Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.

Transgender Youths and Sanctuaries for Gender-Affirming Care.

This Viewpoint suggests ways state and local governments can support transgender youths seeking gender-affirming care amid continued passage of antitransgender legislation.

The role of sleep duration in suicide risk among sexual and gender minority adolescents.

BACKGROUND: Short sleep duration is linked with suicide risk in adolescence. Sexual and gender minority (SGM) adolescents experience substantially increased risk for suicide compared to their non-SGM peers. METHODS: We investigated the role of sleep duration in SGM adolescent suicide risk using population-based, cross-sectional data from the 2022 Minnesota Student Survey (MSS; N = 85,610, Mage = 14.8). Adolescents reported average school-night sleep duration; those reporting <6 h were classified as having very short sleep duration. The MSS additionally assessed past-year suicidal ideation and suicide attempt. Mediation analyses assessed the role of sleep duration in explaining associations between SGM identity and suicide risk. Further, to examine intervention mechanisms, among SGM adolescents (n = 20,171, 23.6%), a logistic regression model assessed associations among demographic factors, perceived parental care, and very short sleep duration. RESULTS: As compared to non-SGM adolescents, SGM adolescents reported substantially higher prevalence of past-year suicidal ideation and suicide attempt and 2.6× higher prevalence of very short sleep duration (all p < 0.001). Mediation analyses demonstrated that very short sleep duration partially mediated the pathway between SGM identity and past-year suicidal ideation (15.5% mediated) and suicide attempt (17.2% mediated). Among SGM adolescents, a striking positive dose-response relationship was observed between level of perceived parental care and very short sleep duration. As perceived parental care decreased, so too did hours of sleep. DISCUSSION: Sleep duration is a crucial and understudied mechanism underlying suicide risk disparities affecting SGM adolescents. Family-based interventions may improve SGM adolescent sleep and reduce suicide risk.

Do supportive work environments matter for minority aging? Work stress and subjective cognitive impairment among middle-age and older lesbian, gay, bisexual, transgender, and queer adults.

Research has documented how people's experiences at work affect their cognitive health outcomes, but how these processes unfold for minority groups, particularly lesbian, gay, bisexual, transgender, and queer (LGBTQ+) populations, is unclear. This study builds on the nascent literature by employing generalized structural equation models to test how experiencing major problems at work and working with LGBTQ+ supportive coworkers affect subjective cognitive impairment among middle-age and older LGBTQ+ adults. We also test for mediated and indirect effects of support and problems at work operating via vascular disease, sleep problems, and depression symptoms. Experiencing major problems at work is associated with a higher likelihood of reporting cognitive symptoms consistent with mild cognitive impairment, but this relationship is mediated by depression symptoms and sleep problems. Having LGBTQ+ supportive coworkers does not have direct effects on mild cognitive impairment, but does operate indirectly by decreasing problems at work and, in turn, decreases the likelihood of reporting cognitive symptoms consistent with mild cognitive impairment. Overall, we find that workplace stressors contribute to cognitive health directly and through mediated and indirect pathways and that supportive contexts reduce exposure to problems at work. We conclude with suggested possibilities to reorganize workplaces to improve long-term cognitive health outcomes for older adults, especially those who are LGBTQ+-identified.

Political network composition predicts vaccination attitudes.

Political polarization is growing rapidly in the United States and has been linked to politicized public health issues including vaccination. Political homogeneity among one's interpersonal relationships may predict polarization levels and partisan bias. In this study, we analyzed if political network structure predicted partisan beliefs about the COVID-19 vaccine, beliefs about vaccines in general, and COVID-19 vaccine uptake. Personal networks were measured by whom the respondent discussed "important matters" with to obtain a list of individuals who are close to the respondent. The number of associates listed who share the political identity or vaccine status with the respondent was calculated as a measure of homogeneity. We find that having more Republicans and unvaccinated individuals in one's network predicted lower vaccine confidence whereas having more Democrats and vaccinated individuals in one's network predicted higher vaccine confidence. Exploratory network analyses revealed that non-kin others are especially impactful on vaccine attitudes when those network connections are also Republican and unvaccinated.

