"There is a paywall to my happiness": the influence of socioeconomic determinants on transgender and gender diverse young adults' experiences with eating disorders.

Transgender and gender diverse (TGD) young adults experience elevated risk for eating disorders (ED), partially due to cissexist discrimination and victimization; less is understood about how socioeconomic determinants contribute to their ED risk. Qualitative data collected from 66 TGD young adults (18-30 years old; 29% self-identified as transgender women, 29% as transgender men, 39% as nonbinary people, and 3% as another gender identity (e.g., mahu)) in eight asynchronous online focus groups explored how socioeconomic determinants in conjunction with other dimensions of identity and lived experience shape disordered eating behavior (DEB) and ED risk. Participants described how economic barriers-including poverty and dependency on others (e.g. parents for health insurance)-and challenges produced by insurance and healthcare systems impeded healthcare access to the detriment of their overall mental health and risk for ED. In addition, participants shared different ways they leveraged financial resources to cope with stress, sometimes in ways that impelled disordered eating behaviors. Finally, participants described how poverty, socioeconomic advantage and disadvantage, and classism compound other systems of oppression (e.g. racism, ableism, weight bias) to adversely impact their general health and ED risk.

Gender-Sexuality Alliance Experiences and LGBTQ+ Inclusive School Policies and Practices Predict Youth's School Belonging.

Gender-Sexuality Alliances (GSAs) and inclusive school policies and practices that affirm youth with minoritized sexual orientations or gender identities (e.g., lesbian, gay, bisexual, transgender, queer youth; LGBTQ+ youth) are two sources of support for LGBTQ+ youth that could promote school belonging. The current study tested a three-level multilevel model in which youth's GSA experiences and the degree to which their schools implemented LGBTQ+ inclusive policies and practices predicted their school belonging over a six-month period. Participants included 627 youth (87% LGBQ+ youth, 45% transgender or nonbinary youth, 48% youth of color) ages 11-22 (Mage = 15.13) in 51 GSAs. At the within-individual level, youth reported greater school belonging on occasions following months when they felt their peers and advisors were more responsive to their needs and when they had taken on more leadership in the GSA. At the between-individual level, youth who generally felt their peers were more responsive over the study period reported greater school belonging than others. At the between-GSA level, GSA members in schools that more thoroughly implemented LGBTQ+ inclusive policies and practices reported greater school belonging over the study period. These findings underscore the relevance of GSAs and inclusive policies and practices in establishing welcoming school environments.

How Gender-Sexuality Alliances cultivate a sense of school belonging from week to week for LGBTQ+ youth.

School belonging can facilitate positive youth development and educational outcomes. Given that LGBTQ+ youth face marginalization in schools, there is a need to identify school supports that could still promote their sense of school belonging. We considered Gender-Sexuality Alliances (GSAs) as LGBTQ+ affirming school clubs. Among 92 LGBTQ+ student members of GSAs in nine states who completed weekly diary surveys over an 8-week period (Mage = 15.83 years, SD = 1.29; 50% youth of color; 51% trans or non-binary), we considered whether a youth's GSA experiences from meeting to meeting predicted their relative levels of school belonging in days following these meetings. There was significant within-individual (37%) and between-individual (63%) variability in youth's sense of school belonging during this time. Youth reported relatively higher school belonging on days following GSA meetings where they perceived greater group support (p = .04) and took on more leadership (p = .01). Furthermore, youth who, on average, reported greater advisor responsiveness (p = .01) and leadership (p = .01) in GSA meetings over the 8-week period reported greater school belonging than others. Findings showcase the dynamic variability in LGBTQ+ youth's sense of school belonging from week to week and carry implications for how schools and GSAs can support LGBTQ+ youth and sustain their ties to school.

Complicating critical discussions in gender sexuality alliances: Youth desire for intersectional conversations and the experience of fragmentation.

