"I felt like a freak when I would go to the doctor": Investigating healthcare experiences across the lifespan among older LGBT and transgender/gender diverse adults.

In the past several decades, the United States has enacted civil rights legislation protecting lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations from discrimination, including enacting proactive healthcare laws such as the Affordable Care Act. However, given today's divisive politics, LGBTQ people's access to appropriate and respectful health care is precarious. This study explored the disconnections from and connections to health care and the respective health effects among two self-identified groups: i) older LGBT adults and ii) transgender and gender-diverse (TG/GD) adults. Using a life course perspective, qualitative data from 17 older LGBT and TG/GD participants were analyzed. Thematic and content analyses indicated that despite progress made, discrimination and prejudice in obtaining health care persist, particularly among TG/GD people of color. The results highlight the ongoing challenges LGBTQ populations face as they risk being denied care by healthcare providers and disconnected from the healthcare system.

Mapping the Dynamic Complexity of Sexual and Gender Minority Healthcare Disparities: A Systems Thinking Approach.

Sexual and gender minority (SGM) populations experience extensive health disparities compared to their straight and cisgender counterparts. The importance of addressing these disparities is paramount, as SGM groups often encounter significant barriers to accessing comprehensive healthcare, including societal stigma, provider bias, and financial constraints. This study utilizes a community-based system dynamics approach to understand and visualize the barriers to and facilitators of healthcare engagement for SGM groups across their life course. It aims to identify core constructs, relationships, and dynamic feedback mechanisms related to the experiences of connection/disconnection with physical, mental, and dental healthcare of SGM individuals. Barriers to access, such as discriminatory practices and the limited availability of SGM-informed healthcare professionals, exacerbate these disparities, underscoring the urgency of developing targeted interventions. System dynamics, a complex systems science (CSS) methodology, was used for this research. Group model building sessions were conducted with diverse SGM groups, including youth, older adults, and trans and gender-expansive community members. Causal loop diagrams were developed according to an iterative process, and a meta-model of their collective experiences was created. The study revealed extensive, dynamic, and shifting structural barriers for SGM community members accessing healthcare. Societal and structural stigma, provider bias, and pathologization were identified as significant barriers throughout their life course. Community-led interventions and SGM-focused holistic healthcare were identified as critical facilitators of SGM healthcare connection. The findings highlight the need for SGM-affirming and culturally responsive healthcare settings. This paper calls for a concerted effort from SGM health researchers to use CSS in developing interventions to reduce SGM health disparities.

Sexual and Gender Minority Youth in Foster Care: An Evidence-Based Theoretical Conceptual Model of Disproportionality and Psychological Comorbidities.

Sexual and gender minority youth (SGMY) are overrepresented in the foster care system and experience greater foster-care-related stressors than their non-SGM peers. These factors may further elevate their risk of anxiety/depressive, post-traumatic stress disorder, self-harm, and suicidality. The system currently produces unequal and disproportionate adverse mental health outcomes for SGMY and needs points of intervention to disrupt this status quo. This article provides an empirically grounded conceptual-theoretical model of disproportionate representation and burden of psychological comorbidities experienced by SGMY in the foster care system. We apply findings from an integrated literature review of empirical research on factors related to overrepresentation and mental health burden among SGMY to minority stress theory to explicate how and why the foster care system exacerbates mental health comorbidities for SGMY. Searches were conducted in June 2020 in PubMed using MeSH terms and title/abstract terms for foster care, sexual or gender minorities, and psychological comorbidities. Inclusion criteria are studies conducted in the United States, published in English, focused on mental illness, and published between June 2010 and 2020. Developmental/intellectual and eating disorders were excluded. The initial search returned 490 results. After applying inclusion criteria, 229 results remained and are utilized to build our conceptual-theoretical model. We assert that the phenomenon of disproportionate psychological comorbidities for SGMY in foster care is best represented as a complex and dynamic system with multiple feedback loops. Extant empirical and theoretical literature identifies three critical areas for intervention: family acceptance, community belonging and queer chosen/constructed family, and affirming and nondiscriminatory child welfare policy.

