General self-efficacy as a mediator of the association between adverse childhood experiences and psychological distress in gender-minority individuals.

PURPOSE: To investigate the mediating role of general self-efficacy (i.e., belief in one's competence to cope with a broad range of stressful or challenging demands) in the relationship between adverse childhood experiences (ACEs) and psychological distress (i.e., symptoms of stress, anxiety and depression) in gender minority individuals, which include people with a gender identity that is not aligned with their sex assigned at birth. DESIGN AND METHODS: The study sample included gender minority participants who participated in Waves 4 and 5 of Project AFFIRM, a multi-site longitudinal study of gender minority health. ACEs, general self-efficacy, and psychological distress were measured using the Behavior Risk Factor Surveillance System ACE Module at Wave 4, the PROMIS General self-efficacy measure at Wave 4, and the Brief Symptoms Inventory Global Severity Index (GSI) at Wave 5, respectively. After adjustment for covariates, including age, race, sex assigned at birth, and income, multivariable linear regression analyses were conducted to assess each component of the proposed mediation model. Next, mediation analyses were used to determine whether general self-efficacy mediated the association between ACEs and psychological distress. FINDINGS: The sample for this study consisted of 166 gender minority adults with a mean age of 38.6 ± 12.2 years. Most were non-Hispanic White (46.4%) and female assigned at birth (59.6%). Mean ACEs score was 3.2 ± 2.1 (range 0-8), mean general self-efficacy score was 13.9 ± 3.6 (range 4-20), and mean raw-score GSI was 17.3 ± 13.7 (range 0-64). Participants who reported experiencing more ACEs had greater psychological distress (B 1.60; 95% CI = 0.66, 2.54) and lower general self-efficacy (B -0.41; 95% CI = -0.67, -0.15). In addition, lower general self-efficacy was associated with higher psychological distress (B -1.06; 95% CI = -1.61, -0.51). Bootstrap estimation of the indirect effect was significant (95% CI = 0.14, 0.90) and explained 27.1% (95% CI = 7.76, 69.76) of the total effect of ACEs on psychological distress in gender minority adults. CONCLUSIONS: Our findings suggest that general self-efficacy partially mediated the positive association between ACEs and psychological distress in gender minority adults. Interventions that aim to improve general self-efficacy may be beneficial in alleviating psychological distress in gender minority adults. CLINICAL RELEVANCE: Nurses can play an important role in reducing the health risks associated with ACEs by screening gender minority individuals using a trauma-informed approach to care and offering resources and referrals, as appropriate.

Sexual Identity Differences in Health Behaviors and Weight Status among Urban High School Students.

Although racial/ethnic disparities in childhood obesity are well documented in the United States (U.S.), fewer studies have investigated elevated body mass index (BMI) and related health behaviors among sexual minority youth (SMY; gay/lesbian, bisexual, not sure). We examined pooled data from the 2009-2017 Youth Risk Behavior Surveys, which included high school students from 12 urban U.S. school districts. We used sex-stratified logistic regression models to estimate the association of sexual identity with health behaviors and elevated BMI (reference = heterosexual participants). A total of 133,615 participants were included. Sexual minority boys were more likely to report physical inactivity than heterosexual boys. Gay and not sure boys were also less likely to consume the recommended daily intake of fruit. Bisexual girls were more likely than heterosexual girls to report watching television ≥ 3 hours on a school day and to consume sugar-sweetened beverages (AOR 1.30, 95% CI= 1.18-1.43). All SMY reported higher rates of current tobacco use than their heterosexual peers. Sexual minority girls and bisexual boys had significantly higher rates of obesity than their heterosexual counterparts. These findings can inform tailored health promotion initiatives to reduce obesity risk in SMY.

Assessing gender identity differences in cardiovascular disease in US adults: an analysis of data from the 2014-2017 BRFSS.

The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014-2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05-1.72) and transgender men (AOR 1.54, 95% CI 1.07-2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05-1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34-2.68), stroke (AOR 1.88, 95% CI 1.16-3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14-4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14-6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01-1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.

