Structural stigma within inpatient care for people who inject drugs: implications for harm reduction.

BACKGROUND: Individuals suffering with addiction have historically experienced disproportionally high levels of stigma. The process of inpatient care for those with substance abuse disorder (SUD) is multifaceted, shaped by the interplay of human interactions within the healthcare team and overarching structural factors like policy. While existing literature predominantly addresses personal and interpersonal stigma, the influence of structural stigma on care delivery practices remains understudied. Our research aims to investigate the impact of structural stigma on care processes for individuals with SUD admitted to acute medicine units. METHODS: We conducted a secondary analysis of observation notes and interview transcripts utilizing an analytic framework related to structural stigma adapted from previous research. Data was collected from June 2019 to January 2020 in 2 hospitals. 81 participants consented to observation and 25 to interviews. Interviews were conducted with patients (n = 8), healthcare staff (n = 16), and caregivers (n = 1). RESULTS: Each aspect of care for people with SUD is adversely influenced by structural forms of stigma. There was evidence of a gap in accessing care and time pressures which deteriorated care processes. Structural stigma also manifested in the physical spaces designed for care and the lack of adequate resources available for mental health and addictions care. We found that structural stigma perpetuated other forms of implicit and explicit stigma. CONCLUSIONS: Structural stigma and other forms of stigma are interconnected. Improving care for people with SUD in hospital settings may require addressing structural forms of stigma such as how physical spaces are designed and how mental healthcare is integrated with physical healthcare within inpatient settings.

Intersectional Structural Stigma: A Qualitative Study With Persons Experiencing Homelessness in the Southwest United States.

This study explored the manifestations of intersectional structural stigma and stigma-reducing strategies in the context of health among a diverse group of persons experiencing homelessness in the southwest United States. Purposive sampling was used to recruit youth (ages 12-17), young adults (ages 18-24), adults (ages 25 years old or older), women with children, veterans, and males over 60 years old who self-identified as homeless. Grounded theory was applied, and thematic analysis was conducted using data collected from seven focus groups (n = 76 participants). A model of intersectional stigma was adapted from the Health Stigma and Discrimination Framework. This adaptation depicts pathways for addressing intersectional stigmatization experienced by individuals with multiple intersecting identities across the interpersonal, organization, and community levels not explicitly addressed in the Health Stigma and Discrimination Framework. At the interpersonal level, participants indicated they experienced stigmatizing behaviors and practices by service providers due primarily to their identities related to economic or unhoused statuses, gender, age, and mental health. Facilitators of intersectional stigma were identified through organization practices and processes. Multiple stigmatized identities due to social beliefs also facilitated stigmatization at the community level. Health outcomes influenced by stigmatization were also identified. Despite the stigmatization they experienced, participants discussed stigma-reducing strategies related to community assets, medical care, and destigmatizing practices by service providers.

Marital status, State policy environment and Foregone healthcare of same-sex families during the COVID-19 period.

Sexual minorities in the United States have often reported a higher likelihood of forgoing healthcare than heterosexuals, but whether this occurred during the COVID-19 pandemic remains underexplored. This study applies and extends the Andersen model to examine different-sex and same-sex families' likelihood of forgoing healthcare during the pandemic using nationally representative data from the 2020 (May-October) Current Population Survey (N = 139,636). Results are that during the early stage of the pandemic (1) same-sex families overall are more likely than different-sex families to forgo medical care, (2) cohabitating same-sex families were less likely to forgo healthcare than their married counterparts, and (3) state policy environments will moderate only some of the differences in healthcare utilization by family types. Findings provide partial support for hypotheses and suggest a more careful consideration of the role of partnership and state policy in the Andersen model. Policy implications are also discussed.

Same-Sex Marriage Laws, Provider-Patient Communication, and PrEP Awareness and Use Among Gay, Bisexual, and Other Men Who have Sex with Men in the United States.