Trends in paediatric firearm-related encounters during the COVID-19 pandemic by age group, race/ethnicity and schooling mode in Tennessee.

BACKGROUND: Increases in paediatric firearm-related injuries during the COVID-19 pandemic may be due to changes in where children and adolescents spent their time. This study examines changes in the frequency of paediatric firearm-related encounters as a function of schooling mode overall and by race/ethnicity and age group at a large trauma centre through 2021. METHODS: We use data from a large paediatric and adult trauma centre in Tennessee from January 2018 to December 2021 (N=211 encounters) and geographically linked schooling mode data. We use Poisson regressions to estimate smoothed monthly paediatric firearm-related encounters as a function of schooling mode overall and stratified by race and age. RESULTS: Compared with pre pandemic, we find a 42% increase in paediatric encounters per month during March 2020 to August 2020, when schools were closed, no significant increase during virtual/hybrid instruction, and a 23% increase in encounters after schools returned to in-person instruction. The effects of schooling mode are heterogeneous by patient race/ethnicity and age. Encounters increased among non-Hispanic black children across all periods relative to pre pandemic. Among non-Hispanic white children, encounters increased during the closure period and decreased on return to in-person instruction. Compared with pre pandemic, paediatric firearm-related encounters increased 205% for children aged 5-11 and 69% for adolescents aged 12-15 during the school closure period. CONCLUSION: COVID-19-related changes to school instruction mode in 2020 and 2021 are associated with changes in the frequency and composition of paediatric firearm-related encounters at a major trauma centre in Tennessee.

LGBTQ College student health and wellbeing at the onset of the pandemic: additional evidence and lessons learned from COVID-19.

BACKGROUND: The coronavirus (COVID-19) pandemic has killed more than six million people and disrupted health care systems globally. In the United States alone, more than one million people have died from COVID-19 infections. At the start of the pandemic, nearly all aspects of our lives paused to prevent the spread of the novel coronavirus. Many institutions of higher education transitioned to remote learning and enacted social distancing measures. This study examined the health needs and vulnerabilities of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) college students at the start of the COVID-19 pandemic in the United States. METHODS: We fielded a rapid-response online survey between April and June of 2020. We recruited 578 LGBTQ-identifying college students aged 18 years and older by reaching out to LGBTQ-serving organizations on 254 college campuses and via targeted social media advertising. RESULTS: Approximately 40% of LGBTQ college students surveyed were dissatisfied with life at the start of the COVID-19 pandemic, and almost all (90%) were concerned that COVID-19 would threaten their mental health. Moreover, about 40% of LGBTQ college students reported unmet mental health needs, and 28% were worried about seeking care during the pandemic because of their LGBTQ identity. One out of four LGBTQ college students had to go back in the closet because of the pandemic, and approximately 40% were concerned about their finances or personal safety during the COVID-19 pandemic. Some of these adverse outcomes were prominent among younger students, Hispanic/Latinx students, and students with unsupportive families or colleges. CONCLUSIONS: Our study adds novel findings to the large body of research demonstrating that LGBTQ college students experienced distress and elevated mental health needs early in the pandemic. Future research should examine the long-term consequences of the pandemic among LGBTQ and other minoritized college students. Public health policymakers, health care providers, and college and university officials should provide LGBTQ students affirming emotional supports and services to ensure their success as the COVID-19 pandemic transitions to endemic.

Sexual Behavior Change Among Gay and Bisexual Men During the First COVID-19 Pandemic Wave in the United States.

Background: After decades of navigating HIV and other sexually transmitted infections, gay and bisexual men are responding to new and uncertain risks presented by the coronavirus (COVID-19) pandemic by adapting their sexual behavior. Methods: This paper uses data from a national sample of 728 gay and bisexual men collected from April 10 to May 10, 2020, to examine changes to sexual behavior in response to the first wave of the pandemic in the USA. We also assess whether behavior modifications are associated with exposure to statewide public health measures, including Stay-at-Home orders. Results: Sexual minority men report significant changes to their sexual behavior and partner selection during the first wave. Nine out of 10 men reported having either one sexual partner or no sexual partner in the last 30 days at the time of interview, a decrease compared to just before the pandemic for nearly half of men surveyed. Reporting no sexual partners in the last 30 days was significantly predicted by increased exposure to a Stay-at-Home order. Sexual minority men also reduced interactions with casual partners, increased no-contact sexual behaviors (e.g., masturbation and virtual sex), and engaged in new strategies to reduce their risks of infection from partners. HIV-positive men were particularly likely to adopt strategies including avoiding casual partners and avoiding public transportation to meet sexual partners. Conclusion: Sexual minority men's behavior changes during the first wave may have reduced the impact of the coronavirus pandemic on their communities. Despite substantial changes in sexual behavior for most men in our sample during the initial first wave, we identify some concerns around the sustainability of certain behavioral changes over time and nondisclosure of COVID-19 symptoms to partners.