NINR funding dedicated to sexual and gender minority health: 1987-2018.

BACKGROUND: Despite multiple federal initiatives and calls to action, nursing literature on the health of sexual and gender minority (SGM) populations remains sparse. Low levels of funding for SGM-focused research may be a factor. PURPOSE: To examine the proportion and focus of National Institute of Nursing Research (NINR)-funded projects that address SGM health, the number and type of publications arising from that funding, and the reach of those publications over time. METHODS: NINR-funded grants focused on SGM research and bibliometrics of resultant publications were identified using multiple search strategies in NIH RePORTER and PubMed and Scopus, respectively. FINDINGS: Since 1987, NINR has funded 25 projects addressing the health of SGM populations. Pre-doctoral fellowship funding resulted in more publications in nursing journals than research grant funding. DISCUSSION: There are clear differences in patterns of funding for fellowships and research grants with corresponding differences in publications and impact on the nursing literature.

Sexual and gender minority health research in nursing.

BACKGROUND: Sexual and gender minorities (SGMs) experience substantial health disparities. Evidence suggests nurses may be unprepared to work with these populations. A previous literature review of top-ranked nursing journals found that 0.16% of published articles addressed SGM health. PURPOSE: To evaluate changes in coverage of SGM health in the top-ranked nursing journals since the earlier review using a scoping approach. METHODS: Electronic search of articles published between December 2009 and December 2017 in 20 nursing journals with the highest 5-year impact factors. FINDINGS: Thirty-three articles (0.19%) in the top-ranked nursing journals focused on SGM health. There is increasing attention to SGM health recently, evidenced by the numbers of empirical and nonempirical research articles published, as well as nonresearch articles about SGM health. DISCUSSION: In light of well-documented health disparities affecting SGM people, it is essential that nurses continue to conduct and disseminate research related to the health of these populations.

Sexual and Gender Minority Sleep Health Disparities and Minority Stress in Early Adolescence.

PURPOSE: Sleep is essential to adolescent development. Sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender) adults are at high risk for poor sleep, partially due to minority stress (e.g., discrimination). However, sleep has rarely been studied among SGM adolescents. In a national sample of early adolescents, we analyzed sexual minority (SM) and gender minority (GM) identity, gender incongruence, and gender nonconformity in association with sleep and tested minority and general stressors as mediators. METHODS: We cross-sectionally analyzed data from 10,070 adolescents aged 10-14 in the Adolescent Brain Cognitive Development℠ Study. Using logistic regression models, we analyzed associations between identity (SM and GM), sexual identity discrimination, minority and general stressors (sexual identity discrimination, teasing, and conflict with parents) and sleep health (duration, latency, and disturbance). We used Baron and Kenny's method to test for mediation. RESULTS: Participants reported sexual identity (4% SM, 4% questioning) and gender identity (0.4% GM, 0.6% questioning); 65% were White, 20% were Hispanic, and 52% were assigned male at birth. Compared to heterosexual, SM participants had higher odds of short sleep duration, long sleep latency, and sleep disturbance. GM participants and those reporting gender incongruence and nonconformity had higher odds of long sleep latency and sleep disturbance. Sexual identity discrimination and general social stressors partially mediated some associations. DISCUSSION: SGM participants reported poorer sleep. Minority and general social stressors partially accounted for some disparities. Policies need to address SGM identity-based discrimination and challenge social norms that produce minority stress for SGM early adolescents.

Weight Stigma and Mental and Emotional Health Among Sexual and Gender Minority Individuals: A Scoping Review.

