Developing Suicide Safety Protocols for Qualitative Research as a Universal Equity Practice.

Qualitative research offers a range of approaches to elucidate the health and social experiences of populations and communities that are historically oppressed and repressed, yet is not without ethical and practical challenges that may have unintended consequences and added risks for certain individuals and communities. As a result of experiences of trauma and environmental factors, many oppressed and repressed populations have disproportionately high rates of suicide, but there are no widely accepted standards or best practices for addressing suicidality while conducting qualitative research. We describe an example of a qualitative interview during which a participant reported thoughts of suicide, even though the study topic was not directly related to mental health or suicide. We describe how the research team responded and present a framework for developing suicide safety protocols when conducing qualitative research with oppressed and repressed populations.

Sexual Orientation Change Efforts, Adverse Childhood Experiences, and Suicide Ideation and Attempt Among Sexual Minority Adults, United States, 2016-2018.

Objectives. To examine how sexual orientation change efforts (SOCE) are associated with suicide morbidity after controlling for adverse childhood experiences (ACEs).Methods. Cross-sectional survey data are from the Generations survey, a nationally representative sample of 1518 nontransgender sexual minority adults recruited between March 28, 2016, and March 30, 2018, in the United States. Self-identified transgender individuals were included in a separate, related TransPop study. We used weighted multiple logistic regression analyses to assess the independent association of SOCE with suicidal ideation and suicide attempt while controlling for demographics and ACEs.Results. Approximately 7% experienced SOCE; of them, 80.8% reported SOCE from a religious leader. After adjusting for demographics and ACEs, sexual minorities exposed to SOCE had nearly twice the odds of lifetime suicidal ideation, 75% increased odds of planning to attempt suicide, and 88% increased odds of a suicide attempt with minor injury compared with sexual minorities who did not experience SOCE.Conclusions. Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE.Public Health Implications. Evidence supports minimizing exposure of sexual minorities to SOCE and providing affirming care with SOCE-exposed sexual minorities. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e7. doi:10.2105/AJPH.2020.305637).

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016.

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

HIV Testing and ART Adherence Among Unstably Housed Black Men Who Have Sex with Men in the United States.

Black men who have sex with men (BMSM) have the highest HIV incidence rate among all MSM in the United States (US), and are also disproportionately affected by homelessness and housing instability. However, little is known about the effects of homelessness on the HIV testing and care continuum for BMSM. Between 2014 and 2017, the Promoting Our Worth, Equality, and Resilience (POWER) study collected data and offered HIV testing to 4184 BMSM at Black Pride events in six US cities. Bivariate analyses were used to assess differences in sociodemographics and healthcare access between BMSM who self-reported homelessness and those who did not. Multivariable logistic regression models were used to assess differences in HIV testing by homelessness status. Finally, bivariate and multivariable models were used to assess differences in HIV care continuum and treatment adherence outcomes by homelessness status. 615 (12.1%) BMSM in our sample experienced homelessness in the last 12 months. BMSM who self-reported homelessness had higher odds of receiving an HIV test in the past 6 months compared to their stably housed counterparts. BMSM who self-reported homelessness had higher odds of reporting difficulty taking ART and of missing a dose in the past week compared to stably housed BMSM. Findings suggest that HIV testing outreach and treatment-related services targeting unstably housed BMSM may be effective. Future community-based research is needed to investigate how homelessness and housing instability affect ART adherence, and how this population may experience success in HIV testing and adherence despite economic and social marginalization.

Intimate Partner Violence and Depression among Black Transgender Women in the USA: The Potential Suppressive Effect of Perceived Social Support.

Depression among Black transgender women (BTW) in the USA is an often understudied mental health concern with far-reaching consequences for overall physical and mental health at both the individual and community levels. Intimate partner violence (IPV) among BTW is also a frequently understudied and important social determinant of health in need of further exploration. This study sought to address the gap in research on the relationship between IPV and depression among BTW using a time- and location-based community sample of BTW from six US cities. In addition, it sought to explore the potential protective or suppressive effect of perceived social support on this relationship. Generalized structural equation models were used to assess conditional direct and indirect effects of IPV on depression via the suppression effect of perceived social support. Evidence was found of a statistically significant conditional direct effect of IPV on depression as well as a statistically significant suppression effect for perceived social support. Specifically, there was a 20% lower likelihood of increased depressive symptomatology for every 1-unit increase in perceived social support reported by participants. These findings indicated that perceived social support may be an important intervention point for helping to improve the mental health and well-being of BTW.

