The Predictive Syndemic Effect of Multiple Psychosocial Problems on Health Care Costs and Utilization among Sexual Minority Women.

Previous studies documenting sexual minority women's disproportionate risk for a range of medical, mental health, and substance use disorders have not provided a predictive framework for understanding their interrelations and outcomes. The present study aimed to address this gap by testing the syndemic effect of co-occurring psychosocial problems on 7-year health care costs and utilization among sexual minority women. The sample was comprised of sexual minority women (N = 341) who were seen at an urban LGBT-affirmative community health center. Medical and mental health care utilization and cost data were extracted from electronic medical records. Demographically adjusted regression models revealed that co-occurring psychosocial problems (i.e., childhood sexual abuse, partner violence, substance use, and mental health distress [history of suicide attempt]) were all strongly interrelated. The presence of these indicators had a syndemic (additive) effect on medical costs and utilization and mental health utilization over 7-year follow-up, but no effect on 7-year mental health costs. These results suggest that the presence and additive effect of these syndemic conditions may, in part, explain increased medical costs and utilization (and higher medical morbidity) among sexual minority women.

Interrelationships between LGBT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities.

Research has documented significant relationships between sexual and gender minority stress and higher rates of suicidality (i.e. suicidal ideation and attempts) and substance use problems. We examined the potential mediating role of substance use problems on the relationship between sexual and gender minority stress (i.e. victimization based on lesbian, gay, bisexual, or transgender identity [LGBT]) and suicidality. A nonprobability sample of LGBT patients from a community health center (N = 1457) ranged in age from 19-70 years. Participants reported history of lifetime suicidal ideation and attempts, substance use problems, as well as experiences of LGBT-based verbal and physical attacks. Substance use problems were a significant partial mediator between LGBT-based victimization and suicidal ideation and between LGBT-based victimization and suicide attempts for sexual and gender minorities. Nuanced gender differences revealed that substance use problems did not significantly mediate the relationship between victimization and suicide attempts for sexual minority men. Substance use problems may be one insidious pathway that partially mediates the risk effects of sexual and gender minority stress on suicidality. Substances might be a temporary and deleterious coping resource in response to LGBT-based victimization, which have serious effects on suicidal ideation and behaviors.

Sexual and gender minority health: what we know and what needs to be done.

We describe the emergence of lesbian, gay, bisexual, and transgender (LGBT) health as a key area of study and practice for clinicians and public health professionals. We discuss the specific needs of LGBT populations on the basis of the most recent epidemiological and clinical investigations, methods for defining and measuring LGBT populations, and the barriers they face in obtaining appropriate care and services. We then discuss how clinicians and public health professionals can improve research methods, clinical outcomes, and service delivery for lesbian, gay, bisexual, and transgender people.

Characteristics and Correlates of Tobacco Use in a Community Sample of Sexual Minority Men and Women: Implications for Smoking Cessation Program Development.

PURPOSE: Tobacco use is the single most preventable cause of disease, death, and disability in the United States. Research suggests that sexual minorities have an increased risk for smoking and tobacco use. This study aimed to identify characteristics of patients affected by tobacco use disparities and examined demographic and substance use differences between tobacco users and nonusers in a sample of sexual minorities. METHODS: Patients at an urban community health center (specializing in the needs of sexual and gender minorities) were invited to complete a cross-sectional 25-item questionnaire. RESULTS: Of the 3068 questionnaire respondents, 1543 identified as gay, lesbian, or bisexual. Of these sexual minority respondents, most identified as White (84.4%), 67.3% identified as male and 32.7% as female, with a mean age of 37.7 (SD = 9.44). More than a quarter of sexual minority men (26.7%) and women (28.3%) reported current tobacco use. Among men, younger age (OR = 0.97, CI: 0.95-0.98, P < 0.001), less education (OR = 0.58, CI: 0.35-0.96, P < 0.01), heroin use (OR = 3.3, CI: 1.18-9.39, P < 0.05), and alcohol use (OR = 3.0, CI: 1.86-4.80, P < 0.001) were associated with increased odds of current tobacco use. Among women, younger age (OR = 0.97, CI: 0.95-0.99, P = 0.004), less education (OR = 0.45, CI: 0.22-0.91, P < 0.001), and alcohol use (OR = 3.78, CI: 1.87-7.65, P < 0.001) were associated with current tobacco use. CONCLUSION: Cessation programs placed within the context of co-occurring substance and alcohol use for young sexual minority tobacco users from lower socioeconomic backgrounds may be particularly effective.

The promise of outreach for engaging and retaining out-of-care persons in HIV medical care.