Purpose: Weight stigma is associated with poor mental and emotional health and may be especially harmful to sexual and gender minority (SGM) individuals due to co-occurring minority stress. The literature on this topic has not been synthesized. We conducted a scoping review of the literature on weight stigma and mental and emotional health among SGM individuals to synthesize findings, highlight gaps, and identify clinical and research implications. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, we searched PubMed, CINAHL, PsycINFO, and Scopus in April 2022. Included studies examined the relationship between weight stigma and mental and emotional health among SGM people of any age. We did not restrict study design or publication date. Results: Of 513 records identified, 23 met inclusion criteria. Most focused on sexual minority individuals; one focused specifically on gender minority individuals. Weight stigma was associated with poorer mental and emotional health in nearly all studies. The most common outcomes examined were self-esteem, maladaptive eating, and depressive symptoms. Five studies, all using the same dataset, focused on adolescents; none focused on older adults. Conclusions: Weight stigma is associated with poorer mental and emotional health among SGM individuals and, through its intersections with minority stress, might impact SGM individuals differently than their cisgender and heterosexual counterparts. There are important gaps regarding weight stigma's effect on SGM adolescents and gender minority individuals and its relationship with a broader range of mental and emotional health outcomes.

Prevalence of substance use and mental health problems among transgender and cisgender U.S. adults: Results from a national probability sample.

Transgender individuals experience numerous health disparities relative to cisgender individuals. However, most transgender-health studies have focused on convenience samples with limited generalizability. This study utilized data from the 2016-2018 TransPop Study, the first national probability sample of transgender adults (n=274) with a cisgender comparison sample (n=1162). Using multivariable logistic regression, adjusted for demographics, we compared the prevalence of hazardous drinking, problematic drug use, serious psychological distress, suicidality, and non-suicidal self-injury between transgender and cisgender individuals and among transgender men (n=78), transgender women (n=120), and transgender nonbinary individuals (n=76). Among transgender individuals, 28.2% (95%CI 21.2-35.2) and 31.2% (95%CI 23.8-38.7) reported hazardous drinking and problematic drug use, respectively; 44.4% (95% CI 35.8-53.0) reported recent suicidal ideation, 6.9% (95% CI 2.3-11.5) reported a recent suicide attempt, and 21.4% (95% CI 14.5%-28.4%) reported recent non-suicidal self-injury. In their lifetime, 81.3% (95%CI 75.1-87.5) of transgender respondents had suicidal ideation, 42.0% (95%CI 34.2-49.8) had attempted suicide, and 56.0% (95% CI 48.2-63.8) reported non-suicidal self-injury. Most (81.5%; 95%CI 75.5-87.5) had utilized formal mental health care and 25.5% (95%CI 18.5-32.4) had sought informal mental health support. There were no differences in alcohol or drug-use outcomes between transgender and cisgender adults. Compared to cisgender adults, transgender adults had higher odds of serious psychological distress (aOR=3.1; 95%CI 1.7-5.7), suicidal ideation (recent: aOR=5.1, 95%CI 2.7-9.6); lifetime: aOR=6.7, 95%CI 3.8-11.7), lifetime suicide attempts (aOR=4.4, 95%CI 2.4-8.0), and non-suicidal self-injury (recent: aOR=13.0, 95%CI 4.8-35.1); lifetime: aOR=7.6, 95%CI 4.1-14.3). Transgender nonbinary adults had the highest odds for all outcomes, including substance use outcomes. Findings from these national probability samples support those of earlier convenience-sample studies showing mental health disparities among transgender adults relative to cisgender adults, with nonbinary individuals at highest risk. These findings also highlight variations in risk across sub-groups of transgender individuals.

The messiness of the menstruator: assessing personas and functionalities of menstrual tracking apps.

