Gender Nonconformity, Perceived Stigmatization, and Psychological Well-Being in Dutch Sexual Minority Youth and Young Adults: A Mediation Analysis

Dutch sexual minority youth and young adults (106 females and 86 males, 16–24 years old) were assessed to establish whether there was a relation between gender nonconformity and psychological well-being and whether this relation was mediated by perceived experiences of stigmatization due to perceived or actual sexual orientation and moderated by biological sex. The participants were recruited via announcements on Dutch LGBTQ-oriented community websites and then linked to a protected online questionnaire. The questionnaire was used to measure gender nonconformity, perceived experiences of stigmatization, and psychological well-being. Gender nonconformity was found to predict lower levels of psychological well-being and the mediation analysis confirmed that lower levels of psychological well-being were related to the perceived experiences of stigmatization. This mediation was not moderated by biological sex. These findings show that both research and interventions should pay more attention to gender nonconformity among young people in order to create a more positive climate for young sexual minority members.     

Promoting the Successful Development of Sexual and Gender Minority Youths

Because of societal discomfort with atypical expressions of sexual orientation and gender identity, lesbian, gay, bisexual and transgender (LGBT) youths have experienced enhanced developmental challenges compared with their heterosexual peers.A recent special issue of the American Journal of Public Health delineated how social stigma affecting LGBT youths has resulted in a wide range of health disparities, ranging from increased prevalence of depression and substance use to downstream effects, such as an increased risk for cancer and cardiovascular disease when older.We review the clinical significance of these findings for health care professionals, who need to become informed about these associations to provide better care for their sexual and gender minority youth patients, and to be able to educate their parents and other caregivers.Homosexual and gender nonconforming behaviors have been variably expressed in different cultures since the beginning of recorded history. However, only in recent years has there been sufficient scholarship about sexual and gender minority youths to enable clinicians to learn more about the unique health needs of these populations.1 For most of the 20th century and previous centuries, sexual and gender minority people were not recognized as discrete populations that required specific, culturally responsive attention from health care professionals and public health programs. However, awareness increased after the emergence of the gay liberation movement in the late 1970s, and was exponentially enhanced as clinicians began to recognize an increasingly varied panoply of sexually transmitted infections, culminating with the AIDS epidemic. These observations were only the tip of the iceberg, because many health issues faced by sexual and gender minorities were not exclusively related to their sexual behavior, but were often a response to the stigma and discrimination they experienced.2 Societal understanding of these issues has been informed by the emerging awareness of health disparities that are not only prevalent among racial and ethnic minority populations, but are common among sexual and gender minority populations.3 This emerging awareness has also led to the recognition that health systems must become responsive to the reality of a diverse array of minority health disparities, to enhance access to appropriate health care for disenfranchised populations.4 An understanding of the reasons why specific populations may not fully engage in care is critical to creating more culturally responsive systems for health care, as well as the specific clinical conditions that may be more prevalent in subpopulations. It is also important that clinicians learn how to improve the ways that sexual and gender minority youths experience their clinical care, including evaluating how provider attitudes may affect physicians’ ability to provide nonjudgmental care.For sexual and gender minority populations, the recognition of the importance of addressing their unique health needs is a recent development.5 Historically, many key professional documents, such as the early versions of the Diagnostic Management System (DSM) of the American Psychiatric Association, presumed that individuals who were homosexual or who displayed gender nonconformity were ipso facto experiencing a mental health illness. Only in recent decades have health professionals recognized that past dogma and professional bias caused much harm, and prevented development of ways for providers to help their sexual and gender minority patients to optimize their resilience to lead confident, healthy, productive lives.6,7 Health care professionals’ understanding of sexual and gender minority subcultures is particularly important to ensure the successful growth and development of lesbian, gay, bisexual and transgender (LGBT) youths, given young people’s developmental vulnerabilities, and the normative role that trusted health professionals can play. The February 2014 issue of the American Journal of Public Health has provided a wide array of studies based on recent data from the Youth Risk Behavioral Survey (YRBS) system, which provides data that can inform and improve the clinical care of sexual and gender minority youths.Careful analyses of the life experiences of sexual and gender minority populations suggest that proximate causes of psychological distress and risk-taking behavior for some stem from early childhood experiences, including physical and emotional abuse by family or peers, as well as general societal stigma and discrimination (Institute of Medicine5 [IOM]), resulting in dysfunctional behavior.8,9 Similar health disparities (e.g., increased risk for HIV or sexually transmitted infection), depression, and substance use are now being recognized among sexual and gender minorities in developing countries.10 These findings suggest that successful responses to the global HIV/AIDS epidemic will require the development of culturally sensitive programs that address concomitant clinical concerns and root causes, such as societal and institutional homophobia. Research is needed to understand how the majority of sexual and gender minority people lead resilient and productive lives in the face of discrimination and to develop assets-based interventions that build on the community supports that they have created.     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Depression and Sexual Orientation During Young Adulthood: Diversity Among Sexual Minority Subgroups and the Role of Gender Nonconformity

Sexual minority individuals are at an elevated risk for depression compared to their heterosexual counterparts, yet less is known about how depression status varies across sexual minority subgroups (i.e., mostly heterosexuals, bisexuals, and lesbians and gay men). Moreover, studies on the role of young adult gender nonconformity in the relation between sexual orientation and depression are scarce and have yielded mixed findings. The current study examined the disparities between sexual minorities and heterosexuals during young adulthood in concurrent depression near the beginning of young adulthood and prospective depression 6 years later, paying attention to the diversity within sexual minority subgroups and the role of gender nonconformity. Drawn from the National Longitudinal Study of Adolescent Health (N = 9421), we found that after accounting for demographics, sampling weight, and sampling design, self-identified mostly heterosexual and bisexual young adults, but not lesbians and gay men, reported significantly higher concurrent depression compared to heterosexuals; moreover, only mostly heterosexual young adults were more depressed than heterosexuals 6 years later. Furthermore, while young adult gender nonconforming behavior was associated with more concurrent depression regardless of sexual orientation, its negative impact on mental health decreased over time. Surprisingly, previous gender nonconformity predicted decreased prospective depression among lesbians and gay men whereas, among heterosexual individuals, increased gender nonconformity was not associated with prospective depression. Together, the results suggested the importance of investigating diversity and the influence of young adult gender nonconformity in future research on the mental health of sexual minorities.     

Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder

Objectives. We assessed sexual orientation disparities in exposure to violence and other potentially traumatic events and onset of posttraumatic stress disorder (PTSD) in a representative US sample.Methods. We used data from 34 653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions.Results. Lesbians and gay men, bisexuals, and heterosexuals who reported any same-sex sexual partners over their lifetime had greater risk of childhood maltreatment, interpersonal violence, trauma to a close friend or relative, and unexpected death of someone close than did heterosexuals with no same-sex attractions or partners. Risk of onset of PTSD was higher among lesbians and gays (adjusted odds ratio [AOR] = 2.03; 95% confidence interval [CI] = 1.34, 3.06), bisexuals (AOR = 2.13; 95% CI = 1.38, 3.29), and heterosexuals with any same-sex partners (AOR = 2.06; 95% CI = 1.54, 2.74) than it was among the heterosexual reference group. This higher risk was largely accounted for by sexual orientation minorities’ greater exposure to violence, exposure to more potentially traumatic events, and earlier age of trauma exposure.Conclusions. Profound sexual orientation disparities exist in risk of PTSD and in violence exposure, beginning in childhood. Our findings suggest there is an urgent need for public health interventions aimed at preventing violence against individuals with minority sexual orientations and providing follow-up care to cope with the sequelae of violent victimization.Sexual orientation disparities in exposure to violence over the life course are well documented.^1–10 Individuals with minority sexual orientation (e.g., gay, lesbian, bisexual) report elevated frequency, severity, and persistence of physical and sexual abuse in childhood.^1,3,4 Throughout their lives, sexual orientation minorities are more likely to experience violence in their communities, including hate crimes.^5,10–12 Intimate partner violence and sexual assault in adulthood are also disproportionately prevalent among sexual orientation minorities.^3,9 It is unknown whether sexual orientation disparities also exist in exposure to other types of potentially traumatic events.Despite the growing recognition of sexual orientation disparities in violence exposure, population-representative research examining possible sexual orientation differences in risk of posttraumatic stress disorder (PTSD) is very limited. PTSD is a mental disorder that develops in response to exposure to a potentially traumatic event, including violence (e.g., childhood abuse, sexual assault) or other negative life experiences (e.g., disasters, accidents). The disorder is characterized by persistent reexperiencing of the event, persistent avoidance of stimuli associated with the event, emotional numbing, and hyperarousal. For PTSD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, symptoms must be present for at least 1 month and result in functional impairment.¹³The public health consequences of PTSD are staggering and include secondary mental disorders, substance dependence,^14,15 impaired role functioning, health problems,^16–18 and reduced life course opportunities (e.g., higher rates of unemployment).¹⁹ The lack of data on PTSD among sexual orientation minorities is a critical gap because, of all civilian traumas, interpersonal violence is associated with the highest conditional risk of developing PTSD.^20,21 We examined sexual orientation disparities in exposure to violence and other potentially traumatic events and in risk of PTSD in a US representative sample.Previous studies have found elevated rates of PTSD among sexual orientation minorities in comparison with heterosexuals.^6,10,22,23 However, our understanding of the burden of PTSD in this vulnerable population is constrained by 3 limitations of extant research. First, as far as we know, only 1 study compared rates of PTSD across sexual orientation groups in a nationally representative sample.²³ Several studies relied on convenience samples; selection factors in such samples could bias observed associations among sexual orientation, violence exposure, and PTSD. Second, the only study of sexual orientation and PTSD in a nationally representative sample categorized members into a sexual orientation group solely by reports of the gender of their sexual partners. Other dimensions of sexual orientation, such as sexual orientation identity and feelings of sexual attraction, which have been shown to be important correlates of physical and mental health,^24,25 were not measured. Third, no previous study attempted to link possible sexual orientation disparities in PTSD directly to elevated risk of exposure to violence and other traumatic events in the minority sexual orientation population. Type of potentially traumatic event exposure—particularly elevated rates of exposure to violence, exposure to multiple events, and younger age at exposure—are all important determinants of PTSD^{20,21,26–28} that may account for the disparities in PTSD by sexual orientation.We designed our study to document the public health burden of potentially traumatic event exposure and PTSD in US residents with minority sexual orientations. We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large, nationally representative survey of US adults.²⁹ Respondents were asked to report on 3 dimensions of sexual orientation: identity (i.e., heterosexual, gay, lesbian, or bisexual), same-sex and opposite-sex attractions, and same-sex and opposite-sex sexual partners. We also investigated the causes of observed disparities in PTSD by analyzing NESARC''s detailed information on type of traumatic events and age at first exposure. These are therefore the most comprehensive data reported to date, derived from a nationally representative sample and aimed at quantifying disparities in potentially traumatic events and associated PTSD by sexual orientation.     

