Psychological Distress and Suicidality Among Transgender Young Adults in the United States.

PURPOSE: Transgender young adults (TYA) are burdened by adverse mental health outcomes. Guided by intersectionality and minority stress frameworks, we compared prevalence of psychological distress and suicidality among TYA of different social identities to inform future interventions. METHODS: In this secondary data analysis of 12,738 TYA, ages 18-25 years, from the 2015 United States Transgender Survey, we developed multivariable regression models examining associations between social identities and psychological distress and suicidality, adjusting for relevant covariates. Self-reported identities were used as proxies for minority stress resulting from structural oppressions related to gender binarism, transmisogyny, heterosexism, and racism. RESULTS: Overall, 53% met criteria for serious psychological distress, and 66% reported suicidal ideation. Statistically higher odds of serious psychological distress and suicidal ideation and plan were found for TYA assigned male compared to assigned female at birth (adjusted odds ratios [aORs] = 1.14-1.50). Nonbinary TYA assigned male at birth also had lower odds of all outcomes compared to all other TYA (aORs = 0.6-0.7). Compared to White TYA, Latiné/x TYA were more likely to experience serious psychological distress (aOR = 1.19, 95% confidence interval: 1.02, 1.39) and multiracial TYA were more likely to report suicide plan(s) and attempt(s) (aORs = 1.25-1.30). Finally, compared to heterosexual TYA, bisexual/pansexual TYA were more likely to report suicide plan(s) (aOR = 1.28, 95% confidence intervals: 1.04, 1.52), and all sexual minority TYA were more likely to report serious psychological distress and suicidal ideation (aORs = 1.31-2.00). DISCUSSION: Results highlight complex associations between intersectional minority stress and mental health outcomes among TYA. Associations between identities and mental health morbidity highlight an urgent need for targeted mental health interventions.

Sexual orientation in transgender adults in the United States.

BACKGROUND: Sexual orientation refers to a person's enduring emotional, romantic, or sexual attractions to other people. Sexual orientation measures do not typically consider desires for, or sexual behavior with, transgender people. We describe measures inclusive of transgender people and characterize sexual orientation identity, behavior, and attraction in a representative sample of the U.S. transgender population. METHODS: Between April 2016-December 2018, a U.S. national probability sample of transgender (n = 274) and cisgender (n = 1,162) adults were invited to complete a self-administered web or mailed paper survey. We assessed sexual identity with updated response options inclusive of recent identity terms (e.g., queer), and revised sexual behavior and attraction measures that included transgender people. Multiple response options were allowed for sexual behavior and attraction. Weighted descriptive statistics and sexual orientation differences by gender identity groups were estimated using age-adjusted comparisons. RESULTS: Compared to the cisgender population, the transgender population was more likely to identify as a sexual minority and have heterogeneity in sexual orientation, behavior, and attraction. In the transgender population, the most frequently endorsed sexual orientation identities were "bisexual" (18.9%), "queer" (18.1%), and "straight" (17.6%). Sexually active transgender respondents reported diverse partners in the prior 5 years: 52.6% cisgender women (CW), 42.7% cisgender men (CM), 16.9% transgender women (TW), and 19.5% transgender men (TM); 27.7% did not have sex in the past 5 years. Overall, 73.6% were "somewhat"/ "very" attracted to CW, 58.3% CM, 56.8% TW, 52.4% TM, 59.9% genderqueer/nonbinary-females-at-birth, 51.9% genderqueer/nonbinary-males-at-birth. Sexual orientation identity, behavior, and attraction significantly differed by gender identity for TW, TM, and nonbinary participants (all p < 0.05). CONCLUSIONS: Inclusive measures of sexual orientation captured diverse sexual identities, partner genders, and desires. Future research is needed to cognitively test and validate these measures, especially with cisgender respondents, and to assess the relation of sexual orientation and health for transgender people.

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

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

Minority stress theory: Application, critique, and continued relevance.

The minority stress model has been influential in guiding research on sexual and gender minority health and well-being in psychology and related social and health sciences. Minority stress has theoretical roots in psychology, sociology, public health, and social welfare. Meyer provided the first integrative articulation of minority stress in 2003 as an explanatory theory aimed at understanding the social, psychological, and structural factors accounting for mental health inequalities facing sexual minority populations. This article reviews developments in minority stress theory over the past two decades, focusing on critiques, applications, and reflections on its continued relevance in the context of rapidly changing social and policy contexts.

