age group, with ORs ranging from 0.58 (ages 25-39) to 0.67 (ages 60+). Workplace coverage was associated with lower SHS exposure only among younger adults (OR = 0.81; 95% CI = 0.65-0.99). Within the full sample and among adults ages 40-59, hospitality laws were associated with narrowing SHS exposure differentials between males and females. Among adults ages 40-59, workplace laws were associated with narrowing exposure differentials between males and females, but worsening exposure disparities by PIR. CONCLUSIONS: Smoke-free laws may reduce SHS exposure among adult nonsmokers, but may be insufficient to improve disparities in SHS exposure. IMPLICATIONS: In a repeated cross-sectional sample of adult nonsmokers, smoke-free laws in hospitality venues were consistently associated with lower odds of SHS exposure and appeared to narrow exposure differentials between males and females. Associations between workplace smoke-free laws and SHS exposure were variable by age. Among adults ages 40-59, workplace laws were associated with narrowing exposure differentials between males and females while exacerbating exposure differentials by PIR. Differential patterns of association highlight the need to examine the impacts of tobacco control policies on downstream health equity.

A "tax" on gender affirmation and safety: costs and benefits of intranational migration for transgender young adults in the San Francisco Bay area.

Many transgender (trans) young adults migrate to urban enclaves with known infrastructures to fulfil gender affirmation needs such as obtaining trans-inclusive healthcare and support. This study sought to explore experiences of intranational migration (i.e. migration within a single country) for gender affirmation among trans young adults who relocated to San Francisco. A convenience sample of 61 trans young adults aged 18 to 29 (32% nonbinary, 28% trans women, and 40% trans men; 84% identified as a person of colour) participated in a one-time qualitative interview as part of a larger study. Thematic analysis was used to develop and refine the codes and themes. Three overarching themes became apparent regarding intranational migration and gender affirmation needs: (1) access to basic gender affirmation needs; (2) safety; and (3) the price of gender affirmation. Migration for gender affirmation and safety placed informants at risk for structural vulnerabilities including homelessness, unemployment and racism. Despite these structural vulnerabilities, participants were willing to "pay" the price in order to gain gender affirmation and safety. Findings underscore the importance of moving beyond individual-level risk factors to understand how unmet gender affirmation needs may place trans young adults in structurally vulnerable positions that can affect health and wellness.

State Policies and Healthcare Use Among Transgender People in the U.S.

INTRODUCTION: The introduction and passing of restrictive and protective transgender-specific state policies have increased during the past decade. These policies are critical for the health of transgender and other gender diverse people; however, little is known about the relationship between these policies and healthcare use, and the role that race/ethnicity plays in this relationship. METHODS: Analysis was conducted in 2018-2019 using multilevel modeling and data from the 2015 U.S. Trans Survey (conducted by the National Center for Transgender Equality among nearly 28,000 transgender and other gender diverse people across the U.S.) to explore associations between transgender-specific state policies and healthcare avoidance because of fear of mistreatment. State policies included those related to experiences of discrimination, health insurance coverage, and changing legal documents. Restrictive and protective policies were measured individually and as a composite index. The relationship between race/ethnicity and healthcare use was also examined to determine whether there were differences in the association between race/ethnicity and healthcare avoidance by state. RESULTS: None of the individual policies were associated with healthcare use, but the composite index was significant, such that living in states with more protective policies was associated with reduced odds of avoiding health care because of fear of mistreatment. The relationship between race/ethnicity and health care also varied across states. CONCLUSIONS: Findings suggest the importance of advocating for more protective transgender-specific policies to improve healthcare access for transgender and other gender diverse people in the U.S., particularly for transgender and other gender diverse people of color.

Healthcare providers and community perspectives on expedited partner therapy (EPT) for use with gay, bisexual and other men who have sex with men.