Religious Climate and Health Risk Behaviors in Sexual Minority Youths: A Population-Based Study

Objectives. We examined whether the health risk behaviors of lesbian, gay, and bisexual (LGB) youths are determined in part by the religious composition of the communities in which they live.Methods. Data were collected from 31 852 high school students, including 1413 LGB students, who participated in the Oregon Healthy Teens survey in 2006 through 2008. Supportive religious climate was operationalized according to the proportion of individuals (of the total number of religious adherents) who adhere to a religion supporting homosexuality. Comprehensive data on religious climate were derived from 85 denominational groups in 34 Oregon counties.Results. Among LGB youths, living in a county with a religious climate that was supportive of homosexuality was associated with significantly fewer alcohol abuse symptoms (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40, 0.85) and fewer sexual partners (OR = 0.77; 95% CI = 0.60, 0.99). The effect of religious climate on health behaviors was stronger among LGB than heterosexual youths. Results remained robust after adjustment for multiple confounding factors.Conclusions. The religious climate surrounding LGB youths may serve as a determinant of their health risk behaviors.Stigma operates through both discrete events and pervasive environments in threatening the health of its targets.1 Explanations of lesbian, gay, and bisexual (LGB) youths’ higher level of engagement in health risk behaviors relative to their heterosexual peers have largely relied on reports of encounters with discrete stigmatizing events, such as parental rejection and peer victimization.2 Yet, when social structures, institutions, and norms transmit disapproval or invalidation of LGB identities and life experiences, they have the potential to threaten LGB youths’ health independent of individual-level events.1,3,4The social climate surrounding LGB individuals both worldwide5 and in the United States6 is shaped by the moral debate regarding the legitimacy of homosexuality. Given that social ideology is closely intertwined with religious ideology in the United States, expressed attitudes toward homosexuality are largely aligned with degree and type of religious affiliation.6,7 A majority of US residents report that advancement of LGB rights, such as the legal recognition of same-sex marriage, clashes with their religious beliefs.8 Approximately 85% of individuals in the United States identify as religious, and more than half of the US population in 2003 believed that homosexuality is sinful.9Although condemnation of homosexuality has long been a part of many religious doctrines, not all religions hold similar beliefs toward homosexuality.10 Indeed, a 2011 survey of the US population showed that about half of religious adherents believe that society should accept homosexuality,11 highlighting a shift from the results of earlier studies and mirroring the changing attitudes toward same-sex marriage that also exist across some religious groups.12 In all, the US public''s view of homosexuality is changing and varies as a function of several characteristics, including religious affiliation.LGB youths construct their sexual identities within social climates shaped by these religious influences, with some LGB youths encountering more threatening climates than others given that religious demography varies widely by geographical region.13 The health risk behaviors of LGB youths may thus vary according to the religious composition of the communities in which they live, in that encountered stigma influences health-impairing coping behaviors.14 However, existing research has focused almost exclusively on associations between personal religiosity and health behaviors among LGB youths.15–17 Thus, research on the intersection of religious climate and the health behaviors of LGB youths remains limited.To address this gap in the literature, we used an objective index of community religiosity to predict tobacco use, alcohol abuse, and sexual behaviors in a sample of LGB and heterosexual youths. We hypothesized that religious climate would be associated with these health outcomes over and above the influence of other environmental factors surrounding LGB youths (e.g., school bullying policies, presence of Gay-Straight Alliances) and that the association would be stronger for LGB youths than for heterosexual youths. We also expected that religious climate would exert these health effects independent of established individual-level psychosocial predictors of health risk behaviors.     

Characteristics of Sexual Abuse in Childhood and Adolescence Influence Sexual Risk Behavior in Adulthood

Childhood and adolescent sexual abuse has been associated with subsequent (adult) sexual risk behavior, but the effects of force and type of sexual abuse on sexual behavior outcomes have been less well-studied. The present study investigated the associations between sexual abuse characteristics and later sexual risk behavior, and explored whether gender of the child/adolescent moderated these relations. Patients attending an STD clinic completed a computerized survey that assessed history of sexual abuse as well as lifetime and current sexual behavior. Participants were considered sexually abused if they reported a sexual experience (1) before age 13 with someone 5 or more years older, (2) between the ages of 13 and 16 with someone 10 or more years older, or (3) before the age of 17 involving force or coercion. Participants who were sexually abused were further categorized based on two abuse characteristics, namely, use of penetration and force. Analyses included 1177 participants (n=534 women; n=643 men). Those who reported sexual abuse involving penetration and/or force reported more adult sexual risk behavior, including the number of lifetime partners and number of previous STD diagnoses, than those who were not sexually abused and those who were abused without force or penetration. There were no significant differences in sexual risk behavior between nonabused participants and those who reported sexual abuse without force and without penetration. Gender of the child/adolescent moderated the association between sexual abuse characteristics and adult sexual risk behavior; for men, sexual abuse with force and penetration was associated with the greatest number of episodes of sex trading, whereas for women, those who were abused with penetration, regardless of whether the abuse involved force, reported the most episodes of sex trading. These findings indicate that more severe sexual abuse is associated with riskier adult sexual behavior.     