Violent victimization at the intersections of sexual orientation, gender identity, and race: National Crime Victimization Survey, 2017-2019.

INTRODUCTION: Prior research has found that experiences with violence in the U.S. differ across individual demographic characteristics, including race, gender, and sexual orientation. However, peer reviewed studies have yet to examine the relationship between the intersections of race, gender, and sexual orientation, victimization risk, and characteristics of victimization. METHODS: We use data from three years (2017-2019) of the National Crime Victimization Survey, the primary source of information on criminal victimization in the United States, to examine victimization at the intersection of sexual orientation, gender, and race/ethnicity. We test whether non-Hispanic Black, Hispanic, and non-Hispanic White sexual and gender minority (SGM) persons aged 16 or over are victimized at greater rates than their non-SGM counterparts and assess whether there are differences between sexual minority females and males of each racial group. We further document characteristics of victimization such as reporting to the police by SGM status and race or ethnicity. RESULTS: We find that SGMs are disproportionately more likely to be victims of violent crime than non-SGM people, and these disparities are present across the assessed racial and ethnic groups (non-Hispanic Black odds ratio [OR] = 3.3, 90% CI [CI] = 1.36, 5.16; Hispanic OR = 4.5, CI = 2.25, 6.71; non-Hispanic White OR = 4.8, CI = 2.25, 6.71). However, sexual orientation disparities are statistically distinguishable for lesbian or bisexual (LB) non-Hispanic White and Hispanic females but not for non-Hispanic Black LB females. Among LB females, the overall differences in victimization were primarily driven by bisexual respondents. We further find racial and ethnic differences among SGM victims in the likelihood of having the victimization reported to the police, in the utilization of community (non-police) resources, and in other aspects of victimization experiences, such as whether arrests occurred or in the suspicion that the violent incident was a hate crime. CONCLUSIONS: Our findings raise indicate a complex picture of how sexual orientation, gender identity, sex, and race and ethnicity interact in victimizations and their characteristics that should be further explored.

Hate crimes against LGBT people: National Crime Victimization Survey, 2017-2019.

We estimate the prevalence and characteristics of violent hate crime victimization of lesbian, gay, bisexual, and transgender (LGBT) people in the United States, and we compare them to non-LGBT hate crime victims and to LGBT victims of violent non-hate crime. We analyze pooled 2017-2019 data from the National Crime Victimization Survey (n persons = 553, 925;n incidents = 32, 470), the first nationally representative and comprehensive survey on crime that allows identification of LGBT persons aged 16 or older. Descriptive and bivariate analysis show that LGBT people experienced 6.6 violent hate crime victimizations per 1,000 persons compared with non-LGBT people's 0.6 per 1,000 persons (odds ratio = 8.30, 95% confidence interval = 1.94, 14.65). LGBT people were more likely to be hate crime victims of sexual orientation or gender bias crime and less likely to be victims of race or ethnicity bias crimes compared to non-LGBT hate crime victims. Compared to non-LGBT victims, LGBT victims of hate crime were more likely to be younger, have a relationship with their assailant, and have an assailant who is white. Compared to LGBT victims of non-hate violence, more LGBT hate crime victims reported experiencing problems in their social lives, negative emotional responses, and physical symptoms of distress. Our findings affirm claims that hate crimes have adverse physical and psychological effects on victims and highlight the need to ensure that LGBT persons who experience hate crime get necessary support and services in the aftermath of the crime.

Mental Health Among Sexual and Gender Minority Youth Incarcerated in Juvenile Corrections.

