An mHealth Intervention for Gay and Bisexual Men's Mental, Behavioral, and Sexual Health in a High-Stigma, Low-Resource Context (Project Comunica): Protocol for a Randomized Controlled Trial.

BACKGROUND: The World Health Organization reported that 80% of new HIV diagnoses in Europe in 2014 occurred in Central and Eastern Europe. Romania has a particularly high HIV incidence, AIDS prevalence, and number of related deaths. HIV incidence in Romania is largely attributed to sexual contact among gay and bisexual men. However, homophobic stigma in Romania serves as a risk factor for HIV infection for gay and bisexual men. The Comunica intervention aims to provide a much-needed HIV risk reduction strategy, and it entails the delivery of motivational interviewing and cognitive behavioral therapy skills across 8 live text-based counseling sessions on a mobile platform to gay and bisexual men at risk of HIV. The intervention is based on the information-motivation-behavior and minority stress models. There is preliminary evidence suggesting that Comunica holds promise for reducing gay and bisexual men's co-occurring sexual (eg, HIV transmission risk behavior), behavioral (eg, heavy alcohol use), and mental (eg, depression) health risks in Romania. OBJECTIVE: This paper describes the protocol for a randomized controlled trial designed to test the efficacy of Comunica in a national trial. METHODS: To test Comunica's efficacy, 305 gay and bisexual men were randomized to receive Comunica or a content-matched education attention control condition. The control condition consisted of 8 time-matched educational modules that present information regarding gay and bisexual men's identity development, information about HIV transmission and prevention, the importance of HIV and sexually transmitted infection testing and treatment, heavy alcohol use and its associations with HIV transmission risk behavior, sexual health communication, finding social support, and creating sexual health goals. Participants undergo rapid HIV and syphilis testing and 3-site chlamydia and gonorrhea testing at baseline and the 12-month follow-up. Outcomes are measured before the intervention (baseline) and at the 4-, 8-, and 12-month follow-ups. RESULTS: The study was funded in September 2018, and data collection began in May 2019. The last participant follow-up was in January 2024. Currently, the data analyst is cleaning data sets in preparation for data analyses, which are scheduled to begin in April 2024. Data analysis meetings are scheduled regularly to establish timelines and examine the results as analyses are gradually being conducted. Upon completion, a list of manuscripts will be reviewed and prioritized, and the team will begin preparing them for publication. CONCLUSIONS: This study is the first to test the efficacy of an intervention with the potential to simultaneously support the sexual, behavioral, and mental health of gay and bisexual men in Central and Eastern Europe using motivational interviewing support and sensitivity to the high-stigma context of the region. If efficacious, Comunica presents a scalable platform to provide support to gay and bisexual men living in Romania and similar high-stigma, low-resource countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03912753; https://clinicaltrials.gov/study/NCT03912753. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52853.

LGBQ-affirming clinical recommendations for compulsive sexual behavior disorder.

Background and aims: Since the inclusion of Compulsive Sexual Behavior Disorder (CSBD) in the International Classification of Diseases (11th ed.), there has been little effort placed into developing clinical recommendations for lesbian, gay, bisexual, and queer (LGBQ) clients with this condition. Thus, we develop preliminary clinical recommendations for mental health professionals working with LGBQ clients who may be struggling with CSBD. Methods: The present paper synthesizes the CSBD literature with advances in LGBQ-affirming care to develop assessment and treatment recommendations. These recommendations are discussed within the context of minority stress theory, which provides an empirically supported explanation for how anti-LGBQ stigma may contribute to the development of mental health conditions in LGBQ populations. Results: Assessment recommendations are designed to assist mental health professionals in distinguishing aspects of an LGBQ client's sociocultural context from CSBD symptomology, given recent concerns that these constructs may be wrongly conflated and result in misdiagnosis. The treatment recommendations consist of broadly applicable, evidence-based principles that can be leveraged by mental health professionals of various theoretical orientations to provide LGBQ-affirming treatment for CSBD. Discussion and Conclusions: The present article provides theoretically and empirically supported recommendations for mental health professionals who want to provide LGBQ-affirming care for CSBD. Given the preliminary nature of these recommendations, future research is needed to investigate their clinical applicability and efficacy.

