Barriers to Cervical Cancer Screening by Sexual Orientation Among Low-Income Women in North Carolina.

We sought to examine cervical cancer screening barriers by sexual orientation among low-income women in North Carolina. The MyBodyMyTest-3 Trial recruited low-income women (< 250% of federal poverty level) aged 25-64 years who were 1+ year overdue for cervical cancer screening. We compared perceptions of cervical cancer screening among those who self-identified as lesbian, gay, bisexual, or queer (LGBQ; n = 70) to straight/heterosexual women (n = 683). For both LGBQ and straight respondents, the greatest barriers to screening were lack of health insurance (63% and 66%) and cost (49% and 50%). LGBQ respondents were more likely than straight respondents to report forgetting to screen (16% vs. 8%, p = .05), transportation barriers (10% vs. 2%, p = .001), and competing mental or physical health problems (39% vs. 27%, p = .10). Addressing access remains important for improving cervical cancer screening among those under-screened. For LGBQ women, additional attention may be needed for reminders, co-occurring health needs, and transportation barriers.

Mental Health and Substance Misuse Indicators Associated with First-Time Homelessness among a Community Sample of Sexual and Gender Minority Adults.

Homelessness is a priority public health issue in the United States (U.S.) given its strong associations with multiple adverse health outcomes. While overall rates of homelessness have decreased over the last decade, some populations-such as sexual and gender minorities-have not seen equitable decreases. The present study explores the relationship between experiences of first-time homelessness with substance misuse (assessed via the DAST-10) and depression and anxiety (assessed via the PHQ-4) in an adult sample of SGM individuals in South Central Texas. The analytic sample (n = 907) was majority gay/lesbian or same-gender loving (55.8%) followed by bisexual or pansexual (34.7%) or another sexual identity (9.5%) and 12.5% were transgender. First-time homelessness was more common in childhood than adulthood. Multivariate logistic regression models were used to evaluate relationships between first-time homelessness and outcomes of interest. The odds of substance misuse (DAST > 3) were marginally higher for those experiencing first-time homelessness in childhood and significantly higher for those reporting first-time homelessness in adulthood. The odds of experiencing past 2-week depression were significantly greater for those reporting homelessness in childhood or adulthood. However, only first-time homelessness in adulthood was significantly associated with past two-week anxiety. These findings underscore the need to consider intersectionality when exploring solutions to existing health disparities, as this work suggests that both sexual and gender identity and homelessness are important factors in shaping mental and behavioral health outcomes.

The Relationship Between Adverse Childhood Experiences and Utilization of Different HIV Testing Strategies Among Young Men Who Have Sex with Men in Texas.

Adverse childhood experiences (ACEs) are a well-documented HIV-risk factor, but less is known about the relationship between ACEs and different HIV testing strategies. This study used data from an LGBTQ + community health assessment, that was part of a multi-staged community-based participatory research project in San Antonio, Texas. Overall, 464 young men who have sex with men (YMSM; < 36-years-old) completed an online, cross-sectional survey that included questions about ACEs and HIV testing behavior. An association between increased ACEs exposure and the odds of clinic-based testing and HIVST HIV significantly decreased relative to never testing for HIV. Additionally, greater ACEs exposure was significantly associated with increased odds of reporting community-based testing (AOR = 1.09, 95% CI = 1.00, 1.20) and significantly reduced odds of HIV self-testing (AOR = 0.72, 95% CI = 0.63, 0.82) compared to clinic-based testing. Cumulative ACEs exposure is important in understanding HIV testing behaviors in YMSM and should be considered when developing HIV testing programs.

The 3 levels of HIV stigma in the United States military: perspectives from service members living with HIV.