State-level structural stigma and its consequences in healthcare settings shape access to pre-exposure prophylaxis (PrEP) for HIV prevention among gay, bisexual, and other men who have sex with men (GBMSM). Our objective was to assess the relationships between same-sex marriage laws, a measure of structural stigma at the state level, provider-patient communication about sex, and GBMSM awareness and use of PrEP. Using data from the Fenway Institute's MSM Internet Survey collected in 2013 (N = 3296), we conducted modified Poisson regression analyses to evaluate associations between same-sex marriage legality, measures of provider-patient communication, and PrEP awareness and use. Living in a state where same-sex marriage was legal was associated with PrEP awareness (aPR 1.27; 95% CI 1.14, 1.41), as were feeling comfortable discussing with primary care providers that they have had sex with a man (aPR 1.63; 95% CI 1.46, 1.82), discussing with their primary care provider having had condomless sex with a man (aPR 1.65; 95% CI 1.49, 1.82), and discussing with their primary care provider ways to prevent sexual transmission of HIV (aPR 1.39; 95% CI 1.26, 1.54). Each of these three measures of provider-patient communication were additionally associated with PrEP awareness and use. In sum, structural stigma was associated with reduced PrEP awareness and use. Policies that reduce stigma against GBMSM may help to promote PrEP and prevent HIV transmission.

Typologies of interactions between abortion seekers and healthcare workers in Australia: a qualitative study exploring the impact of stigma on quality of care.

BACKGROUND: Abortion stigma involves the stereotyping of, discrimination against, and delegitimization of those who seek and provide abortion. Experiences of abortion care are shaped by stigma at the meso (e.g., lack of local providers) and macro (e.g., abortion regulations) levels. Yet abortion stigma and quality of care are often examined separately. This study sought to articulate the impact of abortion stigma on quality of care in the context of healthcare interactions. It did so by characterizing the features of stigmatizing and non-stigmatizing care in the context of macro-level stigma and other structural factors that influence abortion-seeking experiences, including the coronavirus pandemic's influence on the health system. METHODS: This qualitative study comprised in-depth interviews with people who sought abortion across Australia between March 2020 and November 2022, recruited through social media and flyers in clinics. Thematic analysis drew on concepts of micro, meso, and macro stigma and person-centered care. We developed typologies of the interactions between abortion seekers and healthcare workers by analytically grouping together negative and positive experiences to characterize features of stigmatizing and and non-stigmatizing care in the context of macro-level influences. RESULTS: We interviewed 24 abortion seekers and developed five typologies of stigmatizing care: creating barriers; judging; ignoring emotional and information needs; making assumptions; and minimizing interactions. There are five corresponding positive typologies. Macro-level factors, from abortion regulations to rural and pandemic-related health system pressures, contributed to poor experiences in care. CONCLUSIONS: The positive experiences in this study illustrate how a lack of stigma enables patient-centered care. The negative experiences reflect the interrelationship between stigmatizing beliefs among healthcare workers, macro-level (policy and regulatory) abortion stigma, and structural health service limitations exacerbated during the pandemic. Interventions are needed to reduce stigmatizing interactions between abortion seekers and healthcare workers, and should also consider macro-level factors that influence the behaviors of healthcare workers and experiences of abortion seekers. Without addressing stigma at multiple levels, equitable access to high-quality abortion care will be difficult to achieve. Efforts to integrate stigma reduction into quality improvement have relevance for maternal and reproductive health services globally.

Health disparities in one of the world's most progressive countries: a scoping review of mental health and substance use among sexual and gender minority people in the Netherlands.

BACKGROUND: Evidence from many parts of the world shows that sexual and gender minority (SGM) people have poorer health than their cisgender heterosexual counterparts. Minority stressors, particularly stigma and discrimination, have been identified as major contributors to sexual orientation- and gender identity-related health disparities, particularly negative mental health and behavioral health outcomes. To better understand factors that contribute to these disparities, we conducted a scoping review of SGM mental health and substance use research in the Netherlands-a country with a long-standing reputation as a pioneer in SGM equality. METHODS: Using Joanna Briggs Institute guidelines and the PRISMA-ScR protocol, we searched seven databases to identify studies published between 2010 and 2022 that focused on substance use and/or mental health of SGM youth and adults in the Netherlands. RESULTS: Although there was some evidence that SGM people in the Netherlands report fewer substance use and mental health concerns than those in less progressive countries, with very few exceptions studies found poorer outcomes among SGM participants than cisgender, heterosexual participants. However, this observation must be considered cautiously given major gaps in the literature. For example, only one study focused exclusively on adult sexual minority women, two focused on older SGM adults, and very little attention was given to nonbinary individuals. Most studies used non-probability samples that were quite homogenous. Many studies, especially those with youth, assessed sexual orientation based on sexual attraction; some studies of adults operationalized SGM status as having a same-sex partner. Importantly, we found no studies that directly assessed associations between structural-level stigma and health outcomes. Studies were mostly focused at the individual level and on health problems; very little attention was given to strengths or resilience. CONCLUSIONS: Findings of persistent health disparities-despite the relatively long history of SGM supportive policies in the Netherlands-highlight the need for more research and greater attention to population groups that have been underrepresented. Such research would not only provide guidance on strategies to improve the health of SGM people in the Netherlands, but also in other countries that are seeking to reduce health inequities. Addressing SGM health disparities in the Netherlands and elsewhere is complex and requires a multifaceted approach that addresses individual, interpersonal and structural factors.