Threats to social safety and neuro-inflammatory mechanisms underlying sexual orientation disparities in depression symptom severity: A prospective cohort study of young adults.

Sexual minority individuals have a markedly elevated risk of depression compared to heterosexuals. We examined early threats to social safety and chronically elevated inflammation as mechanisms contributing to this disparity in depression symptoms, and compared the relative strength of the co-occurrence between chronic inflammation and depression symptoms for sexual minorities versus heterosexuals. To do so, we analyzed data from a prospective cohort of sexual minority and heterosexual young adults (n = 595), recruited from a nationally representative sample, that included assessments of early threats to social safety in the form of adverse childhood interpersonal events, three biomarkers of inflammation (i.e., CRP, IL-6, TNF-α) measured at two time points, and depression symptoms over four years. In pre-registered analyses, we found that sexual minorities experienced more adverse childhood interpersonal events, were more likely to display chronically elevated inflammation, and reported more severe depression symptoms than heterosexuals. Adverse childhood interpersonal events and chronically elevated inflammation explained approximately 23 % of the total effect of the association between sexual orientation and depression symptom severity. Further, there was an increased coupling of chronically elevated inflammation and depression symptoms among sexual minorities compared to heterosexuals. These results provide novel longitudinal, population-based evidence for the role of chronically elevated inflammation in linking threats to social safety during childhood with depression symptom severity in young adulthood, consistent with the primary tenets of the social signal transduction theory of depression. Our study extends this theory to the population level by finding that members of a stigmatized population (i.e., sexual minorities) experience a greater risk of depression because of their greater exposure to adverse childhood interpersonal events and the subsequent link to chronic inflammation, highlighting potential biopsychosocial intervention targets.

Structural stigma and LGBTQ+ health: a narrative review of quantitative studies.

Health disparities related to sexual orientation and gender identity exist across multiple outcomes. Scholarship has begun to evaluate whether structural stigma-ie, societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing-contributes to health burdens among LGBTQ+ individuals. We conducted a comprehensive review of quantitative studies examining this hypothesis. We found 98 articles that linked objective (ie, non-self-reported) measures of structural stigma to mental (n=57), behavioural (ie, substance use; n=27; HIV/AIDS or sexually transmitted infection; n=20), and physical (n=20) health outcomes. There was generally consistent evidence that structural stigma increases risk of poor health among LGBTQ+ individuals. Several methodological strengths were identified, including the use of multiple measures (eg, laws or policies [59%, 58 of 98]), designs (eg, quasi-experiments [21%, 21 of 98]), and samples (eg, probability-based [56%, 55 of 98]). However, important gaps exist. Just over half of studies included area-level covariates or non-LGBTQ+ comparison groups, which are necessary to address alternative explanations for the observed associations. Additionally, while studies (n=90) have begun to identify candidate mechanisms, only nine (10%) formally tested mediation. We offer suggestions for future research to advance this literature, which has implications not only for the identification of structural determinants of LGBTQ+ health but also for the development of public health interventions that reduce LGBTQ+ health disparities.

A qualitative exploration of minority stress, mental health, and sexual health among Arab immigrant sexual minority men in the United States.

OBJECTIVES: To examine experiences of immigration, sexual minority stressors, and mental health and sexual health among first-generation (born outside of the United States) Arab immigrant sexual minority men (SMM) in the United States. METHOD: We conducted in-depth one-on-one virtual interviews with 16 cisgender men residing in different U.S. states. Interview transcripts were analyzed using thematic analysis to identify the most salient themes and relationships among them. RESULTS: The experiences of Arab immigrant SMM centered around five themes: "my whole plan was to come to the U.S. to be open to who I am," "not fitting in" (homophobia, racism, sexual racism, xenophobia), "a lot of impact on my mental health," sexual health (inconsistent condom use, multiple sexual partners, preexposure prophylaxis use, testing), and coping strategies. CONCLUSIONS: Participants reported multiple forms of stressors related to their intersectional identities that affected their mental health, sexual health, and coping strategies. Many stressors were experienced before immigrating to the United States; however, several stressors persisted, and some new ones emerged after immigration. Results call for the development of mental health interventions informed by the unique experiences of Arab immigrant SMM and integrated within community-based organizations to foster adaptive coping strategies, social support, and community belonging. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Stigma and anxiety and depressive symptoms in parents of sexual and gender minority youth.