Gender sexuality alliances (GSAs) represent consciousness-raisings that hold potential for critical consciousness development in youth. In this study, we focus on critical reflection-the understanding that oppression is structured and maintained by human action. We engage intersectionality as our analytical framework and analyze both student interview data (n = 38) and advisor closed-ended and open-ended survey data (n = 58) to examine: (1) the nature/content of critically reflective discussions in GSAs and (2) how advisors support critically reflective discussions in GSAs and their role in these discussions. Our findings suggest that (1) conversations centering race and its intersections with other socio-structural axes occur, albeit infrequently; (2) youth recognize and understand the concept of intersectionality in nuanced ways, desire to have critical intersectional conversations, and experience fragmentation from conversations around race, sexuality, and gender if they are situated at privileged locations on those axes; and (3) students want advisors to engage in critically reflective discussions in GSAs. The findings suggest that interventions and programming are needed that could cultivate advisors' and youth leaders' skills in facilitating intersectional dialogues for critical reflection among members.

What is needed for eating disorder prevention for transgender and gender diverse young adults? Findings from asynchronous online focus groups.

Transgender and gender diverse (TGD) young adults face higher risk of eating disorder (ED) symptoms than cisgender peers. Evidence-based ED prevention programs exist but must be adapted to meet the needs of diverse TGD populations. We conducted eight asynchronous online focus groups in 2019 with 66 ethnically and gender diverse TGD young adults (18-30 years) living in the United States. Participants were recruited online; groups took place over four consecutive days. We conducted inductive thematic analysis of participant responses to three prompts about ED prevention needs and advice for program developers. Findings fell into three domains. In Domain 1: Developing Program Content, themes included (1.1) need to address multiple dimensions of gender; (1.2) intersectional representation matters; (1.3) limitations of ED research; (1.4) being responsive to trauma. Domain 2: Program Delivery Considerations, included preferences for (2.1) group composition, (2.2) intervention modality, and (2.3) program leadership. Domain 3: Cultivating Affirming Spaces included themes addressing the need for programs to (3.1) create judgment-free environments and (3.2) center lived experience. TGD young adults in this study described a range of needs and recommendations for ED prevention content and delivery, with relevance to clinicians, program designers, and ED prevention advocates.

Binge drinking disparities by gender identity, race, and ethnicity in California secondary schools.

Our objective was to estimate disparities in binge drinking among secondary school students in California at the intersection of gender identity, race, and ethnicity, without aggregating racial and ethnic categories. We combined two years of the Statewide middle and high school California Healthy Kids Survey (n=951,995) and regressed past month binge drinking on gender identity (i.e., cisgender, transgender, or not sure of their gender identity), race (i.e., white, American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, or multiracial), and ethnicity (i.e., Hispanic/Latinx or non-Hispanic/Latinx), and their interaction. Transgender students had greater odds of reporting past month binge drinking than cisgender students, with greater magnitudes among students with minoritized racial or ethnic identities compared to non-Hispanic/Latinx white students. For example, among non-Hispanic/Latinx white students, transgender students had 1.3 times greater odds (AOR=1.30, 95% CI=1.17-1.55), whereas among Hispanic/Latinx Black or African American students, transgender students had 5.3 times greater odds (AOR=5.33, 95% CI=3.84-7.39) of reporting past month binge drinking than cisgender students. Transgender adolescents, particularly those with minoritized racial or ethnic identities, may be at disproportionate risk of binge drinking. Interventions that address systemic racism and cisgenderism from an intersectional perspective are needed.

Developing evidence for building sanitation justice: A multi methods approach to understanding public restroom quantity, quality, accessibility, and user experiences.