OBJECTIVES: This study examined differences by sexual and gender minority (SGM) and incarceration statuses in mental health indicators among youth. METHODS: Population-based, cross-sectional data are from the 2019 Minnesota Student Survey (N = 72 324) and includes public school students (Mage = 15.49) and youth incarcerated in juvenile correctional facilities (Mage = 15.48). We categorized youth into 4 groups: (1) non-SGM youth in public schools, (2) non-SGM youth in correctional facilities, (3) SGM youth in public schools, and (4) SGM youth in correctional facilities. Multivariable regression models assessed associations among SGM and incarceration statuses and mental health indicators after controlling for sociodemographic characteristics and exposure to adverse childhood experiences. RESULTS: More youth in juvenile correctional facilities identified as SGM (28.8%) compared with youth in public schools (20.4%, P = .002). SGM youth in correctional facilities reported a higher prevalence of suicidal ideation (42.2%), suicide attempt (37.5%), and self-harm (57.8%) compared with all other groups. Depressive symptom severity was similarly elevated among SGM youth in correctional facilities and SGM youth in public schools. SGM youth in correctional facilities, compared with non-SGM youth in public schools, demonstrated elevated odds of suicide ideation (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [95% CI] = 1.3-3.9), suicide attempt (aOR = 6.3, 95% CI = 3.6-10.9), and self-harm (aOR = 3.6, 95% CI = 2.1-6.3). CONCLUSIONS: Incarcerated SGM youth disproportionately experience negative mental health indicators. Findings suggest that tailored, intersectional, and responsive mental health interventions are needed to support incarcerated SGM youth.

Sexual Identity and Birth Cohort Differences in Social Support and Its Link with Well-Being among Sexual Minority Individuals.

This study examined sexual identity and birth cohort differences in social support and its association with well-being, using a longitudinal national probability sample of 706 cisgender and non-binary sexual minority individuals from the USA. The data allowed for extensive descriptions of perceived social support and support networks across subgroups. Findings demonstrated that sexual identity and birth cohort differences in overall sizes of support networks and levels of perceived social support were small. Furthermore, fixed effects analyses indicated that changes in the size of respondents' social support networks were not related to well-being, with a one-person change being associated with a .04 SD change in well-being or less, depending on the indicator of well-being being tested. Moreover, changes in perceived social support were only limitedly related to changes in respondents' well-being, a 1-point change in the scale of perceived social support being associated with a .11 SD change in life-satisfaction. Associations were smaller for overall well-being or psychological distress, the other two indicators of well-being used. Together, these findings could imply that cross-sectional research has overestimated the relevance of social support for the well-being of sexual minority individuals, but also that general social support is insufficiently tailored to the support needs of the sexual minority population.

Social change and relationship quality among sexual minority individuals: Does minority stress still matter?

Objective: This study examined whether positive changes in social attitudes and policies surrounding sexual minority relationships have translated to diminished deleterious effects of minority stress on relationship quality. Background: Sexual minority emerging adults now come of age at a time of greater equality and acceptance than previous generations. Research has demonstrated consistent negative effects of stigma-theorized as minority stress-on relationship quality for sexual minority individuals. However, given the improving social climate, questions remain regarding whether minority stress has the same deleterious effects on the romantic relationships of sexual minority emerging adults. Method: Five-hundred forty-nine individuals in relationships drawn from a US national probability sample completed a survey containing validated measures of minority stressors and relationship satisfaction. Responses from emerging adults (aged 18-25) were compared to two cohorts who came of age during the HIV/AIDS crisis (aged 34-41) and post Stonewall (aged 52-59). Results: Emerging adults were more satisfied with their relationships than older cohorts. Experiences of everyday discrimination were associated with decreased relationship satisfaction for all cohorts; however, felt stigma, stigma concealment, and internalized stigma were associated with lower relationship satisfaction for older but not younger cohorts. Conclusion: Findings illustrate the continued but shifting role of minority stress and provide the first evidence that social and policy changes may have translated into more positive relationship experiences for sexual minority emerging adults.

Distribution and Prevalence of Health in a National Probability Sample of Three Cohorts of Sexual Minority Adults in the United States.

Purpose: This study examined the health profile of a national probability sample of three cohorts of sexual minority people, and the ways that indicators of health vary among sexual minority people across age cohorts and other defining sociodemographic characteristics, including sexual identity, gender identity, and race/ethnicity. Methods: The Generations Study, the first national probability sample of three age cohorts of sexual minority people (n = 1507) in the United States collected in 2016-2017, was used to examine general health profiles across several broad domains: alcohol and drug abuse; general health, physical health, and health disability; mental health and psychological distress; and positive well-being, including general happiness, social well-being, and life satisfaction. Results: There were no cohort differences in substance abuse or positive well-being. The younger cohort was physically healthier, but had worse psychological health than both the middle and older cohorts. Conclusions: Cohort differences in physical health were consistent with patterns of aging, whereas for mental health, there were distinct cohort differences among sexual minority people. Given that compromised mental health in the early life course creates trajectories of vulnerability, these results point to the need for mental health prevention and intervention for younger cohorts of sexual minority people.