Parents of sexual and gender minority (SGM) youth play an important role in supporting their SGM child's mental health in the face of stigma. Yet, parents of SGM youth may themselves experience stigma, including discrimination/rejection, and its emotional consequences, including vicarious stigma and shame. The present cross-sectional study leveraged a national sample of parents of SGM youth to investigate associations between parents' stigma experiences and self-reported anxiety and depression symptoms. Further, we additionally explored sociodemographic and contextual correlates of parents' stigma experiences. Participants included 264 parents (Mage = 46) who reported having at least one SGM child under age 30 (Mage = 18). The Lesbian, Gay, Bisexual-Affiliate Stigma Measure (LGB-ASM) assessed parents' experiences of discrimination/rejection (e.g., actual and anticipated rejection experiences due to having an SGM child), vicarious stigma (e.g., worry and concern for one's SGM child), and shame (e.g., feeling embarrassed for having an SGM child). Parents indicated their anxiety and depressive symptoms using respective Patient-Reported Outcomes Measurement Information System-short forms. Results showed that vicarious stigma and shame, but not discrimination/rejection, were uniquely associated with parents' increased symptoms of anxiety (vicarious stigma: ß = 1.59, p < .001; shame: ß = 2.15, p < .001) and depression (vicarious stigma: ß = 0.90, p < .01; shame: ß = 2.77, p < .001). Further, parents with more accepting religious, racial, ethnic, and/or cultural communities reported lower stigma experiences. This study advances understanding of how the psychological consequences of stigma extend beyond SGM people themselves and contribute to mental health difficulties in parents of SGM youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Adolescents' Sexual Orientation and Behavioral and Neural Reactivity to Peer Acceptance and Rejection: The Moderating Role of Family Support.

Sexual-minority adolescents frequently endure peer rejection, yet scant research has investigated sexual-orientation differences in behavioral and neural reactions to peer rejection and acceptance. In a community sample of adolescents approximately 15 years old (47.2% female; same-sex attracted: n = 36, exclusively other-sex attracted: n = 310), we examined associations among sexual orientation and behavioral and neural reactivity to peer feedback and the moderating role of family support. Participants completed a social-interaction task while electroencephalogram data were recorded in which they voted to accept/reject peers and, in turn, received peer acceptance/rejection feedback. Compared with heterosexual adolescents, sexual-minority adolescents engaged in more behavioral efforts to ingratiate after peer rejection and demonstrated more blunted neural reactivity to peer acceptance at low, but not medium or high, levels of family support. By using a simulated real-world social-interaction task, these results demonstrate that sexual-minority adolescents display distinct behavioral and neural reactions to peer acceptance and rejection.

Experiences of stigma, mental health, and coping strategies in Lebanon among Lebanese and displaced Syrian men who have sex with men: A qualitative study.