Access to basic sanitation is a human right and a critical environmental determinant of health. In this paper, we detail the development of three tools to investigate sanitation justice: (1) our public restroom spatial database, (2) our field assessment tool, and (3) survey of restroom access experiences. We document our process to collect these data in a consistent, health equity-driven framework. Together, these tools comprise a suite of methods for the examination of public restrooms from the macro- to the micro-level, and highlight key opportunities to promote health and well-being among restroom-reliant populations (e.g., people experiencing homelessness) by advancing sanitation justice in the built environment. With an illustrative case study, we demonstrate how methods triangulation, using the tools in concert, can provide a comprehensive assessment of basic sanitation access in a given region-San Diego, CA. We also detail how each tool can also be used separately to assess key sanitation justice and health equity questions that may be of interest to researchers, public health practitioners, policymakers, and advocates, including: (1) where do public restrooms exist (mapping)?; (2) how accessible are public restroom facilities, and what health-supportive features do they have (field assessment)?; and (3) what are the experiences of people most reliant on the available public restroom facilities (survey)? The results of our case study demonstrate that these adaptable tools can be used to provide meaningful data on and a holistic picture of public restroom quantity, quality, accessibility, and the experiences of public restroom users in a given region.

Gender-Sexuality Alliance meeting experiences predict weekly variation in hope among LGBTQ+ youth.

Hope is considered a marker of resilience among youth facing oppression, including LGBTQ+ youth. This 8-week weekly diary study among 94 LGBTQ+ youth (ages 14-19; Mage  = 15.91, 46% youth of color, 44% transgender or nonbinary) in 2021 considered whether a youth's meeting-to-meeting experiences in Gender-Sexuality Alliances (GSAs; LGBTQ+ affirming school clubs) predicted subsequent hope from week to week. Youth reported greater hope on days following meetings where they felt more group support, greater advisor responsiveness, and had taken on more leadership responsibilities. Group support and advisor responsiveness were stronger predictors of a youth's hope on days closer to GSA meetings; leadership's effect was stronger when more days had elapsed. Findings suggest how GSAs may cultivate hope among LGBTQ+ youth.

Housing status as a social determinant of disparities in adolescent smoking, vaping, and dual use of cigarettes and e-cigarettes.

Little is known about how various housing situations among adolescents may be associated with differential patterns of smoking and vaping-information with practical relevance for tobacco prevention and control efforts. We analyzed disparities by housing status in past 30-day smoking, vaping, and dual use of cigarettes and e-cigarettes/vape products among adolescents participating in the population-based California Healthy Kids Survey (N = 931,355; 2017-2019). Generalized linear mixed models for a categorical outcome quantified differences in prevalence and adjusted odds ratios (AORs) of smoking only, vaping only, and dual use among adolescents in various housing situations relative to their peers living in a home with one or more parents/guardians or other relatives. Our findings suggest adolescents living in a friend's home; adolescents living in a hotel, motel, shelter, car, campground, or other transitional or temporary housing; and adolescents living in a foster home, group care, or waiting placement evidenced pronounced disparities in past 30-day smoking only (AORs: 3.16-3.40, ps < 0.0001) and dual use of cigarettes and e-cigarettes/other nicotine vape products (AOR: 3.73-5.83, ps < 0.0001) relative to their peers living in a home with one or more parents/guardians or other relatives. Vaping only disparities, although significant, were relatively smaller (AORs: 1.53-1.88, ps < 0.0001). These findings emphasize housing as a social determinant of smoking, vaping, and dual use disparities among adolescents and have implications for multilevel preventive intervention development.

Gender-Sexuality Alliance Advisors' Self-Efficacy to Address Transgender Issues: An Interpersonal Protective Factor for Transgender Student Depression.