Protective School Climates and Reduced Risk for Suicide Ideation in Sexual Minority Youths

Objectives. We examined whether sexual minority students living in states and cities with more protective school climates were at lower risk of suicidal thoughts, plans, and attempts.Methods. Data on sexual orientation and past-year suicidal thoughts, plans, and attempts were from the pooled 2005 and 2007 Youth Risk Behavior Surveillance Surveys from 8 states and cities. We derived data on school climates that protected sexual minority students (e.g., percentage of schools with safe spaces and Gay–Straight Alliances) from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention.Results. Lesbian, gay, and bisexual students living in states and cities with more protective school climates reported fewer past-year suicidal thoughts than those living in states and cities with less protective climates (lesbians and gays: odds ratio [OR] = 0.68; 95% confidence interval [CI] = 0.47, 0.99; bisexuals: OR = 0.81; 95% CI = 0.66, 0.99). Results were robust to adjustment for potential state-level confounders. Sexual orientation disparities in suicidal thoughts were nearly eliminated in states and cities with the most protective school climates.Conclusions. School climates that protect sexual minority students may reduce their risk of suicidal thoughts.Suicide is the third leading cause of death among youths aged 15 to 24 years.1 Decades of research have identified multiple risk factors for adolescent suicide ideation and attempts.2 One of the most consistent findings is that lesbian, gay, and bisexual (LGB, or sexual minority) adolescents are more likely than heterosexual adolescents to endorse suicidal thoughts3,4 and to report having a suicide plan.5 Additionally, a recent review of the epidemiological literature found that LGB youths are between 2 and 7 times more likely to attempt suicide than their heterosexual peers.6Given the elevated risk of suicidal ideation, plans, and attempts among sexual minority youths, researchers have focused on identifying factors that explain these marked disparities. Theories of minority stress7 and stigma8 have highlighted the important roles that social-structural contexts as well as institutional practices and policies play in contributing to mental health disparities. Consistent with these theories, LGB adults who live in states with fewer protective social policies have higher rates of psychiatric and substance use disorders than LGB adults living in states with more protective policies.9,10 For instance, LGB adults in states that passed constitutional amendments banning same-sex marriage experienced a 37% increase in mood disorders, a 40% increase in alcohol use disorders, and nearly a 250% increase in generalized anxiety disorders in the year following the enactment of the amendments.10 These and other studies11 have shown that the broader social contexts surrounding LGB adults shape their mental health.Among adolescents, schools are an important social context that contributes to developmental and health outcomes.12 For sexual and gender minority youths in particular, the social context of schools can promote both vulnerability and resilience.13–16 A variety of methodological approaches have been used to evaluate the mental health consequences of school climates for LGB students. The predominant approach is to ask LGB adolescents to report on the supportiveness of their schools.17–19 Studies using this approach have indicated that LGB youths who report greater school connectedness and school safety also report lower suicidal ideation and fewer suicide attempts.18 Although informative, this research may introduce bias because information is self-reported for both the exposure and the outcome.20 Studies using alternative methodologies may therefore improve the validity of the inferences on the relationship between the social environment and individual health outcomes.An alternative methodological approach has been to develop indicators of school climate that do not rely on self-report, such as geographic location of the school (i.e., urban vs rural)21 and the presence of Gay–Straight Alliances in the school.22 Although this approach has received comparatively less attention in the literature, recent studies have documented associations between these more objective measures of school climate and sexual minority mental health. For example, lesbian and gay adolescents are at lower risk for attempting suicide if they live in counties where a greater proportion of school districts have antibullying policies that include sexual orientation.23 Although they provide important initial insights, existing studies have been limited by examining only 1 aspect of school climate (e.g., antibullying policies or presence of Gay–Straight Alliances),16,22,23 relying on nonprobability samples,16,22 and using a single location,16,22,23 all of which can restrict generalizability.We built on this previous research by using data on multiple school climate variables relevant to LGB students that we obtained from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention (CDC).24 We then linked this information on school climate to population-based data of adolescents living in 8 states and cities across the United States. We hypothesized that LGB adolescents living in states and cities with school climates that are more protective of sexual minority youths would be less likely to report past-year suicidal thoughts, plans, and attempts than LGB youths living in areas with less protective school climates.     

A Sexual Risk and Stress Reduction Intervention Designed for HIV-Positive Bisexual African American Men With Childhood Sexual Abuse Histories