OBJECTIVE: The aim of this study was to examine trends in the intended users and functionalities advertised by menstrual tracking apps to identify gaps in personas and intended needs fulfilled by these technologies. MATERIALS AND METHODS: Two types of materials were collected: a corpus of scientific articles related to the identities and needs of menstruators and a corpus of images and descriptions of menstrual tracking apps collected from the Google and Apple app stores. We conducted a scoping review of the literature to develop themes and then applied these as a framework to analyze the app corpus, looking for alignments and misalignments between the 2 corpora. RESULTS: A review of the literature showed a wide range of disciplines publishing work relevant to menstruators. We identified 2 broad themes: "who are menstruators?" and "what are the needs of menstruators?" Descriptions of menstrual trackers exhibited misalignments with these themes, with narrow characterizations of menstruators and design for limited needs. DISCUSSION: We synthesize gaps in the design of menstrual tracking apps and discuss implications for designing around: (1) an irregular menstrual cycle as the norm; (2) the embodied, leaky experience of menstruation; and (3) the varied biologies, identities, and goals of menstruators. An overarching gap suggests a need for a human-centered artificial intelligence approach for model and data provenance, transparency and explanations of uncertainties, and the prioritization of privacy in menstrual trackers. CONCLUSION: Comparing and contrasting literature about menstruators and descriptions of menstrual tracking apps provide a valuable guide to assess menstrual technology and their responsiveness to users and their needs.

Examining the associations of gender minority stressors with sleep health in gender minority individuals.

OBJECTIVES: Investigate the associations of gender minority stressors (including stigma consciousness [SC] and gender-related discrimination [GRD]) with sleep health in gender minority individuals. DESIGN: Cohort. PARTICIPANTS: 279 gender minority individuals. MEASUREMENTS: SC and GRD were measured using the Stigma Consciousness and Everyday Discrimination scales, respectively. Sleep disturbance was assessed using the PROMIS Sleep Disturbance measure. Subjective short sleep duration (<7 hours) was assessed. We used k-means longitudinal clustering to identify minority stress clusters (including SC and GRD scores). Linear and logistic regression models were used to examine the associations of these clusters with sleep disturbance and sleep duration, respectively, adjusted for demographic characteristics. RESULTS: Mean age was 36.9 ± 13.6 years; most were non-White (54.5%), 52.5% were transmasculine, and 22.6% were heterosexual. Mean sleep disturbance score was 17.2 ± 6.1 (range 6-30) and 52% reported short sleep duration. We identified 3 minority stress clusters. Compared to participants with low SC/low GRD, those with high SC/low GRD (B 3.33, 95% confidence interval [CI] = 1.64, 5.01) and high SC/high GRD (B 4.51, 95% CI = 2.63, 6.39) had worse sleep disturbance scores. Participants in the high SC/high GRD cluster were more likely to report short sleep duration relative to the low SC/low GRD cluster (adjusted odds ratios 2.17; 95% CI = 1.11-4.26). CONCLUSIONS: Participants with both high SC and high GRD had worse sleep health. Future longitudinal studies should examine factors that drive the link between gender minority stress and sleep health in gender minority individuals to inform sleep health interventions tailored for this population.

Suicidality among Gender Minority Youth: Analysis of 2017 Youth Risk Behavior Survey Data.

We examined differences in suicidality based on gender identity while adjusting for known suicide risk factors in a sample of United States adolescents. Using data from the 2017 Youth Risk Behavior Survey we used logistic regression models to examine three suicide-related outcomes. Youth were categorized as transgender (1.3%), gender-questioning (1.4%), or cisgender (97.3%). In fully adjusted models, compared to cisgender youth, transgender youth had 2.71 (95% CI 1.50-4.92) higher odds of past-year suicide attempts and 2.54 (95% CI 1.05-6.15) higher odds of past-year suicide attempts requiring treatment. Gender-questioning youth had 2.31 (95% CI 1.48-3.60) higher odds of past-year suicidal ideation compared to cisgender youth. Policies and interventions are needed to reduce suicidality among gender minority youth, improve access to mental healthcare, and reduce peer victimization and substance use.

Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Transgender and Gender Nonbinary Individuals Engaged in a Longitudinal Cohort Study.

While the COVID-19 pandemic in the United States disproportionately impacts marginalized communities, no empiric US-based research has focused specifically on transgender and gender nonbinary (TGNB) people. We examined the pandemic's impact on an established longitudinal cohort of TGNB individuals (N = 208) by administering an online survey between March-June 2020. We used multivariable linear regression to examine reduced LGBTQ/TGNB community support and disruptions in gender-affirming health care as predictors of psychological distress during the pandemic. We found that the pandemic exacerbated ongoing mental health disparities for TGNB individuals. Furthermore, reduced LGBTQ/TGNB support was associated with increased psychological distress during the pandemic. Interruption and/or delay in gender-affirming health care was not associated with increased psychological distress during the pandemic. Special attention is needed to address the unique ways in which TGNB individuals were affected by the COVID-19 pandemic. This includes increasing access to LGBTQ/TGNB community support and addressing long-standing health disparities.