BACKGROUND: In Lebanon, men who have sex with men (MSM) face high rates of stigma, discrimination, and violence. Minority stress, or the unique stressors related to anti-MSM stigma and discrimination, negatively impacts the mental health of MSM. These stressors are heightened for those with intersectional minority identities such as displaced Syrian MSM in Lebanon. METHODS: In this qualitative study conducted in 2020-21, part of a larger study focused on the mental and sexual health risks among MSM, we collected qualitative data from Lebanese and displaced Syrian MSM living in Lebanon and analyzed reports of their experiences with stigma, mental health, and coping strategies. We conducted semi-structured, in-depth interviews with 12 displaced Syrian MSM and 13 Lebanese MSM. RESULTS: Our findings highlight how MSM in Lebanon navigate stigma and the mental health risks that result. Common stressors among Lebanese and displaced Syrian MSM were related to finances, sexual orientation discrimination, and social isolation. Comparing the two groups, we found that stressors specific to displaced Syrian MSM were related to adverse childhood experiences, recent exposure to the Syrian war, displacement, and discrimination in Lebanon based on their intersectional identities as MSM and Syrians. For Lebanese participants, the most common stigma coping strategies were avoidance, drinking alcohol, using drugs, or having sex. As for displaced Syrian MSM, the most common stigma coping strategy was seeking the freely available mental health services offered to them through non-governmental organizations. CONCLUSION: Our findings suggest that increased targeted mental health and social support interventions, informed by the unique experiences of Lebanese and displaced Syrian MSM, are highly needed to improve the coping and mental health resources of all MSM in Lebanon.

Guided LGBTQ-affirmative internet cognitive-behavioral therapy for sexual minority youth's mental health: A randomized controlled trial of a minority stress treatment approach.

OBJECTIVE: LGBTQ-affirmative cognitive-behavioral therapy (CBT) addresses the adverse impacts of minority stress. However, this treatment has rarely been tested in randomized controlled trials with LGBTQ youth and never using an asynchronous online platform for broad reach. This study examined the feasibility, acceptability, preliminary efficacy, and multi-level stigma moderators of LGBTQ-affirmative internet-based CBT (ICBT). METHOD: Participants were 120 LGBTQ youth (ages 16-25; 37.5% transgender or non-binary; 75.8% assigned female at birth; 49.2% non-Latino White) living across 38 U.S. states and reporting depression and/or anxiety symptoms. Participants were randomized to receive 10 sessions of LGBTQ-affirmative ICBT or only complete 10 weekly assessments of mental and behavioral health and minority stress; all completed measures of psychological distress, depression, anxiety, suicidal thoughts, alcohol use, and HIV-transmission-risk behavior at baseline and 4 and 8 months post-baseline; 20 LGBTQ-affirmative ICBT participants completed a qualitative interview regarding intervention acceptability. RESULTS: Participants randomized to LGBTQ-affirmative ICBT completed, on average, 6.08 (SD = 3.80) sessions. Participants reported that LGBTQ-affirmative ICBT was helpful and engaging and provided suggestions for enhancing engagement. Although most outcomes decreased over time, between-group comparisons were small and non-significant. LGBTQ-affirmative ICBT was more efficacious in reducing psychological distress than assessment-only for participants in counties high in anti-LGBTQ bias (b = -1.73, p = 0.001, 95% CI [-2.75, -0.70]). Session dosage also significantly predicted reduced depression and anxiety symptoms. CONCLUSIONS: LGBTQ-affirmative ICBT represents a feasible and acceptable treatment. Future research can identify more efficacious approaches and modalities for engaging LGBTQ youth, especially those living under stigmatizing conditions, who might benefit most.

Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members.

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW's mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW's health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study's findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW's diverse gender identities and expressions; (2) focusing on SMW's nonbinary stressors; (3) formulating SMW's gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW's lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

Self-schemas and information processing biases as mechanisms underlying sexual orientation disparities in depressive symptoms: Results from a longitudinal, population-based study.