Purpose: Our purpose was to assess the association between Gender-Sexuality Alliances (GSAs) advisors' self-efficacy to address transgender issues and their students' depressive symptoms, by students' gender identity (i.e., transgender vs. cisgender). We predict that higher advisor self-efficacy will be associated with decreases in student depressive symptoms for transgender students, though not necessarily for cisgender students. Methods: Data come from surveys of student members (n = 366) and advisors (n = 58) of 38 purposively sampled GSAs in Massachusetts high schools, in 2016-2017 and 2017-2018. We used a linear mixed-effects model to assess the association between advisor self-efficacy to address transgender issues and student change in Center for Epidemiological Studies Depression-10 scores between the beginning and end of the school year by gender identity, adjusting for student covariates. Results: Students were 10-20 years old (mean = 15, standard deviation [SD] = 1.4); 28% were transgender, 28% were students of color, and 86% were lesbian, gay, bisexual, or queer/questioning or other non-heterosexual identity. The GSA advisor self-efficacy scores ranged from 13 to 25 with a mean of 20.4 (SD = 3.0). Greater advisor self-efficacy to address transgender issues was associated with a decrease in depressive symptoms for transgender students (estimate = -0.47, p = 0.01), but not for cisgender students. Conclusions: GSA advisor self-efficacy to address transgender issues could be protective for transgender student depressive symptoms. Thus, increasing advisor self-efficacy to address transgender issues may help decrease depressive symptomatology for transgender youth, and intervention work in this area is needed to bolster this claim.

GSA Advocacy Predicts Reduced Depression Disparities Between LGBQ+ and Heterosexual Youth in Schools.

OBJECTIVE: Depression disparities between heterosexual youth and lesbian, gay, bisexual, queer, and other non-heterosexual (LGBQ+) youth are robust and linked to discrimination in schools. Advocacy by school-based Gender-Sexuality Alliances (GSAs) to raise awareness of LGBQ+ issues and to counteract discrimination may reduce these disparities within schools, yet has not been investigated schoolwide. We considered whether GSA advocacy over the school year moderated sexual orientation differences in depressive symptoms at the school year's end for students in the general school population (i.e., students who were not members of the GSA). METHOD: Participants were 1,362 students (Mage = 15.68; 89% heterosexual; 52.6% female; 72.2% White) in 23 Massachusetts secondary schools with GSAs. Participants reported depressive symptoms at the beginning and end of the school year. Separately, GSA members and advisors reported their GSA's advocacy activities during the school year and other GSA characteristics. RESULTS: LGBQ+ youth reported higher depressive symptoms than heterosexual youth at the school year's beginning. However, after adjusting for initial depressive symptoms and multiple covariates, sexual orientation was a weaker predictor of depressive symptoms at the school year's end for youth in schools whose GSAs engaged in more advocacy. Depression disparities were significant in schools whose GSAs reported lower advocacy, but were statistically non-significant in schools whose GSAs reported higher advocacy. CONCLUSION: Advocacy could be a means by which GSAs achieve school-wide impacts, benefiting LGBQ+ youth who are not GSA members. GSAs may therefore be a key resource for addressing the mental health needs of LGBQ+ youth.

Associations between body image patterns and body image-related pathology in sexual minority individuals: A mixture-modeling approach.

Body image concerns are associated with disordered eating, body dysmorphic disorder (BDD), and illicit appearance and performance enhancing drug (APED) misuse. Sexual minority individuals are a vulnerable population for body image concerns. Latent profile analyses were used to identify body image patterns in sexual minority men (n = 479) and women (n = 483) and to investigate associations between latent profiles and body image-related pathology. A 5-profile solution demonstrated best fit for men and a 4-profile solution for women. Among women, co-occurring high thinness/muscularity concerns had higher probability of vomiting and dietary restriction than the high thinness/low muscularity concerns profile. The probability of driven exercise did not differ across latent profiles for men and only differed between low thinness/low muscularity and high thinness/high muscularity concerns profiles in women. Men with low thinness/high muscularity concerns had significantly lower probability of vomiting and laxative misuse than all other profiles but did not significantly differ from co-occurring high or moderate thinness/muscularity concerns profiles in binge eating and illicit APED misuse. This study may have implications for future research, treatment, and prevention of body image-related pathology in sexual minority individuals.

Engagement in Gender-Sexuality Alliances Predicts Youth's Positive and Negative Affect: An 8-Week Weekly Diary Study.