Rural-Urban Differences in Human Immunodeficiency Virus Testing Among US Adults: Findings From the Behavioral Risk Factor Surveillance System.

Individuals in rural areas of the United States face barriers to human immunodeficiency virus (HIV)-related health care. We aim to assess differences in frequency of lifetime and past-year HIV testing, and differences in testing site location between rural and urban residents of the United States. METHODS: Data from the Behavioral Risk Factor Surveillance System 2015 were analyzed on 250,579 respondents 18 years or older. Weighted multinomial logistic regression analyses compared urban/rural differences in lifetime and past-year HIV testing. Weighted multinomial logistic regression compared urban/rural differences in HIV testing site. RESULTS: Overall, 26.9% of urban residents and 21.5% of rural residents reported testing for HIV in their lifetime. Of urban residents, 24.5% reported receiving an HIV test in the past year compared with 20.2% of rural residents. Living in a rural area was associated with lower odds of lifetime (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.81-0.90) and past-year HIV testing (OR, 0.84; 95% CI, 0.74-0.95) compared with not testing. Rural residents had higher odds of receiving an HIV test at the hospital or emergency room (adjusted OR, 1.41; 95% CI, 1.23-1.62) or clinic (adjusted OR, 1.21; 95% CI, 1.02-1.24) than a doctor's office. CONCLUSIONS: This study highlights significant rural health disparities in rates of lifetime and past-year HIV testing. Targeted interventions are needed to remove structural barriers in rural communities, such as long distances to clinics and low availability of free HIV testing at clinics serving the uninsured or underinsured. Furthermore, rural providers should be encouraged to routinely offer HIV screening to their patients.

Rural-urban differences in human papillomavirus knowledge and awareness among US adults.

Rural residents of the United States have higher HPV-associated cancer incidence and mortality, and suboptimal HPV vaccine uptake compared to urban residents. This study aimed to assess differences in knowledge and awareness of HPV, the HPV vaccine, and HPV-associated cancers among rural and urban residents. We analyzed data from the Health Information National Trends Survey 2013-2017 on 10,147 respondents ages ≥18 years. Multivariable logistic regression analyses compared urban/rural differences in knowledge and awareness of HPV, associated cancers, and HPV vaccine. Models were adjusted for sex, age, race/ethnicity, education, household income, census region, health insurance, regular provider, internet use, and personal history of cancer. Overall, 67.2% and 65.8% of urban residents were aware of HPV and HPV vaccine, respectively, compared to only 55.8% and 58.6% of rural residents. Adjusted models illustrated that compared to urban residents, rural residents were less likely to be aware of HPV (OR = 0.68, 95% CI = 0.53-0.86) and HPV vaccine (OR = 0.78, 95% CI = 0.63-0.97). Among those who were aware of HPV, rural residents were less likely to know that HPV causes cervical cancer (OR = 0.62, 95% CI = 0.46-0.84) and that HPV can be transmitted through sexual contact (OR = 0.72, 95% CI = 0.56-0.94). No significant differences between rural and urban residents were noted for knowledge that HPV is transmitted sexually and that it causes oral, anal, and penile cancers. This study highlights significant rural health disparities in knowledge and awareness of HPV and the HPV vaccine compared to urban counterparts.

Causes of Death of Transgender and Gender Diverse Veterans.

INTRODUCTION: Transgender and gender diverse (TGD) veterans face numerous challenges due to stigma and marginalization, which have a significant impact on their health and well-being. However, there is insufficient data on cause-specific mortality in TGD veteran populations in the U.S. The purpose of this study was to describe the leading causes of death in a sample of TGD veterans who received care from the Veterans Health Administration. METHODS: A secondary data analysis was conducted using Veterans Health Administration electronic health record data matched with death certificate records from the National Death Index from October 1, 1999 to December 31, 2019. Using record axis codes from National Death Index data, the 25 most frequent underlying and all causes of death were summarized. RESULTS: Deaths occurred in 1,415 TGD veterans. Ranking by any mention on the death certificate, mental and behavioral disorders due to psychoactive substance use (17.2%), conduction disorders and cardiac dysrhythmias (15.3%), chronic obstructive pulmonary disease (15.1%), diabetes mellitus (13.9%), and chronic ischemic heart disease (13.3%) were the top five causes of death. Three distinct methods of suicide appeared as the 7th (firearms), 17th (self-poisoning), and 24th (hanging) underlying causes of death for TGD veterans. CONCLUSIONS: Targeted prevention efforts or interventions to reduce the frequency and severity of causes of death, particularly mental and behavioral health disorders and metabolic disorders, could prevent premature mortality among TGD adults.

