Effectiveness of a paediatric weight management intervention for rural youth (iAmHealthy): Primary outcomes of a cluster randomised control trial.

BACKGROUND: Youth in rural areas are disproportionally affected by obesity. Given the unique barriers rural populations face, tailoring and increasing access to obesity interventions is necessary. OBJECTIVE: This paper evaluates the effectiveness of iAmHealthy, a family-based paediatric obesity intervention delivered to rural children, compared to a Newsletter Control. METHODS: Participating schools (n = 18) were randomly assigned to iAmHealthy or Newsletter Control. iAmHealthy consists of individual health coaching and group sessions delivered via televideo to a participant's home. The child and parent's body mass index (BMI), child physical activity and child dietary intake were assessed at baseline, post-treatment (8 months) and follow-up (20 months). Multilevel modeling estimated the effect of treatment at both time points. RESULTS: Parent and child dyads were recruited (n = 148) and randomised to iAmHealthy (n = 64) or the Control group (n = 84). The Control group had significant increases in child BMIz from baseline to follow-up. iAmHealthy youth had no significant changes in BMIz from baseline to post or follow-up. Child dietary intake, physical activity and parent BMI results are also discussed. CONCLUSIONS: This trial extends previous paediatric obesity work by simultaneously increasing convenience and dose of treatment. Results suggest iAmHealthy resulted in a change in BMIz trajectories and long-term health behaviour for youth.

Roots of Sexual Abuse: A Pathway Model for Adolescents Who Offend.

Theoretical models implicate insecure attachment, peer isolation, hostile masculinity, and the use of sex for coping in sexual perpetration against children. This study builds on previous research and tests the direct and indirect effects of attachment, interpersonal and sexual control problems, and masculine adequacy to explain sex offending against children in adolescents. Structural equation modeling was used to conduct a path analysis using 464 adolescent males. A significant path model was fitted that identified three paths between anxious attachment, social isolation, sexual dyscontrol, masculine adequacy, and offending against a child. The model partially confirms previous research on adolescents who commit sexual abuse. The best fitting model indicates a direct path from anxious attachment to sexual offending against a child, but also indicates two indirect paths, where anxious attachment and committing child sexual abuse was partially mediated by social isolation and masculine adequacy, which, in turn, were negatively associated with each other, and a path including sexual dyscontrol, which was positively associated with both social isolation and masculine adequacy. The results suggest that commission of child sexual abuse by adolescent males is related to individual proclivities, social experiences, and attitudes toward sexuality and masculinity.

Language Skills Influence Transition Planning in Adolescents With Fragile X Syndrome.

Individuals with fragile X syndrome (FXS) and their parents have a range of experiences navigating the crucial transition period between adolescence and adulthood. Semistructured interviews of 47 mothers of adolescents with FXS (mean child age = 15.89 years) were analyzed to identify mothers' changing expectations during the adolescent period and parent goals related to work and postsecondary education. Mothers' work and education goals were explored in relation to child factors such as language skills and autism characteristics. Lower language skills were associated with lower likelihood of reporting vocational goals. Results suggest that adolescents with FXS with lower language ability are less likely to have vocational plans for adulthood during this critical period and may need greater transition planning assistance.

Recruitment and reach in a school-based pediatric obesity intervention trial in rural areas.

Introduction: The purpose of this study is to evaluate two recruitment strategies on schools and participant participation rates and representativeness (reach) within a pediatric obesity treatment trial tailored for families who live in rural areas. Methods: Recruitment of schools was evaluated based on their progress toward enrolling participants. Recruitment and reach of participants were evaluated using (1) participation rates and (2) representativeness of demographics and weight status of participants compared to eligible participants (who did not consent and enroll) and all students (regardless of eligibility). School recruitment, as well as participant recruitment and reach, were evaluated across recruitment methods comparing opt-in (i.e., caregivers agreed to allow their child to be screened for eligibility) vs. screen-first (i.e., all children screened for eligibility). Results: Of the 395 schools contacted, 34 schools (8.6%) expressed initial interest; of these, 27 (79%) proceeded to recruit participants, and 18 (53%) ultimately participated in the program. Of schools who initiated recruitment, 75% of schools using the opt-in method and 60% of schools using the screen-first method continued participation and were able to recruit a sufficient number of participants. The average participation rate (number of enrolled individuals divided by those who were eligible) from all 18 schools was 21.6%. This percentage was higher in schools using the screen-first method (average of 29.7%) compared to schools using the opt-in method (13.5%). Study participants were representative of the student population based on sex (female), race (White), and eligibility for free and reduced-price lunch. Study participants had higher body mass index (BMI) metrics (BMI, BMIz, and BMI%) than eligible non-participants. Conclusions: Schools using the opt-in recruitment were more likely to enroll at least 5 families and administer the intervention. However, the participation rate was higher in screen-first schools. The overall study sample was representative of the school demographics.