Digital phenotyping of sleep patterns among heterogenous samples of Latinx adults using unsupervised learning.

OBJECTIVE: This study aimed to identify sleep disturbance subtypes ("phenotypes") among Latinx adults based on objective sleep data using a flexible unsupervised machine learning technique. METHODS: This study was an analysis of sleep data from three cross-sectional studies of the Precision in Symptom Self-Management Center at Columbia University. All studies focused on sleep health in Latinx adults at increased risk for sleep disturbance. Data on total sleep time (TST), time in bed (TIB), wake after sleep onset (WASO), sleep efficiency (SE), number of awakenings (NOA) and the mean length of nightly awakenings were collected using wrist-mounted accelerometers. Cluster analysis of the sleep data was conducted using an unsupervised machine learning approach that relies on mixtures of multivariate generalized linear mixed models. RESULTS: The analytic sample included 494 days of data from 118 adults (Ages 19-77). A 3-cluster model provided the best fit based on deviance indices (ie, DΔ∼ -75 and -17 from 1- and 2- to 3-cluster models, respectively) and likelihood ratio (Pdiff âˆ¼ 0.93). Phenotype 1 (n = 64) was associated with greater likelihood of overall adequate SE and less variability in SE and WASO. Phenotype 2 (n = 11) was characterized by higher NOAs, and greater WASO and TIB than the other phenotypes. Phenotype 3 (n = 43) was characterized by greater variability in SE, bed times and awakening times. CONCLUSION: Robust digital data-driven modeling approaches can be useful for detecting sleep phenotypes from heterogenous patient populations, and have implications for designing precision sleep health strategies for management and early detection of sleep problems.

A scoping review of sexual minority women's health in Latin America and the Caribbean.

OBJECTIVES: Despite research documenting significant health disparities among sexual minority women (lesbian, bisexual, and other non-heterosexual women) in high-income countries, few studies of sexual minority women's health have been conducted in low- and middle-income countries. The purpose of this scoping review was to examine the empirical literature related to the health disparities and health needs of sexual minority women in Latin America and the Caribbean (LAC), and to identify research gaps and priorities. DESIGN: A scoping review methodology was used. DATA SOURCES: We conducted a comprehensive search of seven electronic databases. The search strategy combined keywords in three areas: sexual minority women, health, and LAC. English, Spanish, and Portuguese language studies published through 2017 in peer-reviewed journals were included. REVIEW METHODS: A total 1471 articles were retrieved. An additional 5 articles were identified following descendancy search; 3 of these met inclusion criteria. After removal of duplicates and title and abstract screening, we screened the full text of 37 articles, of which 22 (representing 18 distinct studies) met inclusion criteria. At least two authors independently reviewed and abstracted data from all articles. RESULTS: More than half of the studies were conducted in Brazil (n = 9) and Mexico (n = 5). Sexual health was the most studied health issue (n = 11). Sexual minority women were at elevated risk for sexually transmitted infections related to low use of barrier contraceptive methods during sexual encounters with men. Findings suggest that sexual minority women are generally distrustful of healthcare providers and view the healthcare system as heteronormative. Providers are believed to lack the knowledge and skills to provide culturally competent care to sexual minority women. Sexual minority women generally reported low levels of sexual health education and reluctance in seeking preventive screenings due to fear of mistreatment from healthcare providers. Sexual minority women also reported higher rates of poor mental health, disordered eating, and substance use (current tobacco and alcohol use) than heterosexual women. Gender-based violence was identified as a significant concern for sexual minority women in LAC. CONCLUSIONS: Significant knowledge gaps regarding sexual minority women's health in LAC were identified. Additional investigation of understudied areas where health disparities have been observed in other global regions is needed. Future research should explore how the unique social stressors sexual minority women experience impact their health. Nurses and other healthcare providers in the region need training in providing culturally appropriate care for this population.