From the beginning of the HIV/AIDS epidemic, outreach workers have been on the frontlines of HIV prevention, working in community venues to increase knowledge and promote behaviors to reduce HIV transmission. As demographics of the HIV-infected population have changed, the need has grown to locate out-of-care individuals and learn how to engage and retain them in HIV care. Through the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Outreach Initiative, 10 sites across the United States implemented and evaluated enhanced outreach models designed to increase engagement and retention in HIV care for underserved, disadvantaged HIV-infected individuals. Although the models differed in response to local needs and organizational characteristics, all made use of a common conceptual framework, and all used the same data collection and reporting protocols. Study teams enrolled and provided behavioral interventions to HIV-infected individuals who have been noticeably absent from research and from practice. Their interventions incorporated coaching, skills-building, and education, and were successful in reducing or removing structural, financial, and personal/cultural barriers that interfered with equitable access to HIV care. Desired outcomes of increased engagement and retention in HIV health care were achieved. Results demonstrate that interventions to promote equitable access to HIV care for disadvantaged population groups can be built from outreach models. Qualitative and quantitative analysis of the multisite data indicates that further development and evaluation of outreach-based interventions will result in effective tools for reaching HIV-infected individuals who would otherwise remain without needed care.

HIV System Navigation: an emerging model to improve HIV care access.

Little is known about the effectiveness of outreach interventions to engage and retain underserved populations living with HIV in stable, primary medical care. This study provided an opportunity to adapt a patient navigation model first developed for cancer care to assess its effectiveness with HIV-infected disadvantaged populations. Four grantees from the Health Resources and Services Administration (HRSA)-funded Outreach Initiative developed and successfully implemented navigation-like interventions. We examined the effectiveness of these interventions in decreasing barriers to HIV primary medical care and improving health outcomes. The conceptual framework laid out in the 1993 Institute of Medicine report Access to Health Care in America provided a valuable heuristic for guiding the analysis, and we used the model to select measures for the study. A reduction in barriers, improvement in mediators, and improved health outcomes were observed over the 12-month intervention period. Structural barriers to HIV care and provider engagement were significantly associated with health outcomes. Based on study results, we propose that an adapted navigation approach referred to as "HIV System Navigation" has promise for improving access to HIV care and warrants further development.

Healthy Aging in Community for Older Lesbians.

PURPOSE: In Boston and Outer Cape, Massachusetts, we explored the expectations of lesbians 60 years and older regarding healthy aging and community importance. METHODS: Focus groups were conducted with participants after completing an anonymous demographic questionnaire. Thematic analysis was used to generate themes and identify how they varied by urban versus rural settings. RESULTS: Group discussions focused on community, finances, housing, and healthcare. Primary concerns included continued access to supportive and lesbian communities as a source of resilience during aging. CONCLUSION: Concerns about discrimination and isolation mirror themes found in national research. The study findings suggest a need for more research into the housing and transportation needs of lesbians approaching later life, with a focus on how those needs relate to affordability, accessibility, and proximity to social support and healthcare. These findings also suggest the need for substantial investments in strengthening the LGBT-related cultural competence of providers of services for the elderly.

Predictors of Suicidal Ideation in a Statewide Sample of Transgender Individuals.

Transgender individuals experience violence and discrimination, which, in addition to gender transitioning, are established correlates of psychological distress. In a statewide sample of 350 transgender adults, we investigated whether a history of violence and discrimination increased the odds of reporting lifetime suicidal ideation (SI) and whether differences in SI were predicted by gender transition status. Violence, discrimination, and transition status significantly predicted SI. Compared with individuals with no plans to transition, individuals with plans or who were living as their identified gender reported greater odds of lifetime SI. We discuss implications for SI disparities using Meyer's minority stress model.

Sexual minority specific and related traumatic experiences are associated with increased risk for smoking among gay and bisexual men.

OBJECTIVE: This study examined the hypothesis that sexual minority specific stress and trauma histories may explain some of the risk for smoking among gay/bisexual men. METHODS: Patients at a Boston community health center were invited to complete a 25-item questionnaire assessing demographics, general health, trauma history, and substance use. Of the 3103 who responded, 1309 identified as male and gay or bisexual (82.8% White and mean age of 38.55 [sd = 9.76]). RESULTS: A multinomial logistic regression with never smoked as referent group and covariates of age, education, employment, HIV status, and race, showed that the number of sexual minority stressors/traumas were significantly related to the odds of both current and former smoking. In comparison to participants with no trauma history, those who reported 1, 2, 3, and 4 traumas had respectively 1.70 (OR = 1.70: 95% CI: 1.24-2.34), 2.19 (OR = 2.19: 95% CI: 1.48-3.23), 2.88 (OR = 2.88: 95% CI: 1.71-4.85), and 6.94 (OR = 6.94: 95% CI: 2.62-18.38) the odds of identifying as a current smoker. Adjusted logistic regression analysis revealed a significant dose effect of number of sexual minority stressors/traumas with odds of ever smoking. Experiencing intimate partner violence, anti-gay verbal attack, anti-gay physical attack, and childhood sexual abuse were each independently associated with increased odds of the smoking outcomes. CONCLUSION: A sexual minority specific trauma history may represent a vulnerability for smoking among gay/bisexual men. Interventions that address trauma may enhance the efficacy of smoking cessation programs and improve the mental health of gay/bisexual men.