Prospectively predicting naturalistic exposure to fitspiration and thinspiration in young women with disordered eating by leveraging an ecological momentary assessment design.

OBJECTIVE: Although a growing body of research has examined the impacts of ED-salient content, such as fitspiration and thinspiration, on eating disorder (ED) symptoms, there is less known about the characteristics of who may be at risk for accessing this content on Instagram. Current research is limited by cross-sectional and retrospective designs. This prospective study used ecological momentary assessment (EMA) to predict naturalistic exposure to ED-salient content on Instagram. METHODS: Female university students with disordered eating (N = 171, Mage = 20.23, SD = 1.71, range = 18-25) completed a baseline session, followed by a seven-day EMA protocol, in which they reported on Instagram use and exposure to fitspiration and thinspiration. Mixed-effects logistical regressions were used to predict exposure to ED-salient content on Instagram from four principal components (e.g., behavioral ED symptoms and trait social comparison) controlling for duration of Instagram use (i.e., dose) and day of study. RESULTS: Duration of use was positively associated with all types of exposure. Purging/cognitive restraint and excessive exercise/muscle building prospectively predicted access to any ED-salient content and fitspiration only. Restricting positively predicted thinspiration only access. Purging/cognitive restraint positively predicted accessing fitspiration and thinspiration (dual exposure). Day of study was negatively associated with any exposure, fitspiration only, and dual exposure. CONCLUSIONS: Baseline ED behaviors were differentially associated with exposure to ED-salient Instagram content; however, duration of use was also a significant predictor. Limiting use of Instagram may be important for young women with disordered eating to reduce probability of encountering ED-salient content.

Maternal well-being and family adaptation during COVID-19 in fragile X syndrome.

Mothers of children with fragile X syndrome are at increased risk of experiencing anxiety and depression due to potential genetic risk and to stress associated with parenting a child with significant behavioral, emotional, and educational support needs. During the initial shutdown and subsequent restrictions of the COVID-19 pandemic, mothers of children with fragile X reported experiencing elevated levels of anxiety and depression relative to their usual levels of well-being. Many indicated that the negative consequences of exposure to COVID-19 and related stressors, as well as the impacts of the pandemic on their family, directly affected their anxiety and depression. Mothers reported on specific sources of distress as well as potential sources of resilience and positive adaptation that occurred during the first year of the COVID-19 pandemic.

Validation of remote height and weight assessment in a rural randomized clinical trial.

BACKGROUND: The purpose of this study is to describe and assess a remote height and weight protocol that was developed for an ongoing trial conducted during the SARS COV-2 pandemic. METHODS: Thirty-eight rural families (children 8.3 ± 0.7 years; 68% female; and caregivers 38.2 ± 6.1 years) were provided detailed instructions on how to measure height and weight. Families obtained measures via remote data collection (caregiver weight, child height and weight) and also by trained staff. Differences between data collection methods were examined. RESULTS: Per absolute mean difference analyses, slightly larger differences were found for child weight (0.21 ± 0.21 kg), child height (1.53 ± 1.29 cm), and caregiver weight (0.48 ± 0.42 kg) between school and home measurements. Both analyses indicate differences had only minor impact on child BMI percentile (- 0.12, 0.68) and parent BMI (0.05, 0.13). Intraclass coefficients ranged from 0.98 to 1.00 indicating that almost all of the variance was due to between person differences and not measurement differences within a person. CONCLUSION: Results suggest that remote height and weight collection is feasible for caregivers and children and that there are minimal differences in the various measurement methods studied here when assessing group differences. These differences did not have clinically meaningful impacts on BMI. This is promising for the use of remote height and weight measurement in clinical trials, especially for hard-to reach-populations. TRIAL REGISTRATION: Clinical. Registered in clinicaltrials.gov ( NCT03304249 ) on 06/10/2017.

Evaluating associations between fitspiration and thinspiration content on Instagram and disordered-eating behaviors using ecological momentary assessment: A registered report.