BACKGROUND: Epidemiological surveillance data indicate that a majority of HIV-infected in the United States (U.S.) military are African-Americans and men who have sex with men. There is limited research about barriers to HIV prevention among military service members and the unique factors that contribute to HIV stigma. METHODS: A convenience sample of 30 U.S. service members were recruited from an infectious disease clinic. In depth interviews were conducted and data analyzed using a thematic coding process. RESULTS: Two broad categories were identified: 1) Outcomes of HIV Stigma: Fear of Rejection, Shame, and Embarrassment; and 2) Strategies for combating stigma which include increasing HIV education and prevention resources. Military policies and institutional culture regarding sexuality were found to contribute to stigma. CONCLUSIONS: Participants identified a need for HIV education and suggested individuals living with HIV serve as mentors. A peer-to-peer intervention for delivering HIV prevention education may address these needs and reduce HIV stigma.

The Moderating Effect of Resilience on the Relationship between Adverse Childhood Experiences (ACEs) and Quality of Physical and Mental Health among Adult Sexual and Gender Minorities.

Sexual and gender minority (SGM) individuals experience a greater burden of poor mental health compared to heterosexual individuals. One factor that helps to explain this disparity is trauma experienced during childhood. SGM are more likely to report traumatic experiences during childhood contributing to this disparity. Previous research has shown that resilience moderates the relationship between childhood trauma and adults mental health outcomes. As part of the Strengthening Colors of Pride project, data on 463 SGM adults living in San Antonio were collected using surveys. A diverse recruitment strategy was used in conjunction with a community advisory board. The brief resilience scale (BRS) was used to assess intrapersonal level resilience to determine if there was an effect on the relationship between ACEs and quality of mental and physical health. Differences were noted for some items across low, normal, and high levels of resilience. Both ACEs and BRS significantly predicted quality of mental and physical health. We also noted a significant interaction between ACEs and BRS with regard to quality of mental health. Findings suggest there is a relationship between intrapersonal level resilience, ACEs, and quality of mental health.

Influences of health care access on resilience building among transgender and gender non-binary individuals.

Background: Health care disparities between transgender/gender non-binary individuals and the general population are well-documented and related to both interpersonal and institutional discrimination. Resilience has been found to buffer the negative health effects of discrimination among gender diverse individuals as well as other stigmatized populations. Aims : The purpose of this study was to identify and understand resilience related to health and health care among a community sample of transgender and gender non-binary individuals in the southern United States. Methods: We conducted 35 longitudinal photo elicitation interviews with 21 participants among a community sample of transgender and gender non-binary individuals in the Southern US. Interview transcripts were coded using thematic analysis and themes were organized according to the Resilience Activation Framework. Results: Overall, individual and community-level resources within the domains of social and human capital were frequently activated to navigate challenges related to seeking and receiving health care. Lack of access to resources in economic and political capital domains constrained resilience. Discussion: This work demonstrates how stakeholders can identify target areas for interventions and policy change aimed at improving resilience in transgender and gender non-binary communities by utilizing the Resilience Activation Framework. In our sample, we found that resources should be directed toward building economic and political capital at the community level so participants have the ability and opportunity to marshal such resources.

Perceived Social Norms About Oral PrEP Use: Differences Between African-American, Latino and White Gay, Bisexual and Other Men Who Have Sex with Men in Texas.

Correct and consistent condom use has been the primary method of HIV prevention until the FDA approve the use of PrEP in 2012. While strong evidence existing regarding the efficacy of PrEP, uptake has remained slower than anticipated. While work is underway to better understand the factors impacting uptake, the majority of this work as been focused on white gay, bisexual, and other men who have sex with men (GBMSM) living in metropolitan regions of the coastal U.S. The current study used a community-based framework to assess perceived social norms through a elicitation survey. A total of 104 GBMSM met inclusion criteria for the study. Several analytic categories emerged across questions and a number of differences were found across race and ethnicity such as who would approve or disapprove off PrEP and who would be likely to use PrEP. Further, we found differences between injunctive and descriptive norms. These findings suggest that there are unique factors contributing to PrEP uptake among racial and ethnic minority GBMSM and that to fully understand uptake a more robust measure of perceived norms may be needed.