Sexual minority individuals experience higher prevalence of major depression and more frequent depressive symptoms compared to heterosexual individuals. Although existing theories have suggested cognitive mechanisms that may explain these disparities, empirical tests are limited by a reliance on cross-sectional designs, self-reported measures, and nonprobability samples. We analyzed data from a longitudinal, population-based study of young adults (N = 1,065; n = 497 sexual minority) who completed validated measures of depressive symptoms over a 3-year period; at Wave 2, participants completed the self-referent encoding task, a behavioral task assessing self-schemas and information processing biases. Self-schemas were measured with the drift rate, which was estimated via the composite of endorsement of positive or negative words as self-referential (or not) and the reaction time for these decisions. Information processing biases were operationalized as the total number of negative words that were both endorsed as self-referential and recalled after the task, divided by the total number of words endorsed and recalled. Compared to heterosexuals, sexual minorities displayed significantly higher negative self-schemas and recalled a significantly higher proportion of negative words endorsed as self-referential, relative to total number of words. In turn, these differences in self-schemas and information processing biases mediated the sexual orientation disparity in depressive symptoms. Moreover, among sexual minorities, perceived discrimination predicted greater negative self-schemas and information processing biases, which mediated the prospective association between discrimination and depressive symptoms. These findings provide the strongest evidence to date for cognitive risk factors that underlie sexual orientation disparities in depression, highlighting potential intervention targets. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rejection Sensitivity and Sexual Minority Men's Social Anxiety Disorder: The Moderating Role of Sexual Identity Strength.

Although gay-related rejection sensitivity (RS) is associated with social anxiety among sexual minority men, little attention has been given to the validity of gay-related RS measures and to individual differences that might moderate the association between gay-related RS and social anxiety. In a population-based sample of sexual minority men, Study 1 (N = 114) investigated the incremental validity of gay-related RS and showed that gay-related RS scores significantly added to the prediction of social anxiety symptoms, even after controlling for personal RS scores. In a clinical sample of sexual minority men, Study 2 (N = 254) examined interrelationships among gay-related RS, sexual identity strength, and current social anxiety symptoms and disorder diagnosis. Results revealed that the expected count of current social anxiety symptoms and the odds of social anxiety disorder diagnosis, as assessed with a structured diagnostic interview, increased as a function of gay-related RS scores. Sexual identity strength moderated these relationships, such that the associations between gay-related RS scores and interviewer-assessed social anxiety symptoms and disorder were only significant for those high, but not low, in sexual identity strength. Together, results from the present studies lend support to the incremental validity of gay-related RS scales in predicting social anxiety symptoms and suggest that sexual minority men who consider their sexual orientation to be self-defining might be particularly vulnerable to the mental health correlates of gay-related RS.

Moderators of LGBQ-affirmative cognitive behavioral therapy: ESTEEM is especially effective among Black and Latino sexual minority men.

OBJECTIVE: Lesbian, gay, bisexual, and queer (LGBQ)-affirmative cognitive behavioral therapy (CBT) focused on minority stress processes can address gay and bisexual men's transdiagnostic mental and behavioral health concerns. Identifying moderators of treatment outcomes may inform the mechanisms of LGBQ-affirmative CBT and subpopulations who may derive particular benefit. METHOD: Data were from a clinical trial in which gay and bisexual men with mental and behavioral health concerns were randomized to receive Effective Skills to Empower Effective Men (ESTEEM; an LGBQ-affirmative transdiagnostic CBT; n = 100) or one of two control conditions (n = 154): LGBQ-affirmative community mental health treatment (CMHT) or HIV counseling and testing (HCT). The preregistered outcome was a comorbidity index of depression, anxiety, alcohol/drug problems, and human immunodeficiency virus (HIV) transmission risk behavior at 8-month follow-up (i.e., 4 months postintervention). A two-step exploratory machine learning process was employed for 20 theoretically informed baseline variables identified by study therapists as potential moderators of ESTEEM efficacy. Potential moderators included demographic factors, pretreatment comorbidities, clinical facilitators, and minority stress factors. RESULTS: Racial/ethnic minority identification, namely as Black or Latino, was the only statistically significant moderator of treatment efficacy (B = -3.23, 95% CI [-5.03, -1.64]), t(197) = -3.88, p < .001. Racially/ethnically minoritized recipients (d = -0.71, p < .001), but not White/non-Latino recipients (d = 0.22, p = .391), had greater reductions in comorbidity index scores in ESTEEM compared to the control conditions. This moderation was driven by improvements in anxiety and alcohol/drug use problems. DISCUSSION: Black and Latino gay and bisexual men experiencing comorbid mental and behavioral health risks might particularly benefit from a minority stress-focused LGBQ-affirmative CBT. Future research should identify mechanisms for this moderation to inform targeted treatment delivery and dissemination. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Incorporating macro-social contexts into emotion research: Longitudinal associations between structural stigma and emotion processes among gay and bisexual men.