Social Change and the Health of Sexual Minority Individuals: Do the Effects of Minority Stress and Community Connectedness Vary by Age Cohort?

This study examined the extent to which social stress stemming from a stigmatized social status (i.e., minority stress) was associated with three domains of health in younger as compared with older age cohorts of sexual minority individuals. Data were analyzed from the Generations Study, a longitudinal study using a probability sample (N = 1518) of age cohorts of sexual minority individuals in the USA. Exposure to a variety of minority stressors was associated with poorer health for all age cohorts. We hypothesized that because of improved social and legal environments in recent years, the associations between minority stress and health would be diminished in the younger cohort. As expected, we found that the associations between some minority stressors and health outcomes were diminished in the younger cohort compared to older cohorts. Positive associations between community connectedness and mental health and social well-being were observed for all participants but were attenuated in the younger cohort. Findings demonstrate the continuing negative association between minority stress and health among sexual minorities, which, despite some attenuation, persists even for young cohorts of sexual minority individuals in a more equal and accepting social climate.

"White, Tall, Top, Masculine, Muscular": Narratives of Intracommunity Stigma in Young Sexual Minority Men's Experience on Mobile Apps.

What forms of intracommunity stigma do young sexual minority men narrate as they participate in communities through mobile apps? In a content analysis of 32 interviews with a racially diverse sample of young sexual minority men (ages 19-25; 84.4% non-White) from four regions of the USA, a majority of men (62.5%) spontaneously discussed mobile apps (e.g., Grindr, Scruff) when asked about their experience of community more broadly. Men's narratives revealed engagement with intracommunity stigma related to body size, race/ethnicity, gender expression, and sexual position (e.g., bottom). Stigma related to HIV status, substance use, and social class were not spontaneously narrated in response to questions about men's experience in communities. Expressions of stigma were frequently experienced intersectionally, particularly regarding racialized stereotype expectations (e.g., "Asian men are twinks, effeminate"). We discuss the ways in which sexual minority men reproduce dominant ideologies related to racism, misogyny, and masculine body ideals as they engage with one another on mobile apps. To the extent that many young men rely on mobile apps for community connection, their experiences of community might serve to exacerbate, rather than ameliorate, the deleterious impact of stigma.

Mental Health Among Black and Latinx Sexual Minority Adults Leading Up to and Following the 2016 U.S. Presidential Election: Results from a Natural Experiment.

Purpose: Multi-level hostility toward sexual minority (SM; includes, but is not limited to those identifying as gay, lesbian, bisexual, queer, or same-gender loving) and other minority populations (e.g., racial/ethnic) increased after the 2016 U.S. presidential election. This may generate stress and mental health problems among those groups, and particularly among SM people of color. This study assessed whether the mental health of Black and Latinx SM adults declined after the 2016 U.S. presidential election. Methods: Data were from a daily national probability survey (thus, mean changes in mental health outcomes over time may reflect population shifts in mental health) of Black and Latinx SM adults (N = 537), recruited 7 months before and 17 months after the November 8, 2016 election. Using a between-subjects design, spline-based regressions (spline set at election date), adjusted for sociodemographic characteristics, estimated four mental health outcomes (past-month number of "poor mental health" days and psychological distress, past-year suicidal ideation, and social wellbeing) as a function of survey completion date. Results: There was marked worsening in each of the mental health outcomes over the postelection period (past-month poor mental health days, B = 0.05, standard error [SE] = 0.02, p < 0.05; psychological distress, B = 0.28, SE = 0.14, p < 0.05; suicidal ideation, odds ratio = 1.13, 95% confidence interval >1.00-1.26, p < 0.05; and social wellbeing, B = -0.05, SE = 0.02, p < 0.05). None of the outcomes varied over the pre-election period. Conclusions: This study provides evidence of worsening mental health among Black and Latinx SM adults in the United States during the 1.5 years after the 2016 U.S. presidential election.

Cardiovascular Disease in a Population-Based Sample of Transgender and Cisgender Adults.