Sexual self-identification among behaviorally bisexual men in the midwestern United States.

Previous social and behavioral research on identity among bisexual men, when not subsumed within the category of men who have sex with men (MSM), has primarily focused on samples of self-identified bisexual men. Little is known about sexual self-identification among men who are behaviorally bisexual, regardless of sexual identity. Using qualitative data from 77 in-depth interviews with a diverse sample of behaviorally bisexual men (i.e., men who have had sex with at least one woman and at least one man in the past six months) from a large city in the Midwestern United States, we analyzed responses from a domain focusing on sexual self-identity and related issues. Overall, participants' sexual self-identification was exceptionally diverse. Three primary themes emerged: (1) a resistance to, or rejection of, using sexual self-identity labels; (2) concurrent use of multiple identity categories and the strategic deployment of multiple sexual identity labels; and (3) a variety of trajectories to current sexual self-identification. Based on our findings, we offer insights into the unique lived experiences of behaviorally bisexual men, as well as broader considerations for the study of men's sexuality. We also explore identity-related information useful for the design of HIV/STI prevention and other sexual health programs directed toward behaviorally bisexual men, which will ideally be variable and flexible in accordance with the wide range of diversity found in this population.

A syndemic of psychosocial health disparities and associations with risk for attempting suicide among young sexual minority men.

OBJECTIVES: We examined a syndemic of psychosocial health issues among young men who have sex with men (MSM), with men and women (MSMW), and with women (MSW). We examined hypothesized drivers of syndemic production and effects on suicide attempts. METHODS: Using a pooled data set of 2005 and 2007 Youth Risk Behavior Surveys from 11 jurisdictions, we used structural equation modeling to model a latent syndemic factor of depression symptoms, substance use, risky sex, and intimate partner violence. Multigroup models examined relations between victimization and bullying experiences, syndemic health issues, and serious suicide attempts. RESULTS: We found experiences of victimization to increase syndemic burden among all male youths, especially MSMW and MSM compared with MSW (variance explained = 44%, 38%, and 10%, respectively). The syndemic factor was shown to increase the odds of reporting a serious suicide attempt, particularly for MSM (odds ratio [OR] = 5.75; 95% confidence interval [CI] = 1.36, 24.39; P < .001) and MSMW (OR = 5.08; 95% CI = 2.14, 12.28; P < .001) compared with MSW (OR = 3.47; 95% CI = 2.50, 4.83; P < .001). CONCLUSIONS: Interventions addressing multiple psychosocial health outcomes should be developed and tested to better meet the needs of young MSM and MSMW.

Sexual orientation disparities in sexually transmitted infection risk behaviors and risk determinants among sexually active adolescent males: results from a school-based sample.

OBJECTIVES: We examined disparities in risk determinants and risk behaviors for sexually transmitted infections (STIs) between gay-identified, bisexual-identified, and heterosexual-identified young men who have sex with men (YMSM) and heterosexual-identified young men who have sex with women (YMSW) using a school-based sample of US sexually active adolescent males. METHODS: We analyzed a pooled data set of Youth Risk Behavior Surveys from 2005 and 2007 that included information on sexual orientation identity, sexual behaviors, and multiple STI risk factors. RESULTS: Bisexual-identified adolescents were more likely to report multiple STI risk behaviors (number of sex partners, concurrent sex partners, and age of sexual debut) compared with heterosexual YMSW as well as heterosexual YMSM and gay-identified respondents. Gay, bisexual, and heterosexual YMSM were significantly more likely to report forced sex compared with heterosexual YMSW. CONCLUSIONS: Our results provide evidence that sexual health disparities emerge early in the life course and vary by both sexual orientation identity and sexual behaviors. In particular, they show that bisexual-identified adolescent males exhibit a unique risk profile that warrants targeted sexual health interventions.

Gender matters: condom use and nonuse among behaviorally bisexual men.