The role of social support on cognitive function among midlife and older adult MSM.

OBJECTIVE: This study examines the association between social support and cognitive function among midlife and older MSM living with or without HIV. DESIGN: We analyzed longitudinal data from participants enrolled from October 2016 to March 2019 in the Patterns of Healthy Aging Study, a substudy of the Multicenter AIDS Cohort Study. METHODS: We conducted a cross-sectional analysis to estimate the association between social support and three measures of cognitive function [Trail Making Test (TMT) Part A, TMT Part B to A ratio, and Symbol Digit Modalities Tasks (SDMT)]. We also used linear mixed-effects models to estimate the association between baseline social support and cognitive function across four subsequent time points. We evaluated a multiplicative interaction term between baseline social support and time, in order to determine whether cognitive trajectories over time vary by baseline social support. RESULTS: Social support was associated with lower TMT Part A scores at baseline and over the subsequent 2 years, indicating better psychomotor ability. Social support was associated with higher SDMT scores at baseline and across 2 years, indicating better information processing. We observed no association between social support and TMT B to A ratio at baseline or across 2 years, indicating no effect on set-shifting ability. Longitudinal cognition outcome trajectories did not vary by the level of baseline social support. CONCLUSION: Social support and cognitive function were associated in this sample over a short time period. Further research should explore causal relationships over the lifespan.

A Comparison of Health-Related Quality of Life Among Transgender Adults in the United States.

Few studies exist that examine within-group differences of the transgender population. This paper aims to assess differences in sociodemographic characteristics and health-related quality of life (HRQoL) among transgender men (TM), transgender women (TW), and transgender gender nonconforming (TGNC) individuals in the United States. Data were pooled from the 2014-2017 Behavioral Risk Factor Surveillance System. Chi-square tests and weighted multivariable logistic regression models investigated differences in HRQoL by gender identity and separately identified predictors of HRQoL in these groups. Overall, TGNC individuals self-reported worse general health than TW or TM. TW and TGNC individuals who also identified as lesbian, gay, or bisexual (LGB) had higher odds of reporting frequent mental distress compared to their heterosexual counterparts. Race/ethnicity, education, and employment also emerged as predictors of HRQoL. Findings support the need to disaggregate these subpopulations of transgender individuals to address the unique needs of each subgroup.

"Words Aren't Supposed to Hurt, But They Do": Sexual and Gender Minority Youth's Bullying Experiences.

Sexual and gender minority youth (SGMY) are more likely to experience bullying and violence compared to the youth who do not identify as SGMY, leading to increased risk of poor mental and physical health outcomes, and poor academic performance. Few studies explore the entire range of bullying experienced by sexual and gender minority youth (SGMY). The purpose of this study was to qualitatively describe the ways in which SGMY experience bullying victimization. We conducted semi-structured interviews with a diverse sample of 20 SGMY aged 14-18 years (median age 16 years) recruited from online social media. The sample included 10 participants who identified as cisgender girls, 4 who identified as cisgender boys, 2 who identified as transgender, and 4 who identified as another gender identity. Ten participants identified as bisexual, six identified as lesbian, and four identified as gay. Findings indicated six common experiences of bullying among the participants: (a) verbal harassment; (b) gender policing; (c) physical violence; (d) sexual harassment; (e) treated as sexual perpetrators and deviants; and (f) and social exclusion. SGMY described how bullying victimization ranged from overt to concealed attitudes and behaviors, and they articulated how several forms of bullying are likely not experienced by heterosexual and cisgender youth. These results support findings from prior qualitative studies and suggest that efforts to address school-based bullying may benefit from a more complete awareness of the range of bullying victimization experienced by SGMY. Development of multi-item scales of bullying that reflect the six common experiences of bullying presented in this study would allow researchers to quantitatively explore the range of bullying behaviors experienced by SGMY, and would aid in the conceptualization and successful implementation of anti-bullying interventions.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV.

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Does Social Support Predict Depressive Symptoms? A Longitudinal Study of Midlife and Older Men Who Have Sex with Men from the Multicenter AIDS Cohort Study.