Gender-Sexuality Alliances (GSAs) are school clubs for LGBTQ + youth and peer allies to support one another. This 8-week weekly diary study considered whether a youth's positive and negative affect during a given week could be predicted by experiences in their most recently attended GSA meeting. Ninety-nine GSA members (Mage = 15.90, SD = 1.33; 79% LGBQ + ; 41% trans/non-binary; 59% youth of color) in 11 states completed weekly surveys between January and May 2021. On average, some youth reported higher positive and negative affect than others. Youth also varied notably in their own positive and negative affect from week to week. Youth reported relatively higher positive affect on days following GSA meetings where they were more engaged than in other meetings and had spent time socializing in the meeting. Youth reported relatively higher negative affect on days following GSA meetings where they had discussed personal concerns, and relatively lower negative affect on days following meetings where they were more engaged and perceived greater advisor responsiveness. These findings offer a dynamic portrayal of youth's varied experiences across GSA meetings and the more immediate predictive effects of GSA experiences.

Internalization of muscularity and thinness ideals: Associations with body dissatisfaction, eating disorder symptoms, and muscle dysmorphic symptoms in at risk sexual minority men.

OBJECTIVE: In the tripartite influence model, appearance-ideal internalization is identified as a prominent risk factor for the development of body dissatisfaction and subsequent eating disorder (ED) behaviors. For men, prior research has emphasized the importance of both thin-ideal internalization and muscular-ideal internalization in explaining later ED behaviors and muscle dysmorphia (MD) symptoms. Previous research in heterosexual men has shown that the associations between muscular-ideal internalization and ED or MD symptoms may depend on whether the individual has also internalized the thin ideal. However, this interaction has not been examined in research with sexual minority men (SMM). METHOD: The current study collected self-report data from 452 at risk SMM (i.e., endorsed body dissatisfaction), with ages ranging from 18 to 35 years. Linear regression models were conducted to test the interaction effects between thinness and muscularity internalization on ED symptoms, MD behaviors, and general body dissatisfaction. Simple slopes and the Johnson-Neyman technique were used to investigate significant interaction terms. RESULTS: Thin- and muscular-ideal internalization were positively associated with muscular appearance intolerance and dietary restriction with no significant interaction. Muscular drive for size was highest when both muscularity internalization and thinness internalization were high. Muscular-ideal internalization was positively associated with both cognitive restraint and general body dissatisfaction, but only at lower levels of thinness internalization. DISCUSSION: Given the interacting association between thinness and muscularity internalization and aspects of body dissatisfaction, attitudes, and behavior, prevention and intervention programs for EDs and MDs in SMM should seek to dismantle both thinness and muscularity internalization. PUBLIC SIGNIFICANCE STATEMENT: Internalizing-or adopting as one's own-the ideal of a body with low body fat and high muscularity has been shown to lead to muscle dysmorphia and eating disorder symptoms in men. The current study examines whether the combination of thin-ideal and muscular-ideal internalization is associated with worse symptoms than either facet alone in sexual minority men. Treatment efforts in sexual minority men should address both types of internalization.

Prevalence of Disordered Eating and Associations With Sex, Pubertal Maturation, and Weight in Children in the US.

This cross-sectional study assesses the prevalence of disordered eating in children and its associations with sex, pubertal maturation, and weight.

Gay Community Involvement and Condomless Anal Sex Among Sexual Minority Men in the USA.

Sexual minority men (SMM) remain disproportionately burdened by sexually transmitted infections. Although gay community involvement has been theorized to be protective against many negative health outcomes, research examining the association between community involvement and condomless anal sex (CAS) has yielded conflicting results. The current study, conducted between 2018-2020, examined whether the importance one places on various aspects of community involvement was associated with CAS among a sample of young adult SMM aged 18-34 years with body image concerns (N = 180). Gay community involvement was measured using the Importance of Gay Community Scale, and the results of an exploratory factor analysis indicated the presence of two factors: "social activism" and "going out/nightlife." A zero-inflated Poisson regression was conducted to examine the association between gay "social activism," "going out/nightlife," and their interaction with the number of CAS partners. Upon examining a significant interaction, "social activism" had a protective effect against CAS at low levels of "going out/nightlife," but this effect was non-significant at higher levels. These results suggest that encouraging gay community involvement through activism could be effective at reducing CAS and addressing the health disparity that exists within this population.