Objectives. HIV transmission risk is high among men who have sex with men and women (MSMW), and it is further heightened by a history of childhood sexual abuse (CSA) and current traumatic stress or depression. Yet, traumatic stress is rarely addressed in HIV interventions. We tested a stress-focused sexual risk reduction intervention for African American MSMW with CSA histories.Methods. This randomized controlled trial compared a stress-focused sexual risk reduction intervention with a general health promotion intervention. Sexual risk behaviors, psychological symptoms, stress biomarkers (urinary cortisol and catecholamines), and neopterin (an indicator of HIV progression) were assessed at baseline and at 3- and 6-month follow-ups.Results. Both interventions decreased and sustained reductions in sexual risk and psychological symptoms. The stress-focused intervention was more efficacious than the general health promotion intervention in decreasing unprotected anal insertive sex and reducing depression symptoms. Despite randomization, baseline group differences in CSA severity, psychological symptoms, and biomarkers were found and linked to subsequent intervention outcomes.Conclusions. Although interventions designed specifically for HIV-positive African American MSMW can lead to improvements in health outcomes, future research is needed to examine factors that influence intervention effects.HIV/AIDS continues to disproportionately affect African Americans relative to other racial/ethnic groups.1,2 In 2009, for example, African Americans represented only 14% of the US population but accounted for 44% of all new HIV diagnoses.1 Male-to-male sexual contact is the greatest category of risk among Blacks, accounting for 73% of new infections among Black men.1 HIV infection rates are higher among Black men who have sex with men (MSM) than in any other racial/ethnic MSM group.1,2 Despite this disparity, few interventions have been designed specifically for African American MSM3–6 or for men who have sex with men and women (MSMW).Prevention strategies that emphasize HIV education and access to condoms may be inadequate in effecting sexual risk reduction in these populations. Preexisting risk factors and mediational mechanisms may operate differently among African American MSMW, who may also be less likely to respond to interventions that are developed for gay men3,7–9 or to those that are not contextualized for African American experiences. Intervention strategies that focus on less commonly examined mediators may influence sexual behavior changes and HIV transmission and serve as new modalities for addressing the HIV epidemic among African American MSMW.Individual behavior change is complicated by personal, environmental, historical, and institutional factors.10 Trauma exposure, a social determinant operating at multiple ecological levels, may be contributing to the HIV epidemic. Childhood sexual abuse (CSA) is a significant predictor of generalized emotional distress, anxiety, and posttraumatic stress disorder (PTSD) in adulthood,11–15 and it has also been associated with an increased risk of sexual revictimization.16–22 Experiencing CSA not only affects people’s health, but it may also have an impact on their interpersonal relationships in adulthood (e.g., how they select and interact with their intimate sexual partners). Societal and environmental factors such as the stigma associated with sexual abuse may also contribute to negative psychosocial health outcomes.23Acute traumatic and chronic stress is also known to disrupt neurobiological mechanisms essential for survival. Preclinical research demonstrates that all vertebrates share a similar threat system.24 Stimuli identified as potentially challenging to the basic state of equilibrium (i.e., stressors) trigger immediate release of catecholamines and subsequent release of glucocorticoids (e.g., cortisol). These regulatory systems have feedback loops that ensure a return to homeostasis when the threat subsides. However, when chronic or excessive demands are placed on these systems, long-term changes occur in the areas of growth, reproduction, and immune activity.24 These well-known effects are embodied in the allostatic load model,25 which reflects the cumulative burden of stress disruptions on primary mediators such as cortisol and catecholamines. Over time, primary mediator disruptions compromise efficient and effective responses to new demands, secondary downstream mediators (e.g., blood pressure and body mass index) are dysregulated, and ultimately an increased risk of tertiary disease outcomes results.26,27Major life events, including trauma and abuse experiences, and common but chronic challenges such as problems at work and home or relationship issues may all contribute to cumulative stress burdens.28 Among members of ethnic minority groups, racially discriminatory experiences may also be perceived as threatening and precipitate a stress response.29–31 Such chronic stress is thought to contribute to health disparities in racial/ethnic minority groups in a framework referred to as the weathering hypothesis.32,33 In the case of African Americans, racial, sociocultural, and political inequities, as well as trauma experiences such as CSA, may contribute to increased disease risk.Associations between CSA and increased HIV sexual risk behaviors34–38 and mental health symptoms have been reported among men with abuse histories.38,39 However, these relationships are complex. For example, PTSD with co-occurring depression has been shown to act as both a moderating and a mediating variable in the relationship between CSA and number of lifetime sexual partners.38,39 One recent study suggested that the associations of sexual risk behaviors with CSA trauma and with mental health symptoms were influenced by trauma and symptom severity.40 Severe CSA (e.g., forcible penetration over multiple incidents) and an increased number of PTSD symptoms were linked to more sexual risk behaviors among HIV-infected African American men. Also, mixed linear regression models showed that clinically meaningful levels of PTSD symptoms predicted a composite indicator of primary neurohormones (cortisol, norepinephrine, epinephrine, and dopamine) reflecting physical health risks.Although researchers have attempted to identify racial/ethnic differences in risk behaviors to explain disproportionate HIV rates,41 characteristics of trauma and subsequent mental and physical health stress burden have not been adequately examined. Research exploring whether stress reduction intervention components can reduce sexual risk behaviors and improve mental and physical health is still in its infancy. Evidence from HIV interventions links social cognitive models emphasizing relaxation skills, cognitive coping strategies, and social support to the mediation of mood effects and stress-related neurohormones.42–45 Decreased urinary cortisol levels with corresponding decreases in depressive symptoms and decreased urinary norepinephrine levels with reduced anxiety symptoms have been reported.42,46Two meta-analyses showed that cognitive–behavioral interventions decreased psychological symptoms such as depression, anxiety, anger, and stress among people living with HIV/AIDS.43,44 Unfortunately, immune functioning, as evidenced by CD4^43,44 and viral load,43 showed little improvement. A study involving a 15-session individual stress management intervention for people with HIV reported a decreased frequency of unprotected sexual acts but no effect on depression and anxiety symptoms.47 Another intervention, employing cognitive and stress management strategies with people who had HIV/AIDS and a history of CSA, reported decreases in both traumatic stress symptoms48 and unprotected sex acts.49 Comprehensive interventions designed to reduce sexual risk behaviors, psychological difficulties, and stress-related neurohormones are lacking.We conducted a small, randomized clinical trial to develop and test the Enhanced Sexual Health Intervention for Men (ES-HIM) that targeted HIV-positive African American MSMW who did not self-identify as gay and who had histories of CSA. We compared ES-HIM with an attention-matched health promotion intervention (HP) with respect to their efficacy in reducing sexual risk behaviors (i.e., unprotected anal and vaginal sex), numbers of sexual partners, psychological symptoms of PTSD and depression, and primary neurohormonal mediators (cortisol and catecholamines). We also explored the intervention’s effects on neopterin, which is produced primarily in monocytes and macrophages. Because neopterin is responsive to immune-inflammatory stimuli, it can serve as an indicator of HIV disease progression (i.e., deterioration of one’s health status as a result of stress).     

Genome-Wide Linkage and Association Study of Childhood Gender Nonconformity in Males

Archives of Sexual Behavior - Male sexual orientation is influenced by environmental and complex genetic factors. Childhood gender nonconformity (CGN) is one of the strongest correlates of...     