Research into correlates and predictors of emotion regulation has focused almost exclusively on individual differences and the immediate situation. Here, we consider whether features of macro-social contexts may also shape emotion regulation. To test this hypothesis, we conducted a longitudinal study of 502 gay and bisexual men living in 269 U.S. counties that varied in the level of stigma surrounding sexual minorities. We find that gay and bisexual men living in higher- (vs. lower-) stigma counties consistently reported more suppression, which consequently explained longitudinal increases (vs. decreases) in their lack of emotional clarity over 24 months. Results were robust to demographic characteristics, stigma at the interpersonal level (i.e., sexual orientation-related discrimination), and another form of social inequality (i.e., county-level income inequality). These findings suggest that broadening the lens of emotion regulation research to include characteristics of the macro-social environment may yield new insights into determinants of emotion regulation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Explicit and implicit bias among parents of sexual and gender minority youth.

Sexual and gender minority (SGM) youth are at disproportionate risk for poor mental health outcomes, in part due to experiences and expectations of anti-SGM bias including from their own parents. We examined explicit anti-SGM and implicit antisexual minority bias in parents of SGM youth and associations with parenting and parent and youth psychosocial functioning. Heterosexual/cisgender parents (N = 205, Mage = 46.9 years, SD = 8.5) of SGM youth (≤ 29 years old, Mage = 19.4, SD = 4.7) completed an online study including measures of explicit anti-SGM and implicit anti-SM bias, parental acceptance and psychological control, parent-child unfinished business (unresolved negative feelings related to their child's identity), parental depression and anxiety, and youth anxiety, depression, substance use, and exposure to bullying. In models including both explicit anti-SGM and implicit anti-SM bias as predictors of parent and youth outcomes, explicit bias was uniquely associated with lower parental acceptance and greater parental psychological control, parent-child unfinished business, parental anxiety and depression, and youth substance use and exposure to bullying, whereas implicit bias was uniquely associated with greater parent-child unfinished business and parental depression. Further, the combination of high levels of both explicit and implicit bias was associated with the highest levels of parent-child unfinished business, parental depression, and youth anxiety, depression, and exposure to bullying. Results suggest that both types of bias jointly contribute to parenting and parent and youth psychosocial functioning and can help identify families at greatest risk for maladjustment. Findings can inform the development of interventions designed to reduce anti-SGM bias in parents of SGM youth. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and Validation of Two Abbreviated Intraminority Gay Community Stress Scales.

Social stressors stemming from within the gay community might render gay and bisexual men vulnerable to mental health problems. The 20-item intraminority Gay Community Stress Scale (GCSS) is a reliable measure of gay community stress, but the scale's length limits its widespread use in sexual minority mental health research. Using three independent samples of gay and bisexual men, the present research developed two abbreviated versions of the GCSS using nonparametric item response modeling and validated them. Results indicated that eight items provided maximal information about the gay community stress construct; these items were selected to form the eight-item GCSS. The eight-item GCSS reproduced the factor structure of the parent scale, and gay community stress scores obtained from it correlated with other identity-specific social stress constructs and mental health symptoms. Associations between gay community stress and mental health symptoms remained significant even after controlling for related identity-specific stressors, general life stress, and relevant demographics. A four-item version was also developed and assessed, showing good structural, convergent, criterion, and incremental validity and adequate reliability. The eight- and four-item versions of the GCSS offer efficient measures of gay community stress, an increasingly recognized source of stress for gay and bisexual men.

A Developmental Model of the Sexual Minority Closet: Structural Sensitization, Psychological Adaptations, and Post-closet Growth.