Generational Differences in Internalized Transnegativity and Psychological Distress Among Feminine Spectrum Transgender People.

PURPOSE: This study examined internalized transnegativity and psychological distress in two age groups of transgender individuals who identified their gender identity on the feminine spectrum (rather than congruent with their male sex assigned at birth). Due to greater visibility and acceptance of gender diversity in the United States, we hypothesized that internalized transnegativity would be lower in the younger compared with the older group, and that the younger generation would, therefore, report lower levels of psychological distress than the older generation. METHODS: The study sample consisted of trans-feminine individuals (N = 440) who completed a online survey of the U.S. transgender population and comprised a younger group aged 18-24 years (n = 133) and an older group aged 40 years and older (n = 307). Internalized transnegativity was assessed using the Transgender Identity Survey, and psychological distress was assessed with the Brief Symptom Inventory 18. We used regression and mediation analysis to examine differences between the two groups. RESULTS: Contrary to our expectations, the older group reported significantly lower levels of both internalized transnegativity and psychological distress compared with the younger group. Internalized transnegativity partially mediated the relationship between age group and psychological distress. CONCLUSION: Despite greater visibility of transgender people and increasing acceptance of gender diversity in the United States, the younger trans-feminine individuals reported more psychological distress than the older transfeminine individuals, which was, in part, related to internalized transnegativity. Trans-feminine individuals may benefit from culturally sensitive and clinically competent mental health services to alleviate internalized transnegativity and psychological distress.

Stigma, gender dysphoria, and nonsuicidal self-injury in a community sample of transgender individuals.

We investigated rates of nonsuicidal self-injury (NSSI) and correlates of past-year NSSI among transgender people to better understand factors contributing to this health disparity. A community-based sample of 332 transgender people participated in quantitative in-person interviews. The mean age of participants was 34.56 years (SD = 13.78, range = 16-87). The sample was evenly divided between transfeminine spectrum (50.3%) and transmasculine spectrum identities (49.7%) and was diverse in race/ethnicity. We evaluated associations between sociodemographic characteristics, stigma, hypothesized resilience factors, and identity variables with past-year NSSI. 53.3% of participants reported ever having self-injured in their lifetime. Past-year NSSI was reported by 22.3% of the sample and did not significantly differ based on gender identity. In logistic regression models, past-year NSSI was associated with younger age and felt stigma (perceived or anticipated rejection), but not enacted stigma (actual experiences of discrimination), and with gender dysphoria. Efforts to address the high rates of NSSI among transgender people should aim to reduce felt stigma and gender dysphoria, and promote transgender congruence. Future research using a developmental approach to assess variations in NSSI across the life course and in relation to transgender identity development may illuminate additional processes that affect NSSI in this population.

Risk and Protective Factors for Substance Use among Sexual and Gender Minority Youth: A Scoping Review.

PURPOSE OF REVIEW: Alcohol and drug use are common among youth. Rates are especially high among sexual and gender minority youth (SGMY; lesbian, gay, bisexual, transgender). We conducted a scoping review of research on risk and protective factors for substance use among SGMY published between 2013-2017. RECENT FINDINGS: Ninety-seven studies met our inclusion criteria. Most focused on individual-level minority stress risk factors, particularly stigma. Fewer studies addressed protective factors such as social support or affirming policies, and few focused on gender minority youth (GMY). We identified important, yet understudied differences by race/ethnicity, sex assigned at birth, and sexual orientation. SUMMARY: Findings highlight growing interest in this topic as well as methodological/topical gaps in the literature. Research is needed to examine SGMY substance use in nationally representative samples; expand information about GMY; investigate racial/ethnic and sex/gender differences; improve measurement; and increase translation of findings to support prevention and treatment interventions for this at-risk population.