Stronger together: community participation, structural stigma, and depression among sexual and gender minority adults in 28 European countries.

PURPOSE: Although discriminatory laws, policies, and public attitudes (i.e., structural stigma) are linked to adverse mental health outcomes among sexual and gender minority (SGM) populations, little attention has been paid to protective factors, such as community participation, about which inconsistencies exist whether it ameliorates or exacerbates mental health burdens. Thus, we examined the mediator roles of identity disclosure and victimization and the moderator role of structural stigma in the association of community participation with depression. METHODS: Data from the EU-LGBTI-II survey assessing community participation, identity disclosure, victimization, and depression among sexual minority men (n = 62,939), women (n = 38,976), and gender minority adults (n = 15,845) in 28 European countries were used. Structural stigma was measured as discriminatory legislation, policies, and societal attitudes using publicly available data. RESULTS: Findings showed that community participation predicted lower and higher levels of depression through identity disclosure and victimization, respectively. For sexual minority men and women, structural stigma moderated the indirect effect through identity disclosure, with a larger effect in higher structural stigma countries. Only for sexual minority men, the indirect effect through victimization was also moderated, with a larger effect in high-stigma countries. For gender minorities, no moderation effect was found. CONCLUSIONS: Community participation is differentially linked to depression through identity disclosure and victimization, and as a function of structural stigma. It can be a double-edged sword, especially for sexual minority men in high-stigma countries, who are expected to pay the price while enjoying its benefits, highlighting the targets and considerations for interventions.

Stigma, mental illness & ethnicity: Time to centre racism and structural stigma.

This article critically reviews previous research in the field of stigma, mental illness and 'race' and ethnicity, and argues for a shift of focus from individual and community blame, as inferred by mental illness stigma, to a more comprehensive view of how stigma operates against a backdrop of structural and institutional racism. Ethnic minority people have poorer mental health outcomes compared with White majority populations. Dominant narratives of greater mental illness stigma in ethnic minority populations, due to religious, spiritual or traditional beliefs and leading to a lower use of services, have taken centre stage in the explanations for these consequent poorer outcomes. This article argues that this 'fact' has become taken for granted as knowledge without corresponding comparative research evidence. Research in the field has also failed to robustly consider how racism might operate in conjunction with different forms of mental illness stigma (particularly structural stigma) to exacerbate mental illness and influence pathways to mental health treatment. Future research should centre the role of racism and structural stigma in explaining the poorer mental health outcomes for ethnic minority people.

Kept in the Closet: Structural Stigma and the Timing of Sexual Minority Developmental Milestones Across 28 European Countries.

Structural stigma's role in lesbian, gay, and bisexual (LGB) people's attainment of identity development milestones remains unknown. In a sample of 111,498 LGB people (ages 15 to 65+) living across 28 European countries, associations were investigated between structural stigma measured using an objective index of discriminatory country-level laws and policies affecting LGB people and the timing and pacing of LGB self-awareness, coming out, and closet duration, and subgroup differences in these associations. On average, self-awareness occurred at age 14.8 years old (SD = 5.1), coming out occurred at 18.5 years old (SD = 5.7), and the closet was 3.9 years long (SD = 4.9); thereby highlighting adolescence as a key period for sexual identity development and disclosure. Greater structural stigma was associated with higher odds of never coming out, later age of coming out, and longer closet duration. Gender identity, transgender identity, and sexual identity moderated associations between structural stigma and these developmental milestones. Reducing structural stigma can plausibly promote sexual identity development among LGB populations, especially during adolescence when identity related milestones are often attained.

Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships.

BACKGROUND: Sexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma. PURPOSE: To examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people. METHODS: Participants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes. RESULTS: Among cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health. CONCLUSION: Safe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.

State-Level Policy Stigma and Non-Prescribed Hormones Use among Trans Populations in the United States: A Mediational Analysis of Insurance and Anticipated Stigma.