Across the lifespan, most sexual minority individuals experience the closet-a typically prolonged period in which no significant others know their sexual identity. This paper positions the closet as distinct from stigma concealment given its typical duration in years and absolute removal from sources of support for an often-central identity typically during a developmentally sensitive period. The Developmental Model of the Closet proposed here delineates the vicarious learning that takes place before sexual orientation awareness to shape one's eventual experience of the closet; the stressors that take place after one has become aware of their sexual orientation but has not yet disclosed it, which often takes place during adolescence; and potential lifespan-persistent mental health effects of the closet, as moderated by the structural, interpersonal, cultural, and temporal context of disclosure. The paper outlines the ways in which the model both draws upon and is distinct from earlier models of sexual minority identity formation and proposes several testable hypotheses and future research directions, including tests of multilevel interventions.

Mental Health Provider Training to Improve LGBTQ Competence and Reduce Implicit and Explicit Bias: A Randomized Controlled Trial of Online and In-Person Delivery.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals in most countries face strong stigma and often rely on affirmative mental health care to foster coping and resilience. We tested an LGBTQ-affirmative mental health training for psychologists and psychiatrists by comparing in-person versus online modalities and the added benefit of supervision. Participants were randomized to a two-day training either in-person (n = 58) or via live-stream online broadcast (n = 55). Outcomes were assessed at baseline and 5, 10, and 15 months posttraining. Optional monthly online supervision was offered (n = 47) from months 5 to 15. Given the substantial need for LGBTQ-affirmative expertise in high-stigma contexts, the training took place in Romania, a Central-Eastern European country with some of the highest LGBTQ stigma in Europe. Participants (M age = 35.1) were mostly cisgender female (88%) and heterosexual (85%). Trainees, regardless of whether in-person or online, reported significant decreases from baseline to 15-month follow-up in implicit and explicit bias and significant increases in LGBTQ-affirmative clinical skills, beliefs, and behaviors. LGBTQ-affirmative practice intentions and number of LGBTQ clients did not change. Participants who attended at least one supervision session demonstrated greater reductions in explicit bias and increases in LGBTQ-affirmative behaviors from baseline to 15-month follow-up than participants who did not attend supervision. LGBTQ-affirmative mental health training can efficiently and sustainably improve LGBTQ competence and reduce provider bias in high-stigma contexts. Future research can identify additional ways to encourage mental health providers' outreach to LGBTQ clients in need of affirmative care.

Mechanisms linking distal minority stress and depressive symptoms in a longitudinal, population-based study of gay and bisexual men: A test and extension of the psychological mediation framework.

OBJECTIVE: Gay and bisexual men have significantly higher rates of depression than heterosexual men. The minority stress theory (Meyer, 2003) proposed that distal minority stressors, like interpersonal discrimination, contribute to this disparity. The psychological mediation framework (Hatzenbuehler, 2009) posited several psychosocial mechanisms through which distal minority stress creates elevations in depression among sexual minorities. Despite accumulating support for this framework, there are a number of limitations to existing research, including largely relying on cross-sectional designs; focusing on a small subset of mechanisms and moderators; and using nonprobability samples. METHOD: We recruited a sample of gay and bisexual men (N = 502) obtained from a population-based data set of U.S. adults. Participants completed validated measures of distal minority stress (i.e., interpersonal discrimination), psychosocial mechanisms (i.e., rumination, emotional clarity, and social support), identity-related moderators (i.e., identity centrality, stigma consciousness, and sexual orientation identity), and depressive symptoms at baseline, 6-month follow-up, and 1-year follow-up. RESULTS: Rumination (b = 0.38, 95% CI [0.13, 0.84]), lack of emotional clarity (b = 0.43, 95% CI [0.11, 0.83]), and lack of social support (b = 0.21, 95% CI [0.04, 0.45]) each individually mediated the prospective relationship between interpersonal discrimination and depressive symptoms, controlling for initial symptoms, age, and education. These indirect effects were not moderated by identity-related characteristics or sexual identity. CONCLUSION: Our study provides some of the strongest empirical evidence for the psychological mediation framework to date and suggests targets for interventions focused on reducing the mental health consequences of minority stress for sexual minority men. (PsycInfo Database Record (c) 2022 APA, all rights reserved).