Childhood Abuse and Adolescent Sexual Re-Offending: A Meta-Analysis

Recent research indicates that adolescents who have sexually offended are more likely than other adolescents to have a history of sexual and physical abuse. However, it is unclear whether abuse predicts re-offending among these adolescents. To examine this relationship, a meta-analysis was conducted which included 29 effect sizes drawn from 11 published and unpublished studies involving 1542 sexually abusive adolescents. The results indicate a significant but small relationship between history of sexual abuse and sexual re-offending (O.R. = 1.51, p < .05). In contrast, sexual abuse did not significantly predict general re-offending, although there was significant heterogeneity across studies. The relationship between physical abuse and recidivism (sexual and general) was non-significant. Due to methodological shortcomings in this area, such as limitations in methods of determining abuse history and the scarcity of research, the ability to make conclusions about the relationship between abuse and adolescent sexual recidivism is limited. As such, the discussion outlines how new studies can address these shortcomings and advance knowledge.     

Sexual Abuse in Childhood and Sexual Dysfunction in Adulthood: An Australian Population-Based Study

This study examined self-reported adult sexual functioning in individuals reporting a history of childhood sexual abuse (CSA) in a representative sample of the Australian population. A sample of 1793 persons, aged 18–59 years, were randomly selected from the electoral roll for Australian states and territories in April 2000. Respondents were interviewed about their health status and sexual experiences, including unwanted sexual experiences before the age of 16 years. More than one-third of women and approximately one-sixth of men reported a history of CSA. Women were more likely than men to report both non-penetrative and penetrative experiences of CSA. For both sexes, there was a significant association between CSA and symptoms of sexual dysfunction. In assessing the specific nature of the relationship between sexual abuse and sexual dysfunction, statistically significant associations were, in general, evident for women only. CSA was not associated with the level of physical or emotional satisfaction respondents experienced with their sexual activity. The total number of lifetime sexual partners was significantly and positively associated with CSA for females, but not for males; however, the number of sexual partners in the last year was not related to CSA. CSA in the Australian population is common and contributes to significant impairment in the sexual functioning of adults, especially women. These consequences appear not to extend to the other areas of sexual activity considered in this study.     

Explaining the Suicide Risk of Sexual Minority Individuals by Contrasting the Minority Stress Model with Suicide Models

Many studies have found elevated levels of suicide ideation and attempts among sexual minority (homosexual and bisexual) individuals as compared to heterosexual individuals. The suicide risk difference has mainly been explained by minority stress models (MSTM), but the application of established suicidological models and testing their interrelations with the MSTM has been lacking so far. Therefore, we have contrasted two established models explaining suicide risk, the Interpersonal Psychological Theory (IPT) (Joiner, 2005) and the Clinical Model (CM) (Mann et al., 1999), with the MSTM (Meyer, 2003) in a Bavarian online-sample of 255 adult sexual minority participants and 183 heterosexual participants. The results suggested that the CM and the IPT model can well explain suicide ideation among sexual minorities according to the factors depression, hopelessness, perceived burdensomeness, and failed belongingness. The CM and the IPT were intertwined with the MSTM via internalized homophobia, social support, and early age of coming out. Early coming out was associated with an increased suicide attempt risk, perhaps through violent experiences that enhanced the capability for suicide; however, coming out likely changed to a protective factor for suicide ideation by enhanced social support and reduced internalized homophobia. These results give more insight into the development of suicide risk among sexual minority individuals and may be helpful to tailor minority-specific suicide prevention strategies.     

Gender Nonconformity, Childhood Rejection, and Adult Attachment: A Study of Gay Men

Several childhood factors are reported to be associated with a homosexual orientation in men, including gender nonconformity and rejection by parents and peers. The purpose of this study was to explore the associations between these childhood factors and attachment anxiety (the tendency to experience anxiety regarding potential loss and rejection in close relationships) and attachment avoidance (the tendency to avoid versus seek out closeness in relationships) in gay and bisexual men. A community sample of 191 gay and bisexual men completed questionnaires and an attachment interview. Gender nonconformity was significantly associated with paternal, maternal, and peer rejection in childhood. In addition, paternal and peer rejection, but not maternal rejection, independently predicted attachment anxiety. Peer rejection and, to a lesser extent, paternal rejection mediated the association between gender nonconformity and attachment anxiety. Finally, peer rejection mediated the association between paternal rejection and attachment avoidance. Findings highlight the role of gender nonconformity in contributing to childhood rejection and the importance of peer relationships in the socialization of gay men.     

Psychosocial Predictors of Sexual HIV Transmission Risk Behavior among HIV-Positive Adults with a Sexual Abuse History in Childhood

Childhood sexual abuse (CSA) is associated with HIV sexual risk behavior. Although many psychosocial correlates of sexual risk among HIV-positive persons have been identified, studies predicting continued risk among HIV-positive adults with histories of CSA are limited. This cross-sectional study identified variables predictive of sexual transmission risk behavior among an ethnically diverse sample of 256 HIV-positive adults (women and men who have sex with men; MSM) with CSA histories. Participants were assessed for trauma symptoms, shame related to HIV and sexual trauma, substance use, coping style, and sexual risk behavior. Logistic regression analyses were conducted to identify variables predictive of unprotected sexual behavior in the past 4 months. Unprotected sex was significantly associated with substance use and trauma-related behavioral difficulties among women and men, and less spiritual coping among men. Unprotected sex with HIV negative or serostatus unknown partners was significantly associated with greater trauma-related behavioral difficulties, more HIV-related shame, and fewer active coping strategies. Thus, trauma symptoms, shame, coping style, and substance use were significantly associated with sexual risk behavior among HIV-positive adults with histories of CSA, with models of prediction differing by gender and partner serostatus. HIV prevention intervention for persons with HIV and CSA histories should address trauma-related behavioral difficulties and enhance coping skills to reduce sexual transmission risk behavior.     