Although frequently cited as being at high risk for HIV/STI transmission, little is known about behaviorally bisexual men's patterns and experiences of condom use and nonuse with male and female sexual partners. Using a variety of recruitment techniques informed by a Community Advisory Committee, a total of 77 behaviorally bisexual men were recruited from Indianapolis, Indiana to participate in semi-structured interviews focused on sexual health. Qualitative data were collected containing detailed information on their patterns and experiences of condom use and nonuse with both male and female partners. Participants described numerous commonly reported barriers for consistent condom use, as well as distinct bisexual-specific barriers. The majority reported consistent condom use with male and female casual partners, but many who did not use condoms described doing so in the context of ongoing relationships. In addition, participants provided reasons for condom use and nonuse that varied based on the gender of the partner and the type of relationship with the partner. Future interventions focused on increasing condom use among behaviorally bisexual men should take into account the unique complexities of gender and relationship configurations in this distinct population.

Two Gender Medicine: Provider-Side Barriers to Caring for Transgender and Gender Diverse Patients.

Experienced and anticipated discrimination during health care visits result in lower health care utilization rates, which contribute to persistent health disparities between transgender and gender diverse (TGD) individuals and the general population. Most strategies for improving health care delivery to TGD patients place the responsibility on providers, overlooking the role of medical systems and institutions in creating the environments where negative health care experiences occur. Relying on the inhabited institutionalism framework, this study explores system- and institutional-level barriers to the provision of quality care to TGD patients identified by health care providers and administrators, including relevant contextual details of, and interactions between, these barriers. Based on interview data from health care providers and administrators from a variety of practices across Texas, we identified two overarching themes and six subthemes. We demonstrate how our interviewees' responses reveal an institutional logic of "two-gender medicine," which creates barriers to health care provision in both formal medical education and training and throughout the managed care model of practice. We also illustrate how health care workers find ways to resist this logic in the course of their practice. Addressing these barriers to delivering competent and compassionate care to TGD patients that providers encounter could make long overdue strides toward addressing health disparities.

Adverse Childhood Experiences, Perceived Discrimination, and Mental Health in Sexual and Gender Minoritized Adults: Comparing Stress Accumulation and Stress Sensitization Models.

Purpose: The purpose of this study was to assess the relationship between adverse childhood experiences (ACEs) exposure, perceived discrimination, and anxiety and depressive symptoms in sexual and gender minoritized (SGM) adults in the United States. Methods: Respondents (n = 4445) from a national Qualtrics research panel completed a web-based survey. Guided by the stress proliferation (mediation model) and stress sensitization (moderation model) models, we examined the relationships between ACEs and perceived discrimination and the severity of anxiety and depressive symptoms in adulthood. Results: Cumulative ACEs exposure was positively associated with everyday discrimination scale (EDS) scores. ACEs and EDS scores had a significant direct association with anxiety and depressive symptoms. We found support for EDS as a mediator for anxiety (ß = 0.12, p < 0.001) and depressive symptoms (ß = 0.14, p < 0.001) and for ACEs as a moderator of the relationship between EDS and anxiety (ß = -0.04, p = 0.004) and depressive (ß = -0.05, p = 0.001) symptoms. Conclusions: These findings suggest that both stress proliferation and stress sensitization likely contribute to disparities in anxiety and depressive symptoms in SGM adults. This finding supports the integration of social safety and minority stress perspectives regarding health disparities in SGM populations. Exposure to early life adversity likely alters neurodevelopment, which in turn increases awareness of the lack of social safety in adulthood, reduces capacity to cope with minority stress exposure, and ultimately contributes to increased anxiety and depressive symptoms. Prevention efforts should focus on building positive and compensatory childhood experiences.

Intention to Use Different Formulations of Longer Acting HIV Pre-Exposure Prophylaxis Among Transgender and Gender Expansive Individuals: The Roles of Social Vulnerability and Medical Mistrust.