INTRODUCTION: Greater use of appearance-focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered-eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs. METHODS: We will evaluate a hypothesized pathway from Instagram use to disordered-eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self-esteem, and trait self-comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7-day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs. RESULTS: Multi-level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress. DISCUSSION: Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just-In-Time Interventions for problematic social media use.

Word retrieval difficulty in adult females with the FMR1 premutation: Changes over time and across contexts.

Individuals with a premutation of the fragile X mental retardation (FMR1) gene are at risk for a variety of psychological, physical, and cognitive issues, including difficulty with word retrieval. The present study examined three indicators of word retrieval difficulty; reduced productivity, reduced lexical diversity, and increased errors in word retrieval in a group of 38 female premutation carriers during standard-length speech samples collected over a period of eight years. Our results revealed that as women aged, they produced fewer words, produced fewer different words, and had greater word retrieval errors. In addition, the rate of word retrieval errors was highly correlated between two speaking contexts, indicating that this difficulty was pervasive and not solely the result of speaking in monologue. Our results suggest that subtle areas of cognitive decline emerge at a much earlier age among female premutation carriers than would be expected during healthy aging.

Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM).

BACKGROUND: A number of studies have found that hypersexuality is associated with a high propensity for sexual excitation. In comparison, less is known about the relationship between hypersexuality and sexual arousal at the state level. Also, previous research has revealed a relationship between hypersexuality and negative mood. However, the possibility that sexual response might not be as negatively impacted by negative mood in hypersexual individuals has, as yet, not been tested. AIM: The purpose of this study was to investigate sexual responsivity and the effects of negative mood on sexual arousal in hypersexual men who have sex with men (MSM). METHODS: A total of 211 MSM were assigned to a hypersexuality (N = 81) or a control (N = 130) group using an interview patterned with a semi-structured Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders format. Participants filled out questionnaires and were shown neutral, sexual, and anxiety- and sadness-inducing films. OUTCOMES: Changes in penile circumference and self-reported sexual arousal were the primary outcomes analyzed in this study. RESULTS: Controlling for age and HIV status, no differences were found in genital response between hypersexual and non-hypersexual men. Also, the 2 groups did not differ in subjective sexual arousal. Moreover, no effects of negative mood were found. Time series clustering analyses revealed 3 groups-low responders and slow and fast high responders. Sexual excitation, but not sexual compulsivity or pornography use, predicted cluster membership. CLINICAL TRANSLATION: Hypersexual MSM may benefit more from an exploration of motivational and behavioral, as compared to psychophysiological, mechanisms underlying possible links between (negative) mood and sexual behavior. STRENGTHS & LIMITATIONS: Strengths of the study include its sample size, making it one of the larger psychophysiological sex studies; the use of clinical interviews for group assignment; the inclusion of genital response measures; and the application of time series clustering to examine differences among participants. Limitations include possible sample heterogeneity and the reliance on researcher-selected stimuli. CONCLUSION: Given the lack of any effects of negative mood on sexual response in hypersexual MSM, future studies could explore in more depth possible motivational and behavioral effects, including, for example, the impact of negative mood on the tendency to seek out sex as a form of distraction or for validation or emotional support. Janssen E, Prause N, Romine RS, et al. Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM). J Sex Med 2020;17:1751-1760.

Association of Multisetting Community Programs and Policies With Child Body Mass Index: The Healthy Communities Study.

INTRODUCTION: Expert opinion suggests that efforts to address childhood obesity should seek to transform the environments in which children operate. The objective of this study was to describe the extent to which multisetting programs and policies interact with community and child predictors and are associated with child body mass index (BMI) in the 130 US communities participating in the Healthy Communities Study. METHODS: For 2 years beginning in fall 2013, we collected data through key informant interviews on community programs and policies related to healthy weight among children that occurred in the 10 years before the interview. We characterized community programs and policies by intensity of efforts and the number of settings in which a program or policy was implemented. Child height and weight were measured during household data collection. We used multilevel modeling to examine associations of community programs and policies in multiple settings and child and community predictors with BMI z scores of children. RESULTS: The mean number of settings in which community policies and programs were implemented was 7.3 per community. Of 130 communities, 31 (23.8%) implemented community programs and policies in multiple settings. Higher-intensity community programs and policies were associated with lower BMI in communities that used multiple settings but not in communities that implemented programs and policies in few settings. CONCLUSION: Efforts to prevent childhood obesity may be more effective when community programs and policies are both intensive and are implemented in multiple settings in which children live, learn, and play.

Weight change before and after adenotonsillectomy in children: An analysis based upon pre-surgery body mass category.