Disparities in Social and Economic Determinants of Health by Sexual Identity, Gender, and Age: Results from the 2015-2018 National Survey on Drug Use and Health.

Purpose: We characterize disparities between lesbian, gay, and bisexual (LGB) adults and heterosexual adults across multiple health determinants in a nationally representative sample. Methods: Data on 153,939 adults (including 11,133 LGB adults) were from the 2015-2018 National Survey on Drug Use and Health. Separate Poisson regression models were used to estimate the relative risk (RR) that gay/lesbian and bisexual adults, respectively, experienced each health determinant, relative to heterosexual adults of the same gender and age group (ages 18-25, 26-34, 35-49, and 50-64). Statistically significant RR estimates were interpreted as a disparity. Results: Bisexual females exhibited disparities on all economic/health care access factors (no college degree, household poverty, means-tested assistance, unemployment, and lacking health insurance) across nearly all age groups; lesbian/gay females exhibited disparities in means-tested assistance and health insurance for some age groups. Notably fewer economic disparities were observed among gay and bisexual males. LGB adults (across identity, gender, and age group) were more likely to live alone, to have never been married, and to report low religious service attendance. Bisexual and lesbian/gay females, across age groups, had 1.7-2.2 times the risk of a lifetime arrest for a criminal offense, relative to same-age heterosexual females. Conclusions: Our results highlight that LGB females, particularly bisexual females, experience significant disparities in economic determinants of health, and all LGB subgroups exhibited disparities in some of the examined social determinants of health. The observed disparities, which spanned across age groups, likely contribute to disparities in physical and mental health observed among LGB adults.

Differential Experiences of Mental Health among Transgender and Gender-Diverse Youth in Colorado.

Young people experience a variety of mental health concerns, including depression, non-suicidal self-injury, and suicidal ideation. These issues are at even higher rates among transgender and gender-diverse (TGD) young people, due to the additional burden of having to navigate a world in which transphobia impacts them at the individual, organizational, and policy levels. However, much of the extant research focuses only on comparing TGD youth to cisgender counterparts. This study explores the nuance within the TDG youth population regarding mental health, examining how gender, race/ethnicity, and sexual orientation change the likelihood of experiencing each of these mental health concerns. Among a sample of over 400 young people, findings indicate that those TGD young people who do not identify themselves within the masculine/feminine binary and those with marginalized sexual orientations were two to three times more likely to experience adverse mental health outcomes, as compared to their peers who are questioning their gender, and who are heterosexual. The implications for mental health professionals and others who work with young people are to recognize that mental health is not a one-size-fits all model for young TGD people, and that the intersection of multiple marginalized identities, must be addressed in order to improve the mental health of this group of young people. Findings can also be used to better understand issues of stigma, discrimination, and victimization in education, health care, and beyond.

Disproportionate Impact of the COVID-19 Pandemic on Perceived Social Support, Mental Health and Somatic Symptoms in Sexual and Gender Minority Populations.

Deaths from COVID-19 continue to rise, and this virus has asymmetric impacts on marginalized communities though specific impacts on sexual and gender minority communities are not well understood. From March 23 to June 20, 2020, in an online cross-sectional survey among 1380 US adults, we assessed physical symptoms, psychological symptoms, rumination, and perceived social support in order to describe differences between sexual and gender minority (n = 290) and cisgender heterosexual (n = 1090) respondents. Sexual and gender minority respondents had more frequent COVID-19-associated physical symptoms and depression and anxiety symptoms. Sexual and gender minorities had a significantly higher proportion of depression and anxiety scores exceeding the clinical concern threshold. Longitudinal studies on the physical and psychological impacts of COVID-19 among sexual and gender minority communities are needed to inform interventions to eliminate these disparities.

Substance Use Disparities at the Intersection of Sexual Identity and Race/Ethnicity: Results from the 2015-2018 National Survey on Drug Use and Health.