The present study was designed to identify social support classes across time among midlife (40-64 years) and older (65+ years) gay, bisexual, and other men who have sex with men (MSM), and whether social support protects against depressive symptoms in this population. This study applied longitudinal latent class analysis across five visits on 1,329 individuals age 40 or older at baseline using data from the Multicenter AIDS Cohort Study (MACS) Healthy Aging substudy collected from April 2016 to October 2018. We identified four classes of social support across time: Partner-centered, that is, high levels of support from one's primary partner(s) and moderate support from friends and family; Friend-centered, that is, high levels of support from friends and chosen family; Low, that is, low levels of support from all sources; and Robust, that is, high levels of support from all sources. We found differences in class membership by age, race/ethnicity, employment status, sexual identity, education, relationship status, and HIV status. Finally, compared to MSM in the low support class, men in the other classes had lower odds of depressive symptoms at the final visit. The most common type of social support was partner-centered, while the least common type was robust. These findings suggest that the presence of any social support, regardless of the source, protects against depressive symptoms.

Feasibility of a Web-Accessible Game-Based Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Results From a Randomized Controlled Trial.

PURPOSE: To address the gap in interventions for improving sexual and gender minority youth (SGMY; e.g., lesbian, gay, bisexual, and transgender youth) health, we tested the feasibility of a game-based intervention for increasing help-seeking, productive coping skills, resource knowledge/use, and well-being. METHODS: We conducted a 2-arm randomized controlled trial testing a theory-based, community-informed, Web-accessible computer role-playing game intervention. Control condition received a list of resources. Primary hypotheses were high levels of implementation success, game demand, and game acceptability. RESULTS: We randomized 240 SGMYs aged 14-18 years into the intervention (n = 120) or control (n = 120) conditions. Participants completed baseline (100%), 1-month follow-up (T2; 73.3%), and 2-month follow-up (T3; 64.4%) surveys. Among intervention participants, 55.8% downloaded and played the game. Of those who played, 46.2% reported a desire to play it again, and 50.8% would recommend it. Game acceptability exceeded hypothesized benchmarks, wherein participants reported high positive affect (M = 2.36; 95% confidence interval [CI]: 2.13, 2.58), low negative affect (M = 2.75; 95% CI: 2.55, 2.95), low tension/annoyance (M = 3.18; 95% CI: 2.98, 3.39), and high competence (M = 2.23; 95% CI: 2.04, 2.43) while playing the game. In multivariable intent-to-treat analyses of 38 secondary/tertiary outcomes, intervention participants reported significantly larger reductions than control participants in cyberbullying victimization (T2 b = -.28; 95% CI: -.56, -.01), binge drinking frequency (T2 b = -.39; 95% CI: -.71, -.06), and marijuana use frequency (T3 b = -2.78; 95% CI: -4.49, -1.08). CONCLUSIONS: We successfully implemented a Web-accessible game trial with SGMY. The game-based intervention was feasible and acceptable to SGMY, and preliminary results show it improved several health-related behaviors. A larger scale trial is needed to test whether the game-based intervention can reduce health inequities for SGMY.

"It's Not Okay for You to Call Me That": How Sexual and Gender Minority Youth Cope with Bullying Victimization.

Sexual and gender minority youth (SGMY) have higher rates of bullying than their heterosexual peers and must disproportionately cope with bullying victimization. The purpose of this research is to highlight various coping strategies employed by SGMY. We conducted 20 cross-sectional, semi-structured online interviews with SGMY about their bullying experiences and coping strategies. We coded interviews with descriptive qualitative research to illustrate a comprehensive summary of bullying-related coping methods. We found SGMY engage in multiple coping strategies that include (1) emotion-focused coping-rumination; self-harm and considering or attempting suicide; seeking social and emotional support; engaging in creative endeavors; self-acceptance and community connectedness-and (2) problem-focused coping-reporting the bully; confronting the bully; conceal orientation; ignoring the bullying; and changing environment. Additionally, most SGMY reported using multiple coping techniques or changing how they coped over time (i.e., coping flexibility). These findings can inform future interventions to promote positive coping mechanisms among SGMY.

Housing and food stress among transgender adults in the United States.