BACKGROUND: Medical gender affirmation (i.e., hormone use) is one-way transgender (trans) people affirm their gender and has been associated with health benefits. However, trans people face stigmatization when accessing gender-affirming healthcare, which leads some to use non-prescribed hormones (NPHs) that increase their risk for poor health. PURPOSE: We examined whether healthcare policy stigma, as measured by state-level trans-specific policies, was associated with NPHs use and tested mediational paths that might explain these associations. Because stigmatizing healthcare policies prevent trans people from participation in healthcare systems and allow for discrimination by healthcare providers, we hypothesized that healthcare policy stigma would be associated with NPHs use by operating through three main pathways: skipping care due to anticipated stigma in healthcare settings, skipping care due to cost, and being uninsured. METHODS: We conducted analyses using data from the 2015 U.S. Transgender Survey. The analytic sample included trans adults using hormones (N = 11,994). We fit a multinomial structural equation model to examine associations. RESULTS: Among trans adults using hormones, we found that healthcare policy stigma was positively associated with NPHs use and operated through insurance coverage and anticipating stigma in healthcare settings. The effect sizes on key predictor variables varied significantly between those who use supplemental NPHs and those who only use NPHs suggesting the need to treat NPHs use as distinct from those who use supplemental NPHs. CONCLUSIONS: Our work highlights the importance of healthcare policy stigma in understanding health inequities among trans people in the USA, specifically NPHs use.

Structural Heteropatriarchy and Birth Outcomes in the United States.

Emerging evidence links structural sexism and structural discrimination against lesbian, gay, and bisexual (LGB) populations to poor health outcomes, but studies have yet to examine the combined effects of these mutually reinforcing systems of inequality. Therefore, we developed a composite measure of structural heteropatriarchy-which includes state-level LGB policies, family planning policies, and indicators of structural sexism (e.g., women's political and economic position relative to men)-and examined its relationship to birth outcomes using data from Waves I to V of the National Longitudinal Study of Adolescent to Adult Health. Multivariate regression analyses demonstrated that higher levels of heteropatriarchy were associated with an increased risk of preterm birth and decreased birth weight, net of important covariates. There was no association between clinical low birth weight and heteropatriarchy, or interactions between heteropatriarchy and individuals' race, ethnicity or sexual identity, suggesting a negative effect of heteropatriarchy on birth outcomes for all pregnant people. This study demonstrates the importance of considering gender and sexuality as mutually reinforcing systems of oppression that impact population health. Future research should examine the impact of heteropatriarchy on additional health outcomes and in conjunction with other structural inequalities such as racism and transgender oppression.

Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis.

BACKGROUND: Research indicates that tailored programming for sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, queer) people, compared to non-tailored programming, is effective for reducing the disproportionate health burden SGM people experience relative to the general population. However, the availability of SGM-tailored programming is often over-reported and inconsistent across behavioral health (i.e., substance use and mental health) facilities in the United States (U.S.). METHODS: Using panel analysis, the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Mental Health Services Survey (N-MHSS), this study examines structural stigma and government funding as two structural determinants affecting the availability of SGM-tailored programming in the U.S. RESULTS: Results indicated that from 2010 to 2020, reductions in structural stigma (i.e., increases in state-level supportive SGM policies) were positively associated with increases in the proportion of substance use treatment facilities offering SGM-tailored programming. This effect was significant after controlling for over-reporting of SGM-tailored programming and time- and state-specific heterogeneity. On average, the effect of reduced structural stigma resulted in approximately two new SGM-tailored programs in the short term and about 31 new SGM-tailored programs in the long term across U.S. substance use treatment facilities. Structural stigma did not predict the availability of SGM-tailored programming in mental health treatment facilities. Government funding was not significant in either data set. However, without correcting for over-reporting, government funding became a significant predictor of the availability of SGM-tailored programming at substance use treatment facilities. CONCLUSIONS: Because SGM-tailored programming facilitates access to healthcare and the current study found longitudinal associations between structural stigma and the availability of SGM-tailored programming in substance use treatment facilities, our findings support claims that reducing structural stigma increases access to behavioral health treatment specifically and healthcare generally among SGM people. This study's findings also indicate the importance of correcting for over-reporting of SGM-tailored programming, raising concerns about how respondents perceive the N-SSATS and N-MHSS questions about SGM-tailored programming. Implications for future research using the N-SSATS and N-MHSS data and for public health policy are discussed.

A Contextual Approach to the Psychological Study of Identity Concealment: Examining Direct, Interactive, and Indirect Effects of Structural Stigma on Concealment Motivation Across Proximal and Distal Geographic Levels.