OBJECTIVES: To determine the standardised body mass index (BMIz) trajectory before and after adenotonsillectomy/tonsillectomy between children in different weight classifications in a larger sample than has been studied previously, and to identify which patient factors would explain the difference in these outcomes. DESIGN: We used a retrospective chart review and leveraged data of weight status pre- and post-adenotonsillectomy/tonsillectomy from a cohort of paediatric patients seen between May 2004 and April 2017. SETTING: Data were collected from an electronic medical record at a single Midwest paediatric health system. PARTICIPANTS: The study population included a convenience sample of 1,751 paediatric patients who underwent adenotonsillectomy or tonsillectomy and had at least two height and weight measurements recorded on the same date both before and after surgery. MAIN OUTCOME MEASURES: Change in BMIz trajectories before and after surgery. RESULTS: Of 1751 paediatric patients (ages 3-11) underwent adenotonsillectomy/tonsillectomy procedures. Age at time of surgery and gender were not significant predictors. Children in different weight classifications demonstrated differences in BMIz trajectory after surgery. Children with overweight/obesity experience a decrease in BMIz, whereas children with underweight or normal weight experience an increase in BMIz. CONCLUSIONS: Improvement in weight status is seen after surgery: increased BMI for those underweight and decreased BMI for those with overweight/obesity. We advocate for behavioural strategies as a first-line treatment in children with underweight or overweight/obesity, and results suggest that coordinating these efforts alongside adenotonsillectomy/tonsillectomy when indicated for medical reasons may be warranted. However, further research is needed to confirm these findings due to the observational nature of this study.

The Transgender Identity Survey: A Measure of Internalized Transphobia.

Purpose: We describe the development of a measure of internalized transphobia, defined as discomfort with one's transgender identity as a result of internalizing society's normative gender expectations. Methods: An item pool was created based on responses from a small clinical sample (N = 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18-72, mean [M] = 37.4, standard deviation [SD] = 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18-66, M = 31.6, SD = 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample. Results: EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test-retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity. Conclusion: Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people's health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.

iAmHealthy: Rationale, design and application of a family-based mHealth pediatric obesity intervention for rural children.

Children in rural areas are disproportionately affected by pediatric obesity. Poor access to healthcare providers, lack of nutrition education, lower socioeconomic status, and fewer opportunities to be physically active are all unique barriers that contribute to this growing health concern. There are very few pediatric obesity interventions that have been developed that target this unique population. iAmHealthy is a family-based behavioral, nutrition and physical activity intervention developed with input from rural children and families that capitalizes on the innovative use of mobile health applications (mHealth). iAmHealthy is a 25-contact hour multicomponent intervention delivered over an 8-month period targeting 2nd-4th grade school children and their families. This paper describes the rationale, design, participant/school enrollment, and planned implementation of a randomized controlled trial of the iAmHealthy intervention in comparison to a monthly newsletter delivered through rural elementary schools. Child Body Mass Index z-score (BMIz) is the primary outcome, along with child 24-hour dietary recall, and child accelerometer-determined physical activity and sedentary behavior as secondary outcomes. The study will include 18 schools (with 8 children each) resulting in a final planned sample size of 144 children. This project also has a strong focus on dissemination and implementation science, and thus includes many measures related to the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Data collection is completed at baseline, end of intervention (8 months), and follow-up (20 months). This study is the first randomized controlled trial to deliver a rurally tailored, empirically supported, family-based behavioral intervention for pediatric obesity solely over mHealth. Registered with ClinicalTrials.gov NCT ID 03304249.

Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory.

INTRODUCTION: One of the major obstacles to conducting epidemiologic research and determining the incidence and prevalence of compulsive sexual behavior (CSB) has been the lack of relevant empirically derived cut points on the various instruments that have been used to measure the concept. AIM: To further develop the Compulsive Sexual Behavior Inventory (CSBI) through exploring predictive validity and developing an empirically determined and clinically useful cut point for defining CSB. METHODS: A sample of 242 men who have sex with men was recruited from various sites in a moderate-size Midwestern city. Participants were assigned to a CSB group or a control group using an interview for the diagnosis that was patterned after the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition. The 22-item CSBI was administered as part of a larger battery of self-report inventories. MAIN OUTCOME MEASURES: Receiver operating characteristic analyses were used to compute area-under-the-curve measurements to ascertain the predictive validity of the total scale, the control subscale, and the violence subscale. Cut points were determined through consensus of experts balancing sensitivity and specificity as determined by receiver operating characteristic curves. RESULTS: Analyses indicated that the 22-item CSBI was a good predictor of group membership, as was the 13-item control subscale. The violence subscale added little to the predictive accuracy of the instrument; thus, it likely measures something other than CSB. Two relevant cut points were found, one that minimized false negatives and another, more conservative cut point that minimized false positives. CONCLUSION: The CSBI as currently configured measures two different constructions and only the control subscale is helpful in diagnosing CSB. Therefore, we decided to eliminate the violence subscale and move forward with a 13-item scale that we have named the CSBI-13. Two cut points were developed from this revised scale, one that is useful as a clinical screening tool and the other, more conservative measurement that is useful for etiologic and epidemiologic research. Miner MH, Raymond N, Coleman E, Swinburne Romine R. Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory. J Sex Med 2017;14:715-720.