Minority Stress and Substance Use in Sexual Minority Adolescents: A Meta-analysis

Lesbian, gay, and bisexual (LGB) adolescents report disparate rates of substance use, and often consume more cigarettes, alcohol, marijuana, cocaine, and ecstasy than their heterosexual peers. It is therefore crucial to understand the risk factors for substance use among LGB adolescents, particularly those unique to their minority status. In an effort to organize the current knowledge of minority-related risk factors for substance use among LGB youth, this study presents results from a systematic review and meta-analysis of the published research literature. Results from 12 unique studies of LGB youth indicated that the strongest risk factors for substance use were victimization, lack of supportive environments, psychological stress, internalizing/externalizing problem behavior, negative disclosure reactions, and housing status. Results are discussed in terms of their implications for targeted intervention programs that address minority stress risk factors for substance use among LGB youth.     

Risk of Substance Abuse and Dependence Among Young Adult Sexual Minority Groups Using a Multidimensional Measure of Sexual Orientation

Objective

We examined associations between two definitions of sexual minority status (SMS) and substance abuse and/or dependence among young adults in a national population.

Methods

A total of 14,152 respondents (7,529 women and 6,623 men) interviewed during wave four of the National Longitudinal Study of Adolescent Health were included in the study (age range: 24–32 years). We used two definitions of SMS based on self-reported attraction, behavior, and identity: 1-indicator SMS (endorsing any dimension) and 3-indicator SMS (endorsing all dimensions). Outcomes included nicotine dependence as well as ≥3 signs of substance dependence, any sign of substance abuse, and lifetime diagnosis of abuse or dependence for alcohol, marijuana, and a composite measure of other drugs. Weighted logistic regression models were fit to estimate the odds of each outcome for each of the sexual minority groups (compared with the heterosexual majority), controlling for sociodemographic covariates.

Results

SMS women were more likely than exclusively heterosexual women to experience substance abuse and dependence, regardless of substance or SMS definition. In adjusted models for women, 3-indicator SMS was most strongly associated with abuse/dependence (adjusted odds ratio [AOR] range: 2.74–5.17) except for ≥3 signs of cannabis dependence, where 1-indicator SMS had the strongest association (AOR=3.35). For men, the 1-indicator SMS group had higher odds of nicotine dependence (AOR=1.35) and the 3-indicator SMS group had higher odds of ≥3 signs of alcohol dependence (AOR=1.64).

Conclusions

Young adult female sexual minority groups, regardless of how defined, are at a higher risk than their heterosexual peers of developing alcohol, drug, or tobacco abuse and dependence.Substance abuse and dependence represent significant problems for young adults in the United States. Data from the 2010 National Survey on Drug Use and Health found that 19.8% of emerging adults aged 18–25 years and 7.0% of young adults aged 26 years or older met the criteria for illicit drug or alcohol abuse or dependence in the preceding year.¹The risk for substance use may be particularly heightened among sexual minority or lesbian/gay/bisexual individuals. Across all ages, sexual minority status (SMS) has been associated with higher odds for smoking,^2–5 binge drinking and heavy alcohol consumption,^2–4,6–8 and illicit drug use.^5,8–11 The potential pathways between sexual orientation and substance use have primarily been examined within the frameworks of social stress and minority-specific stress in particular. Meyer''s Minority Stress Model posits that those in sexual minority groups will experience higher amounts of repeated, lifelong stressors than exclusively heterosexual individuals.¹² The convergence of stressors can negatively bias self-perception, which can decrease coping mechanisms and eventually result in negative mental health outcomes. Pascoe and Richman''s Perceived Discrimination and Health Model further suggests that continuously experienced discrimination and subsequent increased risk of perceiving or internalizing prejudice can result in the adoption of negative coping health behaviors, such as substance use or heavy drinking.¹³Not explicitly stated in these models, however, is the understanding that sexual orientation is not a uniform exposure; rather, it is multidimensional and fluid, reflecting attraction, behavior, and self-applied identity dimensions that are not necessarily consistent for a given individual at one time point, nor stable over time.¹⁴ Further, the pathways between experienced stressors and substance abuse may be moderated by differing patterns of expressed or endorsed orientation dimensions. An examination of SMS identification among adolescents found that participants who defined their identity as heterosexual, yet had experienced same-sex attraction or partnering, were significantly more likely than exclusively heterosexual adolescents to smoke, use hard drugs, and have suicidal thoughts.⁵ Similarly, in an examination among adults participating in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), odds of lifetime alcohol, stimulant, and hallucinogen use disorder were lower among both males and females reporting a heterosexual identity and same-sex attraction (i.e., heterosexual discordant) than among those reporting a gay/lesbian identity and same-sex attraction (i.e., gay/lesbian concordant). When concordance was defined on the basis of behavior, only heterosexual discordant females had higher odds of lifetime use disorders for alcohol and several classes of drugs than those who reported heterosexual identity and behavior (heterosexual concordant), and no association was observed between heterosexual discordant and gay/lesbian concordant women.¹⁵To date, several studies have examined how endorsement of individual dimensions of sexual orientation predicts substance use behaviors. For adolescent respondents (aged 15–24 years) in the National Survey of Family Growth, the odds of substance use were higher among SMS women than among exclusively heterosexual women regardless of dimension considered, with expression of a lesbian or bisexual identity emerging as the strongest predictor of use for all substances except cannabis. For men, however, SMS was predictive only for non-cannabis illicit drug use among men endorsing an SMS identity or attraction.¹⁶ An analysis of 24- to 32-year-old respondents in the National Longitudinal Study of Adolescent Health (Add Health) found higher odds of smoking among sexual minority women for each indicator of orientation, as well as higher odds of binge drinking, both among those reporting a lesbian/bisexual identity and those reporting same-sex attraction. For males, same-sex partnering emerged as the only significant predictor, and only for binge drinking; in contrast to the female literature, the association was negative, with those reporting exclusively male partnering having lower rates of binge drinking.¹⁷ Taken together, these varied findings indicate not only that a more expansive definition of sexual orientation is needed when examining associations between sexuality and substance use, but that it is important to consider biological sex in these investigations.Further, the association between sexual orientation and substance use may differ based on substance use outcome considered. For example, one examination of NESARC respondents found that lesbian-identifying women and sexual minority men (regardless of orientation dimension) were significantly more likely than their exclusively heterosexual peers to have met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria in the past year for alcohol dependence, but not heavy drinking.¹⁸ Substance dependence, which may or may not include “physical dependence” (withdrawal symptoms) or “tolerance” (the need to use increased amounts of a drug to achieve the desired effect), is indicated by taking a drug in larger amounts than intended, an inability to cut down on drug use, excessive time spent to obtain the drug, and continued drug use despite health or social problems caused by the drug. Abuse is indicated by a failure to fulfill major role obligations, legal problems, or continued drug use despite persistent social or interpersonal problems.¹⁹ Given the chronic exposures of both minority stressors and dependence and abuse symptoms, such outcomes may be more relevant to this population, particularly as substance dependence and abuse likely have a more significant impact on health and development than simply substance use.We examined the association between SMS and substance abuse and dependence, incorporating multiple indicators of sexual orientation, in a contemporary population-based sample of young women and men.     