Purpose: Lesbian, gay, and bisexual (LGB) racial/ethnic minority individuals experience minority stress due to both their sexual identity and race/ethnicity and may be at elevated substance use risk (relative to heterosexuals) compared with their White LGB peers. We examined differences in the presence and magnitude of substance use disparities among LGB adults across race/ethnicity. Methods: Using data on 168,560 adults (including 11,389 LGB adults) from the 2015-2018 National Survey on Drug Use and Health, we examined disparities in cigarette smoking, heavy episodic drinking (HED), and marijuana use by race/ethnicity (White, Black, Hispanic, and other race/multiracial). Analyses compared lesbian/gay and bisexual adults, respectively, with heterosexual adults of the same gender and race/ethnicity. We also tested the magnitude of racial/ethnic minority disparities relative to the corresponding White disparity. Results: Significant disparities in smoking, HED, and marijuana use were observed for lesbian/gay and bisexual women across nearly all racial/ethnic groups. Disparities were consistently greater in magnitude for Black and Hispanic LGB women compared with White LGB women. Few disparities were observed among men; the magnitude of observed disparities did not differ by race/ethnicity. Conclusion: Disparities were most pronounced among racial/ethnic minority LGB women, which may reflect their unique experiences of discrimination at the intersection of multiple minority idenities. However, racial/ethnic minority gay and bisexual men were not at elevated risk relative to their White counterparts. Future research on substance use disparities among LGB individuals using an intersectional framework is warranted to elucidate differential minority stress processes that contribute to the observed heterogeneity across race/ethnicity, sexual identity, and gender.

Effects of individual risk and state housing factors on adverse outcomes in a national sample of youth transitioning out of foster care.

INTRODUCTION: Compared to their peers, youth who leave the foster care system without permanency experience greater risks for adverse young adult outcomes, including homelessness, incarceration, substance abuse, and early child birth. Extant literature focuses on individual-level factors related to adversity. In this study, we estimated the impact of state and individual-level risk and protective factors on adverse 19-year-old outcomes among a cohort of U.S. transition age youth. METHODS: We used multilevel modeling to analyze prospective, longitudinal data from two waves of the National Youth in Transitions Database (N = 7449). These data were linked to the Adoption and Foster Care Reporting System, the Administration for Children and Families budget expenditures, and the American Community Survey for the period from 2011 to 2013. RESULTS: Approximately 30% of the variation in each of the 19-year-old outcomes could be attributed to state-level effects. Residence in a state that spent above average of CFCIP budget on housing supports reduced the risk of homelessness and incarceration. Living in a state with a higher proportion of housing-burdened low-income renters significantly increased the risk of substance abuse and child birth. Individual-level risks were significant: racial/ethnic minority, male gender, past risk history, placement instability, child behavioral problems, residence in group home or runaway. Remaining in foster care at age 19 reduced the odds of homelessness, incarceration, and substance abuse. CONCLUSION: Macro factors, including financial support for transition-age youth, and broader housing market characteristics, have a bearing on young adult outcomes, and raise policy questions across social and human service sectors.

Multisystem-Involved Youth: A Developmental Framework and Implications for Research, Policy, and Practice.

Multisystem-involved youth are children and adolescents concurrently served in the child welfare, behavioral health, and/or juvenile justice systems. These youth are a high risk and vulnerable population, often due to their experience of multiple adversities and trauma, yet little is known about their multiple needs and pathways into multisystem involvement. Multisystem-involved youth present unique challenges to researchers, practitioners, and policymakers. In this article, we summarize the literature on multisystem-involved youth, including prevalence, characteristics, risk factors, and disparities for this population. We then describe a developmental cascade framework, which specifies how exposure to adverse experiences in childhood may have a "cascading" or spillover effect later in development, to depict pathways of multisystem involvement and opportunities for intervention. This framework offers a multidimensional view of involvement across service systems and illustrates the complexities of relationships between micro- and macro-level factors at various stages and domains of development. We conclude that multisystem-involved youth are an understudied population that may represent majority of youth who are already served in another service system. Many of these youth are also disproportionately from racial and ethnic minority backgrounds. Currently, for multisystem-involved youth and their families, there is a lack of standardized and integrated screening procedures to identify youth with open cases across service systems; inadequate use of available instruments to assess exposure to complex trauma; inadequate clinical and family-related evidence-based practices specifically for use with this population; and poor cross-systems collaboration and coordination that align goals and targeted outcomes across systems. We make recommendations for research, practice, and systems development to address the needs of multisystem-involved youth and their families.