OBJECTIVES: Expedited partner therapy (EPT) is an effective strategy to reduce rates of chlamydia and gonorrhoea infection and ensure sexual partners are treated. Currently, EPT is provided to heterosexual patients; however, EPT is not routinely recommended for use with gay, bisexual and other men who have sex with men (GBMSM) because of concerns about HIV coinfection. The objective of the qualitative study was to understand provider and community views on the use of EPT with GBMSM. METHODS: Using convenience sampling methods, we recruited a sample of 18 healthcare providers and 21 GBMSM to participate in in-depth, semistructured interviews. Interviews were conducted over the phone and included questions about knowledge, experiences and potential barriers and facilitators to the use of EPT with GBMSM. RESULTS: Most providers wanted to provide EPT to GBMSM and believed that the potential barriers and concerns to EPT use were not unique to a patient's sexual orientation. Several providers noted that they were currently providing EPT to GBMSM as part of HIV prevention services. Community members were generally unaware of EPT as a service and most indicated that they would only use EPT if they were in a committed relationship. Barriers included partner allergies and resistance, pharmacy protocols, structural concerns (eg, insurance coverage, pharmacists onsite and transportation) and potential disclosure issues. Facilitators included cultural humility and telemedicine with patients' partners to overcome these barriers. CONCLUSIONS: Acceptability of EPT use for both chlamydia and gonorrhoea was high among providers and community members. Barriers to EPT use, including concerns about patients' partners' allergies and resistance, disclosure concerns and linkage to HIV prevention services can be overcome through cultural humility trainings and telemedicine. Changing EPT recommendations at the national level to be inclusive of GBMSM is critical to curtail the rising STI and HIV epidemic.

Intersectional minority stress disparities among sexual minority adults in the USA: the role of race/ethnicity and socioeconomic status.

Few studies have examined the intersection of race/ethnicity and socioeconomic status on the experience of minority stressors among sexual minority adults. We examined whether there are differences in reports of minority stressors by race/ethnicity and socioeconomic status, and whether socioeconomic status moderates the associations between race/ethnicity and minority stressors. We analysed data from Project Stride, a community-based sample of 396 self-identified lesbian, gay and bisexual adults in New York City. We conducted a hierarchical multiple regression analysis to examine the associations between race/ethnicity and socioeconomic status on minority stressors. In adjusted models, African American and Latino sexual minority adults experienced greater anticipated stigma relative to their white counterparts. Socioeconomic status significantly moderated the association of race/ethnicity and enacted stigma. For African Americans, higher socioeconomic status was associated with more enacted stigma, whereas higher socioeconomic status was associated with reduced enacted stigma among whites. Minority stress processes are likely to operate differently for sexual minority people of colour compared with white sexual minority people, and for higher-socioeconomic status versus lower-socioeconomic status sexual minority people. Future research should consider the intersectional axes of identity that contribute to enacted stigma and disparities in mental and physical health, especially for US African American sexual minority adults.

Sexual Minority Disparities in Substance Use Willingness Among Youth.

BACKGROUND: Disparities in substance use have been observed in sexual minority youth, but less is known about willingness to use substances, an important precursor to actual use. OBJECTIVE: The goal of this study was to examine willingness to use cigarettes, alcohol, and marijuana among sexual minority youth compared to their non-sexual minority counterparts using both cross-sectional and longitudinal data. METHODS: The present study drew on two waves (Times 1 and 2; 6 months apart) of data collected during high school as part of a prospective study of substance use initiation and progression in Rhode Island. At Time 1, participants (N = 443) ranged in age from 15 to 20 years (M age = 16.7 years, 26.6% sexual minority, 59.5% female, 72.0% White). Participants self-reported their sexual identity and attraction, lifetime use of alcohol, cigarettes and marijuana, and cigarette, alcohol, and marijuana use willingness (i.e., if offered by a best friend or group of friends). RESULTS: In cross-sectional multivariate regression models, sexual minority youth were more likely to report willingness to use cigarettes (p <.05) and marijuana (p <.01) compared to their non-sexual minority counterparts. Longitudinal multivariate regression models revealed that sexual minorities were only significantly more likely to report cigarette willingness at Time 2 compared to their non-sexual minority counterparts (p <.01). There were no significant differences in alcohol use willingness in multivariable cross-sectional or longitudinal models by sexual minority status. CONCLUSIONS: Sexual minority youth reported more willingness than non-sexual minority youth to use substances offered by peers; however, longitudinal analyses revealed that peers appear to play a role only in willingness to smoke cigarettes for these youth, and thus peer influence may be a contributing factor in explaining tobacco-related disparities among sexual minority youth. Given that stigma and peer groups may a particular risk factor for tobacco among sexual minority youth, our findings highlight the importance of prevention programs such as social marketing approaches that correct social norms, reduce stigma, and provide refusal-skills training to reduce tobacco-related disparities among sexual minorities.