Risk Reduction for HIV-Positive African American and Latino Men with Histories of Childhood Sexual Abuse

While the HIV epidemic has disproportionately affected African American and Latino men who have sex with men (MSM), few HIV prevention interventions have focused on African American and Latino men who have sex with both men and women (MSMW). Even fewer interventions target HIV-positive African American and Latino MSM and MSMW with histories of childhood sexual abuse (CSA), a population that may be vulnerable to high-risk sexual behaviors, having multiple sexual partners, and depression. The Men's Health Project, a small randomized clinical trial, compared the effects of two 6-session interventions, the Sexual Health Intervention for Men (S-HIM), guided by social learning theory and aimed at decreasing high-risk sexual behaviors, number of sexual partners, and depressive symptoms, and a standard health promotion control (SHP). A community sample of 137 HIV-positive gay and non-gay identifying African American and Latino MSM and MSMW with histories of CSA was recruited. Results were based on an "intent to treat" analyses of baseline to post, 3 and 6 month follow-ups. The sample as a whole reported reductions in sexual risk behaviors and number of sexual partners from baseline to post-test, and from the 3 to 6 month follow-ups, although the decrease in sexual risk behavior from baseline to post-test was significant only for S-HIM participants. No significant differences between conditions were reported for depressive symptoms, but the total sample reported a significant decrease at 6 months. These findings highlight the importance of addressing sexual decision-making and psychological adjustment for ethnic men, while being sensitive to CSA histories and sexual minority status, and suggest the need to develop additional strategies to heighten HIV risk reduction over time.     

The Influence of Childhood Physical Abuse on Adult Health Status in Sexual Minority Women: The Mediating Role of Smoking

BackgroundAmong women in the general population, childhood physical abuse (CPA) is associated with poor adult health status and engagement in health risk behaviors. Sexual minority women (SMW) are at elevated risk of CPA, have higher rates of smoking, and may be at higher risk for poorer general health. In this study, we examined the influences of CPA on health status in a diverse sample of SMW. We hypothesized that SMW with a history of CPA would report poorer health than those without such histories and that early onset of smoking—an important health risk behavior—would mediate the relationship between CPA and current health status.MethodsStructural equation modeling was used to evaluate the influence of CPA on early health risk behavior (i.e., age of smoking onset) and current perceived health status in a community based sample of 368 SMW.ResultsMore than one fifth of the sample (21.5%) reported a history of CPA. One fourth of the sample was current smokers; the average age of smoking onset was 19 to 20 years old. The mean level of self-rated health status was between “fair” and “good.” When relationships were simultaneously estimated, the effect of CPA on health status was mediated by two sequential smoking factors: CPA was associated with earlier age of smoking onset, and age of smoking onset was associated with current smoker status. Being a current smoker had a negative effect on perceived health status.Implications for Practice and/or PolicyThese results suggest that tobacco use is an important pathway by which CPA influences current health status. Prevention and early intervention initiatives should focus on the reduction of CPA among SMW to eliminate the long-term health consequences of adverse childhood events among SMW.     

Childhood Sexual Abuse and Adult Sexual Dysfunction: Response to Commentary by Rind and Tromovitch (2007)

Rind and Tromovitch (2007) raised four concerns relating to our article (Najman, Dunne, Purdie, Boyle, & Coxeter, 2005. Archives of Sexual Behavior, 34, 517–526.) which suggested a causal association between childhood sexual abuse (CSA) and adult sexual dysfunction. We consider each of these concerns: magnitude of effect, cause and effect, confounding, and measurement error. We suggest that, while the concerns they raise represent legitimate reservations about the validity of our findings, on balance the available evidence indicates an association between CSA and sexual dysfunction that is of “moderate” magnitude, probably causal, and unlikely to be a consequence of confounding or measurement error. Editor’s note. The authors were asked by the Editor to offer a reply to the article by Rind and Tromovitch.