In 2012, the Federal Drug Administration approved daily oral pre-exposure prophylaxis (PrEP) for HIV prevention in adults. Longer acting injectable PrEP (LA PrEP) has been approved and other formulations are in development. A successful LA PrEP rollout requires examining potential facilitators and barriers to PrEP uptake. Given that transgender and gender expansive (TGE) individuals experience more social vulnerability and higher levels of medical mistrust compared to other populations, examining the role of these two factors in LA PrEP uptake is important. This study, PrEP for ALL, is a community-based participatory research project in Texas that engaged TGE community members and organizational partners through a community advisory board. In total, 482 TGE individuals were recruited and responded to all relevant questions in an online survey, including their intentions to use three formulations: a monthly oral pill, a bimonthly intramuscular injection, and an annual subdermal implant. Multiple regression analysis was used to examine the influence of social vulnerability and medical mistrust on intention to use each LA PrEP formulation adjusting for other relevant factors. Findings suggest that individuals with higher levels of social vulnerability had greater intentions to use the monthly oral pill (ß = 0.12, p = 0.009), the bimonthly intramuscular injection (ß = 0.18, p < 0.001), and annual subdermal implant (ß = 0.17, p < 0.001), whereas medical mistrust reduced intentions to use the bimonthly intramuscular injection (ß = -0.18, p < 0.001) and annual subdermal implant (ß = -0.11, p = 0.021). Improvements in gender-affirming clinical care are needed along with LA PrEP formulations that allow for greater autonomy and reduced clinical contact. Clinical Trial Registration number: NCT05044286.

Sexual behaviors and experiences among behaviorally bisexual men in the midwestern United States.

Research examining the sexual behaviors and experiences of behaviorally bisexual men is limited. Most studies focus primarily on highlighting sexual risk behaviors among groups of "men who have sex with men (MSM)" or "gay and bisexual men," which may not be appropriate in terms of behaviorally bisexual men's sexual repertoires with both men and women. This study aimed to assess a broad range of sexual behaviors and associated experiences among bisexual men living in the midwestern United States. An interviewer-administered questionnaire containing items from the National Survey of Sexual Health and Behavior assessed lifetime and recent (i.e., past 6 months and last event) sexual behaviors and experiences with both male and female partners among a diverse sample of 75 behaviorally bisexual men. Responses were quantified and analyzed using descriptive and multivariate statistics. A wide range of sexual behaviors with partners of both genders was found. Vaginal intercourse and oral sex with both men and women were the most commonly reported behaviors. Subjective reports of pleasure, arousal, and sexual function during sexual activity were similar with both male and female sexual partners. Many participants reported using condoms during insertive sexual behaviors with male and female partners, but less during oral sex. Unprotected receptive anal sex was less commonly reported. Overall, participants reported a variety of sexual behaviors and experiences; however, unlike other populations, they shared these with partners of both genders. Results have implications for interventions targeting the sexual behaviors and associated issues among behaviorally bisexual men.

Sexual and gender minority adverse childhood experiences (SGM-ACEs), perceived social support, and adult mental health.

BACKGROUND: Building on decades of research into the long-term developmental impacts of adverse childhood experiences (ACEs), researchers have called for expanding the ACEs framework to include experiences specific to minoritized identities. Recent empirical research has led to the development of a measure of sexual and gender minority adverse childhood experiences (SGM-ACEs). Within the SGM-specific ACEs framework, research on the long-term impact to adult mental health and the role of perceived social support are not well studied. OBJECTIVE: The purpose of this paper was two-fold. First, examine whether SGM-ACEs adversely impact mental health in SGM adults. Second, examine the role of perceived social support in the association between SGM-ACEs and adult mental health. PARTICIPANTS AND SETTING: Data were collected using a multifaceted sampling strategy. In total, 1819 self-identified SGM Texans completed an online survey inquiring about ACEs, SGM-ACEs, mental health, and demographic characteristics. RESULTS: We estimated two competing structural equation models (SEM) examining the associations between SGM-ACEs and anxiety and depressive symptoms, and whether perceived social support may moderate or mediate his association. While both models demonstrated that SGM-ACEs were significantly associated with higher anxiety and depressive symptoms. However, we found more support for the mediation model such that SGM-ACEs had direct effects on anxiety and depressive symptoms, and an indirect effect on anxiety symptoms through family support. CONCLUSIONS: Our findings confirmed that exposure to SGM-ACE is associated with poorer adult mental health. Additionally, SGM-ACEs exposure undermines SGM individuals' perceptions of family support, which increases symptoms of anxiety.