Association of Sexual Orientation with Exposure to Suicide and Related Emotional Distress among US Adults.

OBJECTIVE: Suicide bereavement is a significant public health concern. Using nationally representative survey data, we quantify sexual orientation differences in frequency of suicide exposure and suicide exposure-related emotional distress among US adults. METHODS: We used cross-sectional data from the 2016 General Social Survey (GSS) and included sexual minority (i.e., lesbian, gay, bisexual; (n = 74, 5.3%) and heterosexual (n = 1,207, 94.7%) adults. The GSS asked several questions related to suicide exposure including number of lifetime suicide exposures, emotional distress related to suicide exposure, time elapsed since suicide exposure, and relationship(s) and perceived closeness to the person(s) who died. We use descriptive statistics to describe differences in suicide exposure characteristics across sexual orientation. Among those who were exposed to at least one suicide (n = 698, 51.1%), a weighted multivariable logistic regression model examined the association between sexual orientation and suicide exposure-related emotional distress adjusting for confounders. RESULTS: Sexual minorities reported a similar number of lifetime suicide exposures and were not significantly different from heterosexuals on other suicide exposure characteristics. However, sexual minority, compared to heterosexual, respondents experienced 3.14 greater odds of severe emotional distress related to suicide exposure (95% CI = 1.42-6.94, p = .005). CONCLUSION: Perhaps due to stigmatizing mourning experiences, sexual minority adults are particularly vulnerable to severe suicide exposure-related emotional distress. Future research to understand the scope of sexual minority-specific bereavement support services and public policies (e.g., bereavement leave) as well as intervention development to support sexual minority adults' coping in the wake of suicide exposure is warranted. HIGHLIGHTSApproximately half of sexual minority US adults report a lifetime suicide exposureSexual minority adults experience more severe suicide exposure-related emotional distressPostvention care should be tailored to meet the needs of sexual minority adults.

Association of Affirming Care with Chronic Disease and Preventive Care Outcomes among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults.

INTRODUCTION: Experiences of discrimination and bias in healthcare contribute to health disparities for lesbian, gay, bisexual, transgender, and queer populations. To avoid discrimination, many go to great lengths to find healthcare providers who they trust and who are knowledgeable about their health needs. This study examines whether access to an affirming provider improves health outcomes for lesbian, gay, bisexual, transgender, and queer populations across a range of preventive health and chronic disease management outcomes. METHODS: This cross-sectional study uses Poisson regression models to examine original survey data (n=1,120) from Wave 1 of the Vanderbilt University Social Networks, Aging, and Policy Study, a panel study examining older (aged 50-76 years) lesbian, gay, bisexual, transgender, and queer adults' health and aging, collected between April 2020 and September 2021. RESULTS: Overall, access to an affirming provider is associated with greater uptake of preventive health screenings and improved management of mental health conditions. Participants with an affirming provider are more likely to have ever and recently received several types of preventive care than participants reporting a usual source of care that is not affirming, including past year provider visit, influenza vaccination, colorectal cancer screening, and HIV test. Access to an affirming provider is also associated with better management of mental health conditions. CONCLUSIONS: Inclusive care is essential for reducing health disparities among lesbian, gay, bisexual, transgender, and queer populations. Health systems can reduce disparities by expanding continuing education opportunities; adopting nondiscrimination policies for patients and employees; and ensuring that necessary care is covered by health insurance.