Collective Efficacy as a Key Context in Neighborhood Support for Urban Youth.

Neighborhood context, including the physical and social environment, has been implicated as important contributors to positive youth development. A transactional approach to neighborhood asserts that place and people are mutually constitutive; negative perceptions of place are intrinsically bound with negative portrayals of stigmatized groups, including youth. Adult perceptions of neighborhood youth may contribute to an increased sense of alienation and youth antisocial behavior. This study uses street-intercept interviews with adults (N = 408) to examine the relationship between neighborhood conditions and adult support for neighborhood youth. A path model was used to examine the direct and indirect relationship of neighborhood constructs (safety, aesthetic quality, and walkability) on adult support for neighborhood youth. Neighborhood aesthetic quality and the walking environment were directly associated with adult support for youth, whereas perceived safety was indirectly associated. Collective efficacy partially explained these relationships. Findings support theorized relationships between people and places; improvements to neighborhood physical environment may directly impact resident adults' perceptions of neighborhood young people.

Reciprocal Effects of Positive Future Expectations, Threats to Safety, and Risk Behavior Across Adolescence.

We examined the reciprocal relationships among positive future expectations, expected threats to future safety, depression, and individual substance use and delinquency using 4 waves of data (N = 248-338) from African American and Latino adolescent male participants in the Chicago Youth Development Study. Individual positive future expectations and expected threats to safety were assessed at each wave and modeled as latent constructs. Individual substance use and delinquency were assessed at each wave and represented as ordinal variables ranging from low to high. Categorical autoregressive cross-lagged structural models were used to examine the hypothesized reciprocal relationships between both aspects of future expectations construct and risk behavior across adolescence. Analyses show that future expectations has important effects on youth substance use and involvement in delinquency, both of which in turn decrease positive expectations and increase expectation of threats to future safety across adolescence. Similarly, low positive expectations for the future continued to predict increased substance use and involvement in delinquency. The expected threats to safety construct was significantly correlated with delinquency within time. These effects are observed across adolescence after controlling for youth depression and race. Findings support the reciprocal effects hypothesis of a negative reinforcing cycle in the relationships between future expectations and both substance use and involvement in delinquent behavior across adolescence. The enduring nature of these relationships underscores the importance of future expectation as a potential change mechanism for intervention and prevention efforts to promote healthy development; vulnerable racial and ethnic minority male adolescents may especially benefit from such intervention.

Neighborhood sexual violence moderates women's perceived safety in urban neighborhoods.

Perceptions of neighborhood safety are positively associated with perceptions of neighborhood violence. However, research has yet to examine whether this relationship is moderated by specific types of violence, such as sexual violence, that are more salient for women. Using street-intercept interviews with 343 adults in 9 neighborhoods of a U.S. city with high rates of poverty, unemployment, and crime, we examine the relationship of perceived neighborhood violence to perceived safety in the context of gender while controlling for neighborhood assets that moderate perceptions of neighborhood safety and violence. We hypothesized that gender would moderate the relationship between perceived neighborhood violence and safety, and that women's perceptions of neighborhood safety would be significantly influenced by neighborhood sexual violence, but not other types of violence. Although women and men in these high crime, urban neighborhoods did not differ in their perceptions of neighborhood safety or violence, perceived sexual violence did significantly moderate safety by gender; women's perceptions of neighborhood sexual violence predicted perceived safety in their neighborhood. Importantly, gender did not moderate perceived safety for other types of violence. These results illustrate the importance of taking gender and perceived sexual violence into account to understand neighborhood safety in adults, particularly women.

Multiple Disadvantage and Discrimination: Implications for Adolescent Health and Education.