Extending the Minority Stress Model to Incorporate HIV-Positive Gay and Bisexual Men's Experiences: a Longitudinal Examination of Mental Health and Sexual Risk Behavior.

BACKGROUND: Minority stress theory represents the most plausible conceptual framework for explaining health disparities for gay and bisexual men (GBM). However, little focus has been given to including the unique stressors experienced by HIV-positive GBM. PURPOSE: We explored the role of HIV-related stress within a minority stress model of mental health and condomless anal sex. METHODS: Longitudinal data were collected on a diverse convenience sample of 138 highly sexually active, HIV-positive GBM in NYC regarding sexual minority (internalized homonegativity and gay-related rejection sensitivity) and HIV-related stressors (internalized HIV stigma and HIV-related rejection sensitivity), emotion dysregulation, mental health (symptoms of depression, anxiety, sexual compulsivity, and hypersexuality), and sexual behavior (condomless anal sex with all male partners and with serodiscordant male partners). RESULTS: Across both sexual minority and HIV-related stressors, internalized stigma was significantly associated with mental health and sexual behavior outcomes while rejection sensitivity was not. Moreover, path analyses revealed that emotion dysregulation mediated the influence of both forms of internalized stigma on symptoms of depression/anxiety and sexual compulsivity/hypersexuality as well as serodiscordant condomless anal sex. CONCLUSIONS: We identified two targets of behavioral interventions that may lead to improvements in mental health and reductions in sexual transmission risk behaviors-maladaptive cognitions underlying negative self-schemas and difficulties with emotion regulation. Techniques for cognitive restructuring and emotion regulation may be particularly useful in the development of interventions that are sensitive to the needs of this population while also highlighting the important role that structural interventions can have in preventing these disparities for future generations.

Sexual orientation disparities in smoking vary by sex and household smoking among US adults: Findings from the 2003-2012 National Health and Nutrition Examination Surveys.

OBJECTIVE: This study examined whether sexual orientation-related smoking disparities in males and females varied by household smoking behaviors in a nationally representative sample of American adults. METHODS: Data were drawn from the 2003-2012 National Health and Nutrition Examination Surveys, which assessed 14,972 individuals ages 20 to 59years for sexual orientation, current smoking status, and household smoking. Weighted multivariable logistic models were fit to examine whether differences in current smoking status among sexual minority adults compared to heterosexuals was moderated by household smoking and sex, adjusting for covariates. RESULTS: The main effects of identifying as a sexual minority, being male, and living with a household smoker were all associated with a significantly higher odds of being a current smoker. However, there also was a significant three-way interaction among these variables (adjusted odds ratio=3.75, 95% confidence interval: 1.33, 10.54). Follow-up analyses by sex indicated that the interaction between sexual identity and household smoking was significant for both males (AOR=6.40, 95% confidence interval: 1.27, 32.28) and females (AOR=0.43, 95% confidence interval: 0.23, 0.81) but was in the opposite direction. Among males, living with a smoker was associated more strongly with greater odds of smoking among gay and bisexual males, compared to heterosexual males. In contrast, among females, living with a smoker was more strongly associated with greater odds of smoking for heterosexuals compared to lesbians and bisexuals. CONCLUSIONS: Future research is warranted to examine characteristics of households, including smoking behaviors and composition, to guide more effective and tailored smoking cessation interventions for males and females by sexual orientation.