LGBTQ+ Affirming Care May Increase Awareness and Understanding of Undetectable = Untransmittable among Midlife and Older Gay and Bisexual Men in the US South.

One of the most significant innovations in HIV prevention is the use of HIV treatment to prevent HIV transmission. This information has been disseminated as the "Undetectable = Untransmittable" (U = U) message. Despite evidence of effectiveness, U = U awareness, belief, and understanding remains limited in some communities. In this study, we examine whether having an LGBTQ affirming healthcare provider increases U = U awareness, belief, and understanding among midlife and older gay and bisexual men in the US south, an understudied and underserved population and region where new HIV infections are increasing. We used data from the Vanderbilt University Social Networks Aging and Policy Study (VUSNAPS) on sexual minority men aged 50 to 76 from four southern US states collected in 2020-2021. We found that only one in four men reported prior awareness of U = U, but awareness was higher among men who have an LGBTQ affirming provider. Among HIV negative men, those with an affirming provider were more likely to believe and understand U = U, have more accurate risk perception, and have ever tested for HIV. Improving access to LGBTQ affirming healthcare may improve U = U awareness, belief, and understanding, which could help to curb HIV transmission in the US south.

Network loss following the 2016 Presidential Election among LGBTQ+ adults.

Growing levels of political polarization in the United States have been associated with political homogeneity in the personal networks of American adults. The 2016 Presidential Election in the United States was a polarizing event that may have caused further loss of connections to alters who had different politics. Kinship may protect against loss of politically different ties. Additionally, loss of ties with different political views may be particularly pronounced among LGBTQ+ people as they are more likely to be impacted by public policy decisions compared to their heterosexual counterparts. We analyzed two waves of the University of California, Berkeley Social Networks Study's (UCNets) Main Sample and LGBTQ+ Oversample of older adults that occurred in 2015 and 2017, which provided an opportunity to assess alter loss after the 2016 Presidential Election. When evaluating all adults, we found that politically different alters were more likely to reflect kin ties than partner or friend ties. We also found that politically different kin are less likely to be dropped suggesting that kinship acts as a moderating effect of different political views on alter loss. LGBTQ+ respondents were more likely to drop kin alters with different political views than their cisgender heterosexual counterparts. We discuss the implications these results have for political polarization interventions as well as the social networks impact politics can have on LGBTQ+ individuals.

Effects of the Affordable Care Act Dependent Coverage Mandate on Health Insurance Coverage for Individuals in Same-Sex Couples.

A large body of research documents that the 2010 dependent coverage mandate of the U.S. Affordable Care Act was responsible for significantly increasing health insurance coverage among young adults. No prior research has examined whether sexual minority young adults also benefitted from the dependent coverage mandate despite previous studies showing lower health insurance coverage among sexual minorities. Our estimates from the American Community Survey, using difference-in-differences and event study models, show that men in same-sex couples aged 21-25 experienced a significantly greater increase in the likelihood of having any health insurance after 2010 than older, 27- to 31-year-old men in same-sex couples. This increase is concentrated among employer-sponsored insurance, and it is robust to permutations of periods and age groups. Effects for women in same-sex couples and men in different-sex couples are smaller than the associated effects for men in same-sex couples. These findings confirm the broad effects of expanded dependent coverage and suggest that eliminating the federal dependent mandate could reduce health insurance coverage among young adult sexual minorities in same-sex couples.

Structural competency and the future of firearm research.

In this critical literature review we develop a five-part agenda for pandemic-era research into mass shootings and multiple-victim homicides that promotes understanding the psychologies of individual shooters within larger structures and systems. We show how the momentous events set in motion by the COVID-19 virus, and the structural drivers of inequity and racism that its spread exposed, challenge mental health research on gun trauma to better account for broader terrains of race and place, as well as the tensions, politics, and assumptions that surround guns in the U.S. more broadly. Doing so will broaden mental-health interventions into epidemics of U.S. gun trauma, and challenge mental health research better recognize structural biases inherent in its own purview. We frame the agenda through the rubric of structural competency, an emerging framework that systematically trains health care professionals and others to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases. Developing a structural framework around research into U.S. gun violence addresses the risks, traumas, meanings, and consequences that firearms represent for all communities-and highlights the importance of a renewed focus on mental health and safety for communities of color. Recognizing how gun violence reflects and encapsulates structures helps mental health experts address common sense gun policies within broader contexts-by fighting against structural racism or racially inflected gun policies for instance, or against economic policies that undermine access to mental health care more broadly.