Anxious Attachment, Social Isolation, and Indicators of Sex Drive and Compulsivity: Predictors of Child Sexual Abuse Perpetration in Adolescent Males?

It has been suggested that child sexual abuse is related to poor attachment to parents, which is associated with an inability to form intimate relationships. Seto and Lalumière indicated that there were too few studies of adolescent males to determine whether poor attachment was associated with perpetration. This study was designed to follow up on a previous study and further explored the association between insecure attachment to parents, social isolation, and interpersonal adequacy to child sexual abuse perpetration in adolescents. We compared two samples of adolescent males who had committed sexual offenses, those who committed offenses against children (n = 140) and those who committed offenses against peer or adults (n = 92), with a sample of similarly aged males in treatment for mental health or substance use issues (n = 93). Data were collected using a semi-structured interview and computer-administered questionnaire. We found an indirect association between anxious attachment and sexual offenses against child victims, which was accounted for by measures of social involvement and social isolation. These involvement and isolation measures also did not have a direct association with sexual offenses against child victims, in that their contribution was accounted for by a measure of Masculine Adequacy. This Masculine Adequacy, combined with decreased levels of Sexual Preoccupation and Hypersexuality and increased Sexual Compulsivity, was associated with commission of child sexual abuse. The interpersonal variables did not enter a model predicting sexual offending against peers/adults, which seemed solely associated with the interaction between Sexual Compulsivity and Hypersexuality.

Prevalence and Health Correlates of Overweight and Obesity in Children with Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) may be at increased risk for overweight and obesity, but little information is known about correlates of overweight and obesity in this population. This study compared prevalence rates of parent-reported overweight and obesity and specific health behaviors (i.e., parent report of child sleep, family meal patterns, child screen time, and child physical activity) among children with ASD (N = more than 900 [weighted to represent 690,000; age 10-17]) compared with children without ASD using data from a nationally representative sample. Additionally, the relationship between specific health behaviors (i.e., child sleep, family meals, screen time, and physical activity) and weight status was examined in the ASD population. Data were from the National Survey of Children's Health 2011-2012. Results indicate that children with ASD were more likely to be obese but not more likely to be overweight than non-ASD youth. Children with ASD engaged in physical activity less than children without ASD, but no differences were found on sleep, most measures of screen time, and mealtimes. However, parent perceived poorer sleep was associated with increased weight status, and fewer family meals were associated with normal weight status among children with ASD.

Role of maternal gesture use in speech use by children with fragile X syndrome.

PURPOSE: The purpose of this study was to investigate how maternal gesture relates to speech production by children with fragile X syndrome (FXS). METHOD: Participants were 27 young children with FXS (23 boys, 4 girls) and their mothers. Videotaped home observations were conducted between the ages of 25 and 37 months (toddler period) and again between the ages of 60 and 71 months (child period). The videos were later coded for types of maternal utterances and maternal gestures that preceded child speech productions. Children were also assessed with the Mullen Scales of Early Learning at both ages. RESULTS: Maternal gesture use in the toddler period was positively related to expressive language scores at both age periods and was related to receptive language scores in the child period. Maternal proximal pointing, in comparison to other gestures, evoked more speech responses from children during the mother-child interactions, particularly when combined with wh-questions. CONCLUSION: This study adds to the growing body of research on the importance of contextual variables, such as maternal gestures, in child language development. Parental gesture use may be an easily added ingredient to parent-focused early language intervention programs.

A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons.

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.

Stigma, mental health, and resilience in an online sample of the US transgender population.

OBJECTIVES: We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population. METHODS: In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations. RESULTS: Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity. CONCLUSIONS: Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.