Intersecting identities and substance use problems: sexual orientation, gender, race, and lifetime substance use problems.

OBJECTIVE: Research has documented that sexual minorities are at greater risk for substance use than heterosexuals. However, there are limited studies and mixed findings when investigating these health disparities among racial and ethnic minority samples. We used an intersectionality framework to examine disparities in lifetime substance use problems between heterosexual and sexual minority men and women and within sexual minority groups among a racially diverse sample. METHOD: A nonprobability sample of heterosexual (n = 1,091) and sexual minority (n = 1,465) patients from an urban community health center ranged in age from 18 to 72 years. Participants completed a brief patient survey and reported demographic information and history of lifetime substance use problems. Logistic regressions analyses were used to examine interactions between and among sexual orientation, gender, and race. RESULTS: We found a significant three-way interaction among sexual orientation, gender, and race. Sexual minorities had a greater risk of self-reported lifetime substance use problems than heterosexuals, with nuanced gender and racial differences. Of greatest note, sexual minority women of color had greater risks than heterosexual women of color and than White sexual minority women. Sexual minority men of color did not differ in their risk when compared with heterosexual men of color, and they had lower risk than White sexual minority men. CONCLUSIONS: The results of this study demonstrate that an intersectionality framework is crucial to clearly identify lifetime substance use disparities between racially diverse sexual minority and heterosexual men and women. Future research, treatment, and policy should use intersectionality approaches when addressing substance use disparities.

Transgender Health Disparities: Comparing Full Cohort and Nested Matched-Pair Study Designs in a Community Health Center.

PURPOSE: U.S. health surveillance systems infrequently include measures to identify transgender respondents or monitor the health of this underserved and marginalized population. METHODS: From 2001-2002, transgender and non-transgender adults were sampled at a Massachusetts clinic. Health differences were formatively examined by transgender identity using a cross-sectional, clinic-based sample (n=2,653); and a nested matched-pair subsample (n=155). RESULTS: Both designs produced virtually identical findings: (1) the prevalence of HIV, substance abuse, and smoking did not differ significantly for transgender and non-transgender patients; (2) transgender patients were more likely to endorse a lifetime suicide attempt and ideation compared to non-transgender patients (p<0.05); (3) transgender patients disproportionately reported social stressors (violence, discrimination, childhood abuse) relative to non-transgender patients (p<0.05). CONCLUSION: Findings suggest that a nested design may provide an effective methodology for using clinical data to study transgender health, and underscore the need for routine collection of gender identity in clinical settings.

Sexual risk behavior and behavior change among persons newly diagnosed with HIV: the impact of targeted outreach interventions among hard-to-reach populations.

The secondary effect of a national, targeted, outreach initiative in reducing sexual risk behavior among newly diagnosed persons living with HIV/AIDS (PLWHA) was examined in the present study. The findings propose an optimal number of outreach program contacts associated with a change in sexual risk behavior. The primary goal of the initiative was to implement and evaluate strategies to engage and retain underserved populations (PLWHA) in HIV primary medical care. Participants from 10 sites nationwide were enrolled in outreach interventions from 2004 to 2005 that were designed to engage and retain hard-to-reach PLWH in care. The study population in the subanalysis performed was predominantly male, people of color, sexual minorities; mean age of 32, and 31% reported no visits to an HIV health provider since testing positive. The study design was prospective and nonrandomized; 116 newly diagnosed individuals reported on unprotected sex at baseline, 6-, and 12-month interviews. The proportion of individuals reporting unprotected sex postintervention was reduced significantly compared to baseline. Postbaseline, individuals were 80% less likely to report unprotected sex. Additionally, individuals with 1-3 program contacts per month were 80 times less likely to report risky sexual behavior compared to those with 2 or less contacts (adjusted odds ratio [AOR] = 0.20). Substantial risk exists for secondary HIV transmission; this study shows the promise of a supplemental intervention to ensure access to HIV care, retention in care, and risk reduction for positives.