Multiply disadvantaged youths exhibit worse health and academic success than their less disadvantaged peers, possibly due to greater exposure to social status-based discrimination. Models that capture the additive burden of disadvantage in tandem with multiple forms of discrimination are needed to explicate the unique and combined impact of these factors on adolescent health and academic outcomes. In addition, protective factors like positive family and peer relationships may attenuate these relationships. This study used data from the Beyond High School Study (N = 9,658), which looked at the transition to adulthood among senior class cohorts from 12 high schools in western Washington state, to investigate the influence of multiple disadvantage, four types of discrimination, and protective resources on student physical and mental health and school grades. Results show that both increased multiple disadvantage statuses and experienced discrimination are associated with decrements across outcomes; however, effects are attenuated when protective resources are considered. Yet, as disadvantages mount, the buffering effect of peer and family resources are dampened. No interaction was found between experienced discrimination and protective resources on outcomes.

Socio-psychological mediators of the relationship between behavioral health stigma and psychiatric symptoms.

The stigma associated with mental illness or addiction is significantly and positively related to psychiatric symptoms. According to Modified Labeling Theory, several processes should mediate this relationship, including rejection experiences, stigma management (secrecy coping), and social support. In the first comprehensive test of this theory, we examined a serial mediation model on three waves of data from 138 adults receiving outpatient behavioral health treatment. Participants were recruited from outpatient behavioral health clinics in a large northeastern city in the United States and completed interviews that assessed stigma, rejection experiences, stigma management, social support, and psychiatric symptoms. There was a direct effect between stigma and psychiatric symptoms and an indirect effect in which perceived rejection, secrecy coping and social support sequentially and longitudinally intervened in the stigma and psychiatric symptom relationship. Higher perceptions of stigma predicted more rejection experiences, which marginally increased secrecy coping and decreased social support. In turn, decreased social support increased psychiatric symptoms. We provide support for Modified Labeling Theory and the clinical utility of specific mediators in the relationship between stigma and psychiatric symptoms among adults in behavioral health treatment living in urban settings.

Assessing future expectations of low-income minority young men: Survival-threats and positive expectations.

Future expectations, a subset of overall orientation, represent youths' most realistic appraisals of future outcomes, and has been demonstrated to be associated with a range of health risk behaviors and wellbeing. The current study extends previous measurement efforts to operationalize and measure future expectations by estimating a multidimensional model of future expectations encompassing both positive and survival-based expectations, and using longitudinal data to test the consistency of these constructs over time. The current work uses data from six waves of the Chicago Youth Development Study (n=338), a sample of African American and Latino young men from low income neighborhoods in an urban center, to test a hypothesized multidimensional structure of future expectations across adolescence. Test retest confirmatory factor analyses from six waves of data covering the mean age range of 12 to 19 years reveal good model fit for the hypothesized multidimensional model of future expectations at each wave. Strong measurement invariance based on race/ethnicity is established for the multidimensional model. Implications for a latent construct approach to future expectations with low-income racial/ethnic minority young men are discussed.

Cumulative Disadvantage and Youth Well-Being: A Multi-Domain Examination with Life Course Implications.

PURPOSE: The accumulation of disadvantage has been shown to increase psychosocial stressors that impact life course well-being. This study tests for significant differences, based on disadvantage exposure, on youths' emotional and physical health, as well as family supports, peer assets, and academic success, which hold potential for resilience and amelioration of negative health outcomes. METHODS: A 12 item cumulative disadvantage summed index derived from surveys of a racially and socioeconomically diverse sample of urban high school seniors (n=9,658) was used to distinguish youth at low, moderate, and high levels. RESULTS: Findings supported hypothesized stepped patterns such that as multiple disadvantages accumulate, a concomitant decline is evident across the assessed outcome variables (except positive academic identity). Post-hoc tests indicated a pattern of groups being significantly different from one another. DISCUSSION: Overall, results lend support for an additive stress load associated with stacked disadvantage, with implications for continuing trends into adulthood as well as preventive interventions.