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence.

ABSTRACT: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

Mental Health Needs Among Lesbian, Gay, Bisexual, and Transgender College Students During the COVID-19 Pandemic.

PURPOSE: The abrupt closure of universities across the U.S. in March 2020 may have sent some lesbian, gay, bisexual, and transgender (LGBT) college students home to unsafe or unaccepting families and environments. The objective of this study was to examine the mental health needs of LGBT college students in the U.S. during the COVID-19 pandemic. METHODS: We fielded a rapid-response online survey in the spring of 2020. We recruited 477 LGBT-identifying college students aged 18-25 years by contacting LGBT-serving organizations on 254 college campuses and through targeted social media advertising. RESULTS: Nearly half (45.7%) of LGBT college students have immediate families that do not support or know their LGBT identity. Approximately 60% of sampled LGBT college students were experiencing psychological distress, anxiety, and depression during the pandemic. CONCLUSIONS: Health-care providers, college and university administrators, and campus counseling centers should take swift action to ensure that LGBT students receive mental health support during the pandemic.

Disparities in Health Insurance Coverage and Access to Care for Children By Mother's Sexual Orientation.

OBJECTIVE: Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health insurance status, access to care, and health services utilization for children by mother's sexual orientation. METHODS: We used data on children with lesbian mothers (n = 195), bisexual mothers (n = 299), and heterosexual mothers (n = 23,772) in the 2013-2017 National Health Interview Survey. Logistic regression models were used to compare health insurance status, access to care, and health services utilization while adjusting for demographic and socioeconomic characteristics of the child, mother, and household. RESULTS: After controlling for sociodemographic factors, there were no statistically significant differences in health insurance coverage, access to care, or health services utilization between children of lesbian mothers and children of heterosexual mothers. Compared to children with heterosexual mothers, children with bisexual mothers were more likely to have public health insurance (OR 2.33; 95% CI 1.07-7.68), delayed medical care due to cost (OR 2.33; 95% CI 1.12-4.86), unmet medical care due to cost (OR 2.86; 95% CI 1.07-7.68), and a visit to the emergency room (OR 1.74; 95% CI 1.27-2.39) in the prior year after controlling for child-level characteristics. Some of these differences were attenuated after controlling for maternal demographics and household characteristics. CONCLUSIONS FOR PRACTICE: Children with bisexual mothers experience barriers to routine medical care. Addressing socioeconomic dimensions of health care access and targeted outreach to bisexual parents will help promote health equity for children growing up in sexual minority households.

Beyond Health Effects?: Examining the Social Consequences of Community Levels of Uninsurance Pre-ACA.

The lack of health insurance is traditionally considered a problem faced by individuals and their families. However, because of the geographically bounded organization and funding of healthcare in the United States, levels of uninsurance in a community may affect everyone living there. Health economists have examined how the effects of uninsurance spillover from the uninsured to the insured, negatively affecting healthcare access and quality for the insured. We extend research on uninsurance into the domain of sociologists by theorizing how uninsurance might exacerbate social inequalities and undermine social cohesion within communities. Using data from the Los Angeles Family and Neighborhood Survey, we show that individuals living in communities with higher levels of uninsurance report lower social cohesion net of other individual and neighborhood factors and discuss implications for implementation of the Affordable Care Act.

What an Emerging Trump Administration Means for Lesbian, Gay, Bisexual, and Transgender Health.

The policies of the Trump administration are likely to have direct and indirect implications for lesbian, gay, bisexual, and transgender (LGBT) health. With the assistance of a Republican-controlled Congress, President Trump may repeal President Obama's health reform law, undermine same-sex marriage laws and other nondiscrimination protections, reduce funding for research on sexual and gender minority health, and institutionalize discrimination through new legislation, such as the First Amendment Defense Act. Public health researchers, healthcare providers, and professional organizations must continue to combat discrimination and advocate for LGBT health equity under an emerging Trump presidency.