Psychological theories of identity concealment locate the ultimate source of concealment decisions within the social environment, yet most studies have not explicitly assessed stigmatizing environments beyond the immediate situation. We advanced the identity-concealment literature by objectively measuring structural forms of stigma related to sexual orientation (e.g., social policies) at proximal and distal geographic levels. We linked these measures to a new, population-based data set of 502 gay and bisexual men (residing in 44 states and Washington, DC; 269 counties; and 354 cities) who completed survey items about stigma, including identity-concealment motivation. Among gay men, the association between structural stigma and concealment motivation was (a) observed across three levels (city, county, and state), (b) conditional on one's exposure at another geographic level (participants reported the least motivations to conceal their identity if they resided in both cities and states that were lowest in structural stigma), and (c) mediated by subjective perceptions of greater structural stigma.

State-Level Structural Stigma and Smoking Among Sexual Minority Adults in the USA, 2012-2014.

BACKGROUND: Exposure to structural stigma (i.e., societal norms and policies that constrain access to resources) may help explain poor health outcomes among sexual minority (SM) individuals in the USA. PURPOSE: We examined the relationship between structural stigma and smoking prevalence among U.S. SM and heterosexual adults. METHODS: We adapted an index to capture multiple state-level structural stigma indicators, including attitudes toward same-sex marriage; the geographical density of same-sex couples; and state-level policies toward SMs. The outcome variable was current smoking, derived from the National Adult Tobacco Survey (2012-2014). Poisson regression models stratified by SM status were used to assess the relationship between structural stigma and the prevalence ratio (PR) of current smoking. We included a squared term for stigma to explore nonlinear relationships between stigma and smoking. Interaction terms were used to examine effect modification by sex. RESULTS: Adjusted models suggested a curvilinear PR relationship between stigma and smoking for both SM (linear PR = 1.03 [0.97-1.08]; quadratic PR = 0.98 [0.97-1.00]) and heterosexual (linear PR = 1.00 [0.99-1.02]; quadratic PR = 0.99 [0.988-0.995]) adults. The quadratic term was significant (p < .05) for both SM and heterosexual respondents, however, the change in probability of smoking associated with structural stigma was more pronounced among SM individuals. Specifically, the highest and lowest exposures to stigma were associated with the lowest probabilities of smoking. There was no apparent effect modification by sex. CONCLUSIONS: Findings lend support to addressing SM structural stigma as a driver of smoking, particularly among SM adults.

Country-level structural stigma, identity concealment, and day-to-day discrimination as determinants of transgender people's life satisfaction.

PURPOSE: Discriminatory laws, policies, and population attitudes, surrounding transgender people vary greatly across countries, from equal protection under the law and full acceptance to lack of legal recognition and open bias. The consequences of this substantial between-country variation on transgender people's health and well-being is poorly understood. We therefore examined the association between structural stigma and transgender people's life satisfaction across 28 countries. METHODS: Data from transgender participants (n = 6771) in the 2012 EU-LGBT-survey regarding identity concealment, day-to-day discrimination, and life satisfaction were assessed. Structural stigma was measured using publicly available data regarding each country's discriminatory laws, policies, and population attitudes towards transgender people. RESULTS: Multilevel models showed that country-level structural stigma was associated with lower life satisfaction, an association largely explained by higher levels of identity concealment in higher-structural-stigma countries. Yet identity concealment was also associated with lower day-to-day discrimination and therefore protected against even lower life satisfaction. CONCLUSION: The results emphasize the importance of changing discriminatory legislation and negative population attitudes to improve transgender people's life satisfaction, and also highlight targets for intervention at interpersonal and individual levels.

Identifying psychological responses of stigmatized groups to referendums.

Public votes and referendums on the rights of marginalized communities are utilized in 27 states and occur with some regularity. However, research has only recently begun to examine the psychological consequences of these voter referendums for members of stigmatized groups, and a number of important questions remain regarding the internal validity and generalizability of the existing evidence. The current study advances this literature by combining survey data from a large probability-based sample conducted in 2012 [lesbian, gay, bisexual, and/or transgender (LGBT) n = 939; non-LGBT n = 31,067] with media market ad-buy data in states where marriage equality was on the ballot. Television media markets cross state boundaries, ensuring that there was an unintended group of people in 12 states who were exposed to the same-sex marriage discourse but who did not live in states with the voter referendum ("media market spillovers"). We take advantage of this unique data structure by comparing LGBT people in the media market spillovers to those residing in the same state but in nonspillover markets with no ad exposure. LGBT people are emotionally affected by these campaigns, and non-LGBT people are unaffected. LGBT people in markets with a cumulative total of 400 ads have a 34.0% greater probability of reporting stress than LGBT people not exposed to ads. Additionally, while the negative ads evoked sadness, positive ads evoked enjoyment and happiness. Thus, public votes on minority rights represent both a source of minority stress and resilience.