INTRODUCTION: Existing data on cardiovascular disease among transgender people are inconsistent and are derived from nonrepresentative samples or population-based data sets that do not include transgender-specific risk factors such as gender-affirming hormone use and gender minority stressors. A nationally representative sample of cisgender and transgender adults aged ≥40 years was used to assess the prevalence and correlates of smoking, select cardiovascular disease conditions, and venous thromboembolism. METHODS: Participants were recruited from 2016 to 2018, with analysis conducted in December 2020 with 114 transgender and 964 cisgender individuals. Sample weights and multiple imputations were used for all estimates except for descriptive statistics. Logistic regression models estimated the ORs and 95% CIs expressing the relationship between each outcome variable and a set of independent variables. Each model controlled for race and age. RESULTS: No meaningful differences between cisgender and transgender participants were found in smoking or cardiovascular disease conditions. However, there was an increased odds of venous thromboembolism among transgender women compared with those among cisgender women. Transgender people had greater odds of discrimination, psychological distress, and adverse childhood experiences. These stressors were associated with increased odds of a cardiovascular condition, and everyday discrimination and adverse childhood experiences were associated with increased odds of smoking. Discrimination and psychological distress were associated with venous thromboembolism. CONCLUSIONS: Transgender people face disparities in cardiovascular disease risk. This study provides support for the gender minority stress model as a framework for understanding cardiovascular disease disparities. Future research with larger samples and adjudicated outcomes is needed to advance the field.

Sexual Orientation and Gender Identity Change Efforts and Suicide Morbidity Among Sexual and Gender Minority Adults in Colombia.

Purpose: We assessed the association between sexual orientation and gender identity change efforts (SOGICE) experiences and lifetime suicide morbidity among sexual and gender minority (SGM) groups in Colombia. Methods: A sample of 4160 SGM Colombian adults responded to an online cross-sectional survey. We used binary logistic regression to assess the relationship between SOGICE and suicide morbidity for the overall sample and stratified by SGM group. Results: We found a high prevalence of suicidal ideation (56%), suicide planning (54%), suicide attempt (25%), and SOGICE experiences (22%). There were significant differences in the prevalence of suicide morbidity and SOGICE experiences across SGM groups, with transgender men and gender nonbinary participants being generally most at risk. SOGICE experiences were associated with 69% increased odds of suicidal ideation, 55% increased odds of suicide planning, and 76% increased odds of suicide attempt. Stratified analyses by SGM group showed that the association of SOGICE experiences with suicide morbidity varied by SGM group, and it was particularly detrimental for cisgender sexual minority men. Conclusions: Suicide morbidity among SGM adults in Colombia is high, with rates that are 8-22 times higher than in the general population. SOGICE experiences further exacerbate suicide risk. The study findings highlight the need to design and implement policies affirming diverse sexual orientation and gender identities in Colombia and to ban SOGICE practices. These findings also highlight the importance of recognizing the variability within SGM groups and the need to examine these groups separately rather than treating them as a monolithic group.

Suicidal Behavior and Coming Out Milestones in Three Cohorts of Sexual Minority Adults.

Purpose: We describe the timing of suicidality across the life span in three cohorts of sexual minority adults. We hypothesized that suicide attempts coincide with the coming out period and that younger sexual minority people, who grew up in more accepting social environments, will have lower prevalence of suicide attempts than older generations. Methods: A U.S. national probability sample of 1518 sexual minority adults in three age cohorts of 18-25, 34-41, and 52-59 years (collected 2016-2018) completed a self-administered survey. Results: Sexual minority adults had high prevalence of lifetime suicidal thoughts, plans, and attempts, with the highest attempted suicides in the younger cohort (30.8%, 95% confidence interval [CI] = 26.8-35.1) compared with the middle (23.7%, 95% CI = 19.0-29.1) and older (20.3%, 95% CI = 16.3-25.1) cohorts. There were no differences in suicidal behavior by race and ethnicity or between men and women, but gender nonbinary people had higher prevalence of suicidal thoughts. The mean age at suicidal thoughts, plans, and attempts tracked closely with age of first realization of sexual minority identity. Most suicide attempts (60.9%) occurred within 5 years of realizing one's sexual minority identity, but a significant proportion of attempts (39.1%) occurred outside this range. Conclusion: Our findings are contrary to the hypothesis that younger cohorts of sexual minority people are at lower risk of suicidality.

Health and health care access in the US transgender population health (TransPop) survey.

BACKGROUND: Probability and nonprobability-based studies of US transgender persons identify different disparities in health and health care access. OBJECTIVES: We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two-step screening process. Eligible participants completed self-administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop. RESULTS: Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender-related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS-based analyses, showed no differences in health or health access. DISCUSSION: Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access. CONCLUSION: Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health.