PURPOSE: The purpose of the study was to assess housing and food-related stress in transgender and cisgender adults in the United States. METHODS: Data from the 2014 and 2015 Behavioral Risk Factor Surveillance System were analyzed for 53,060 adults who responded to the Sexual Orientation and Gender Identity module and the Social Context module. We used multiple logistic regression to assess the association of gender identity with housing and food-related stress. RESULTS: There were no significant differences by gender identity in the odds of experiencing housing or food-related stress. A sensitivity analysis revealed that with a broader definition of food-related stress, transgender individuals had higher odds of experiencing food-related stress compared with cisgender individuals. The sample of transgender individuals who experienced food-related stress were young, single, racially diverse, sexual minorities, and the majority had a high school degree or less. Similarly, most transgender individuals who experienced housing-related stress were single, sexual minorities, and had a high school degree or less. CONCLUSIONS: More precise assessments of housing and food insecurity among probability-based samples of transgender individuals are needed to fully understand housing and food-related instability and the stress associated with these experiences.

Considerations on Sampling in Transgender Health Disparities Research.

Collection of gender identity data in national probability-based surveys began in 2014, an important first step toward the inclusion of gender identity measurements in public health surveillance. However, the findings about health disparities from probability-based samples do not align with those from nonprobability samples traditionally used to study transgender populations. These contradictions have yet to be understood fully. In this article, we suggest that the truth about disparities lies somewhere between nonprobability and probability samples. We discuss why generalizability from studies using probability sampling may remain limited for transgender populations and describe potential improvements in sampling methodology for transgender populations.

Pilot Testing the Feasibility of a Game Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Protocol for a Randomized Controlled Trial.

BACKGROUND: Sexual and gender minority youth (SGMY; eg, lesbian, gay, bisexual, and transgender youth) experience myriad substance use and mental health disparities compared with their cisgender (nontransgender) heterosexual peers. Despite much research showing these disparities are driven by experiences of bullying and cyberbullying victimization, few interventions have aimed to improve the health of bullied SGMY. One possible way to improve the health of bullied SGMY is via a Web-accessible game intervention. Nevertheless, little research has examined the feasibility of using a Web-accessible game intervention with SGMY. OBJECTIVE: This study aimed to describe the protocol for a randomized controlled trial (RCT) pilot, testing the feasibility and limited efficacy of a game-based intervention for increasing help-seeking-related knowledge, intentions, self-efficacy, behaviors, productive coping skills use, and coping flexibility and reducing health risk factors and behaviors among SGMY. METHODS: We enrolled 240 SGMY aged 14 to 18 years residing in the United States into a 2-arm prospective RCT. The intervention is a theory-based, community-informed, computer-based, role playing game with 3 primary components: encouraging help-seeking behaviors, encouraging use of productive coping, and raising awareness of Web-based resources. SGMY randomized to both the intervention and control conditions will receive a list of SGMY-inclusive resources, covering a variety of health-related topics. Control condition participants received only the list of resources. Notably, all study procedures are conducted via the internet. We conveniently sampled SGMY using Web-based advertisements. Study assessments occur at enrollment, 1 month after enrollment, and 2 months after enrollment. The primary outcomes of this feasibility study include implementation procedures, game demand, and game acceptability. Secondary outcomes include help-seeking intentions, self-efficacy, and behaviors; productive coping strategies and coping flexibility; and knowledge and use of Web-based resources. Tertiary outcomes include bullying and cyberbullying victimization, loneliness, mental health issues, substance use, and internalized sexual and gender minority stigma. RESULTS: From April to July 2018, 240 participants were enrolled and randomized. Half of the enrolled participants (n=120) were randomized into the intervention condition and half (n=120) into the control condition. At baseline, 52.1% (125/240) of the participants identified as gay or lesbian, 26.7% (64/240) as bisexual, 24.2% (58/240) as queer, and 11.7% (28/240) as another nonheterosexual identity. Nearly half (113/240) of participants were a gender minority: 36.7% (88/240) were cisgender boys, and 16.3% (39/240) were cisgender girls. There were no differences in demographic characteristics between intervention and control condition participants. CONCLUSIONS: Web-accessible game interventions overcome common impediments of face-to-face interventions and present a unique opportunity to reach SGMY and improve their health. This trial will provide data on feasibility and limited efficacy that can inform future Web-based studies and a larger RCT aimed at improving health equity for SGMY. TRIAL REGISTRATION: ClinicalTrials.gov NCT03501264; https://clinicaltrials.gov/ct2/show/NCT03501264 (Archived by WebCite at http://www.webcitation.org/72HpafarW). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12164.