The link between LGBTQ-supportive communities, progressive political climate, and suicidality among sexual minority adolescents in Canada.

Despite supportive structural changes to reduce stigma towards lesbian, gay, and bisexual, transgender, queer, and questioning (LGBTQ) Canadian residents, sexual minority youth still face disparities compared to heterosexual peers. We aimed to characterize LGBTQ-supportive environments and political climates, and examine their links to suicidal behavior among sexual minority adolescents in western Canada. Data were from the 2013 British Columbia Adolescent Health Survey, a cluster-stratified random cross-sectional survey of public school students in BC, Canada; We sampled 2678 self-identified LGB and mostly heterosexual students (69% girls) from 274 schools, representing an estimated provincial population of 24,624 sexual minority students in weighted models. Student reports of past-year suicidal ideation, suicidal attempts, and self-harm behaviors were merged with community-level data assessing diverse aspects of LGBTQ-supportive resources and progressive political climates in communities surrounding the schools. Adjusted multilevel models showed that for sexual minority adolescent girls, higher community LGBTQ-supportiveness predicted marginally significant lower suicidal ideation (aOR = 0.94, 95% CI [0.88, 1.01]) and suicidal attempts (aOR = 0.91, 95% CI [0.83, 1.00]) and significantly lower self-harm behaviors (aOR = 0.91, 95% CI [0.85, 0.98]). Further, progressive political climates predicted marginally significant lower suicidal ideation (aOR = 0.89, 95% CI [0.78, 1.02]) and significantly lower self-harm behaviors (aOR = 0.87, 95% CI [0.77, 0.99]). For sexual minority adolescent boys, no community-level variables were associated with suicidal behavior in adjusted models. Thus, LGBTQ-supportive communities and progressive political climates appear to be protective against suicidal behavior among sexual minority adolescent girls, but not sexual minority adolescent boys.

Perceived Attitudes Toward Lesbian, Gay, and Bisexual (LGB) Issues and Mental Health Among Taiwanese LGB Adults: The Mediating Role of Self-Acceptance.

Research on structural stigma has associated the poor mental health status among lesbian, gay, and bisexual (LGB) people with discriminatory institutions. Yet, less is known about the role of LGB adults' perceptions of social attitudes toward LGB issues. Moreover, the psychological mediation framework posits LGB people's self-acceptance as a mediator between a stigmatizing environment and individual mental health. This study investigated: (a) how perceived attitudes toward LGB issues from different social realms (society, heterosexual friends, and family members) were associated with LGB people's mental health; and (b) whether self-acceptance mediated the effects of perceived attitudes. In this cross-sectional study, 1527 Taiwanese LGB adults (812 men; 715 women) aged between 20 and 62 years were recruited via Facebook to complete an online survey. The majority of respondents self-identified as homosexual (1129) and 399 as bisexual. The survey consisted of assessment of respondents' mental health and questions to rate individual self-acceptance and perceptions of social attitudes. Path analysis showed that self-acceptance partially mediated the association between mental health and perceived societal acceptance of homosexuality and fully mediated the effect of perceptions of friends' acceptance of homosexuality on mental health. Self-acceptance fully mediated the effects of perceived support for same-sex marriage from friends and families. This research yielded evidence about the interplay between perceived social stigma, self-acceptance, and mental health, particularly in the context of public debate about same-sex marriage. The effects of public discourse about sexual diversity and marriage equality on LGB adults' mental health should be addressed by affirmative policies and practices.

Legalizing Same-Sex Marriage Matters for the Subjective Well-being of Individuals in Same-Sex Unions.

We investigate whether the subjective well-being of individuals in same-sex unions improved following the legalization of same-sex marriage in England and Wales in March 2014. We employ repeated cross-sectional data from the 2011-2016 Annual Population Surveys on 476,411 persons, including 4,112 individuals in coresidential same-sex relationships. The analysis reveals increases in subjective well-being for individuals in same-sex relationships following legalization. Additional analysis documents higher subjective well-being for individuals in married same-sex couples compared with individuals who are in a civil partnership or an informal cohabiting same-sex union. However, the subjective well-being of individuals from same-sex couples increased after legalization among all subgroups considered, including those who cohabited informally. This result hints at a general reduction in structural stigma as an important mechanism behind the improved well-being of individuals in same-sex unions.