The Sexual and Gender Minority Adverse Childhood Experiences Scale.

INTRODUCTION: Sexual and gender minority (SGM) adverse childhood experiences (ACEs) are identity-based forms of early life adversity. Exposure to SGM ACEs is associated with increased odds of depression, anxiety, and post-traumatic stress disorder in SGM adults. The purpose of this study was to further test a revised version of the measure in a U.S. sample with more robust and clinically relevant mental health outcomes. METHODS: In May and June 2022, a national sample of SGM adults (N=4,445) was recruited from a Qualtrics Panel to complete a 20-minute online survey that included questions regarding ACEs, SGM ACEs, depression, anxiety, and post-traumatic stress disorder. Exploratory factor analysis and confirmatory factor analysis were used to examine factor structure. Multivariable regression was used to assess criterion validity, and a sensitivity analysis was conducted. Data were analyzed in February 2023. RESULTS: Respondents indicate that vicarious trauma (81%) and school bullying (67%) were the most common experiences and that all SGM ACEs were frequently occurring before adulthood. Confirmatory factor analysis determined a 1-factor solution. Participants with more SGM adverse childhood experiences exposure had worse anxiety, depression, and post-traumatic stress disorder symptoms (ß=0.16, ß=0.18, ß=0.26, respectively, p<0.0001) after controlling for ACEs exposure and demographic factors. A sensitivity analysis indicated that estimates were similar in terms of magnitude and direction. CONCLUSIONS: SGM ACEs commonly and frequently occur before adulthood and impact adult SGM mental health. Overall, the measure had good-to-excellent psychometric properties. Future research should consider integrating SGM ACEs and Minority Stress Theory.

Adverse Childhood Experiences, Substance Use, and Self-Reported Substance Use Problems Among Sexual and Gender Diverse Individuals: Moderation by History of Mental Illness.

Recent research has highlighted the alarmingly high rates at which sexual and gender diverse (SGD) individuals experience Adverse Childhood Experiences (ACE). ACE, in turn, are strongly related to mental illness-an important correlate of substance use. The present study explores whether mental illness moderates the relationship between ACE and substance use outcomes among SGD adults. As part of a larger community-based participatory research study, we assessed ACE, self-reported mental illness, and past-year substance use and misuse among a large and diverse sample of SGD community members in South Central Texas (n = 1,282). Multivariate logistic regression models were used to assess relationships between ACE, mental illness, substance use, and substance misuse (DAST > 3). Interaction terms between ACE and history of mental illness were created to assess moderation effects. Cumulative ACE scores were associated with a significantly higher odds of self-reported past year substance use (AOR = 1.43, 95% CI = 1.34-1.54) and substance misuse (AOR = 1.21, 95% CI = 1.11-1.32). History of mental illness was associated with an increased odds of self-reported substance misuse (AOR = 2.07, 95% CI = 1.20-3.55), but not past year substance use. There was a significant interaction of ACE and history of mental illness on the odds of past year substance use (AOR = 0.78, 95% CI = 0.69-0.89), but not for substance misuse. These results provide support for theoretical models linking ACE, mental illness, and substance use among SGD adults. Longitudinal research designs are needed to address temporality of outcomes and test mediation models of trauma, mental illness, and substance use. Future directions for prevention and intervention are discussed. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-023-00560-y.