A Mixed-Methods Examination of the Unique Associations of Gender-Sexuality Alliance Involvement and Family Support on Bravery in Sexual and Gender Minority Youth.

Research among sexual and gender minority (SGM) youth has suggested associations between Gender-Sexuality Alliance (GSA) involvement and better health. Emergent research has similarly demonstrated associations between family support and general well-being among SGM youth. However, the trait of bravery has received little attention in this literature, despite its relevance for youth in marginalized positions. We examined the association between level of GSA involvement, family support, and bravery among GSA members (n = 295; M age = 16.07), and whether those associations differed based on sexual orientation or gender identity. We then conducted one-on-one interviews with SGM youth (n = 10), to understand how they understood bravery and experienced support in both GSA and family contexts. Greater GSA involvement significantly predicted greater bravery for all youth, whereas greater family support predicted greater bravery only for heterosexual youth. No significant moderation was found for gender minority youth. Our qualitative findings clarified how SGM youth conceptualized bravery and how they experienced it within their GSA and family settings. GSAs were associated with more frequent displays of explicit support for SGM identity, while families were perceived as providing less explicit support.

Feasibility and Acceptability of a Theater-Based HIV Prevention Workshop Developed by and for LGBTQ Youth.

BACKGROUND: Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth may have limited exposure to sexuality education programming that is affirming of their identities and unique experiences. OBJECTIVE: To develop and evaluate the feasibility and acceptability of a theater-based HIV prevention workshop for LGBTQ youth. METHODS: The 3-hour-long workshop (piloted 2014-2015; n = 20 LGBTQ youth, 14-22 years old) consisted of instruction in HIV risk and prevention, humorous role plays, and analysis of HIV prevention strategies using a forum theater format. A mixed methods evaluation focused on feasibility and acceptability, with survey assessment data collected for preliminary efficacy (e.g., HIV knowledge, safer sex self-efficacy). RESULTS: Participants perceived the forum theater format, humor, and reality of the scenes as strengths. The language of workshop scripts and evaluation materials could be further modified to better affirm gender and sexual diversity. CONCLUSION: Preliminary evidence of feasibility and acceptability were demonstrated. Future iterations of the intervention require rigorous quantitative evaluation for efficacy.

The Course of Weight/Shape Concerns and Disordered Eating Symptoms Among Adolescent and Young Adult Males.

PURPOSE: Male weight concerns tend to focus on shape and muscularity as opposed to a desire for thinness and remain underdetected by conventional eating disorder assessments. We aimed to describe the longitudinal course of weight concerns and disordered eating behaviors among males across adolescence and young adulthood. METHODS: We used prospective assessments of 4,489 U S. males, aged 11 to 18 years at baseline of analyses, in the Growing Up Today Study. We assigned mutually exclusive classifications of behaviors consistent with bulimia nervosa (BN), binge eating disorder (BED), purging disorder (PD); high levels of concern with thinness and/or muscularity; and use of muscle-enhancing products. We estimated the probability of maintenance, resolution, or transition to different weight concerns and/or disordered eating behaviors across consecutive survey waves. RESULTS: Less than 1% of participants met full or partial criteria for BN, PD, or BED at baseline. One-quarter (25.4%, n = 1,137) of males reported high weight concerns during follow-up; nearly all these cases (93.7%, n = 1,065) had high muscularity concerns. The most common transition in concerns or behaviors involved the addition of muscularity concerns to a preoccupation with thinness. Eleven percent of participants used muscle-building products during follow-up. Multi-year product use (23.0% [standard deviation 1.0%] of males who used products) was more common than maintenance of bulimic behaviors (3.0% [.7%] of BN/PD, 10.5% [1.2%] of BED cases). CONCLUSIONS: Integrating muscularity concerns and product use into health promotion and screening tools may improve prevention and early detection of harmful body image and weight control among adolescent and young adult males.