Sexual and Gender Minorities' Readiness and Interest in Supporting Peers Experiencing Suicide-Related Behaviors - Ferlatte, O.; Salway, T.; Oliffe, J.L.; Kia, H.; Rice, S.; Morgan, J.; Lowik, A.J.; Knight, R. (Crisis, 2020)
Background: Gatekeeper training is a widely recommended suicide prevention intervention that encourages the development of knowledge and the identification and support of those at risk of suicide. Yet, this strategy has not been implemented among sexual and gender minorities (SGM), a group at high risk of suicide. Aim: The aim of this study was to describe the readiness and interest of SGM in supporting peers experiencing suicide-related behaviors. Method: We analyzed data from an online cross-sectional survey of Canadian SGM (n = 2778). Results: In total, 90% of participants had ≥1 SGM peer with depression, and 73% had ≥1 SGM peer who had previously attempted suicide; 74% said they knew what to do to support a peer experiencing suicide risk, and 77% indicated they knew where to refer them. Furthermore, 94% were interested in learning how to recognize signs of suicidality, while 95% were interested in learning skills to support a peer struggling with suicidality and 81% of those indicated a preference to learn these skills online. Limitations: The study used a nonprobability sample and cross-sectional design. Conclusion: SGM are largely interested in learning suicide prevention skills and, as such, more resources are needed to implement and scale up evidence-based approaches for gatekeeper training among SGM.
Keywords: adult; article; cross-sectional study; female; human; human experiment; human tissue; learning; major clinical study; male; nonprobability sample; scale up; sexual and gender minority; sexuality; skill; suicide attempt

Reducing the Treatment Gap for LGBT Mental Health Needs: the Potential of Telepsychiatry - Whaibeh, E.; Mahmoud, H.; Vogt, E.L. (The journal of behavioral health services & research, 2020)
The high prevalence of psychiatric conditions and the concomitant increase in need for mental illness have posed a challenge across the USA. Patients continue to encounter many barriers to accessing care with only 43% receiving treatment. This situation is even more challenging for LGBT individuals, who experience higher rates of some mental health conditions, with an increased risk of suicidality, due to stressors such as discrimination and trauma. Simultaneously, LGBT individuals face specific barriers at the individual level, clinician level, and systemic level. Telepsychiatry has emerged as an approach that can help overcome some of the challenges faced by LGBT individuals when it comes to healthcare access. This paper examines the ways in which telepsychiatry can overcome the aforementioned barriers and provides recommendations to enhance the quality of telepsychiatry services for LGBT patients. Recommendations include improving medical education, enhancing health-force training on cultural competency, and expanding culturally affirming telehealth programs.
Keywords: adult; article; cultural competence; health care access; human; injury; LGBT people; medical education; mental disease; telepsychiatry

Syndemic behavioral risk and suicidality among bisexual adolescents: A latent class analysis - Choi, A.Y.; Israel, T.; Nylund-Gibson, K. (Journal of Consulting and Clinical Psychology, 2020)
Objective: We explored the internal structure of within-group variation in the syndemic construct among bisexual adolescents, an understudied and highly vulnerable population known to experience health disparities compared with monosexuals (those attracted to a single gender). We sought to identify patterns of co-occurrence among three domains of high priority behavioral risks-sexual risk factors, substance use, and victimization-and their implications for suicidality. Method: We used a national sample of 1,053 ethnically/racially diverse, high school age bisexual adolescents drawn from the 2015 Youth Risk Behavior Surveillance System (YRBSS). We applied latent class analysis (LCA) to 15 indicators measuring the three aforementioned domains and modeled predictors and an outcome of class membership. Results: Within-group variation in the syndemic construct appears categorical, systematic, and comprised of Low Risk (38%), Alcohol Use (20%), Peer-victimization (14%), Sexually Active (11%), Syndemic (11%), and Risk-taking (7%) classes. Classes were well-separated per classification statistics. The proportions of bisexual identification, sex, and race varied significantly across classes. Syndemic and Peer-victimization classes were equivalent and elevated in their suicidality risk, out of all classes. Conclusions: Results revealed multiple and diverging forms of conjoint behavioral risk that conferred differential health implications; illuminated the shape and functional form of the syndemic construct among bisexual adolescents; and illustrated the utility of LCA for classifying typologies of risky and normative health behavior patterns. Psychologists are recommended to carefully consider the comorbidly operant nature of behavioral risks in this population. Future directions include addressing replication, multiple-group invariance, additional auxiliary variables, and alternative mixture techniques. This study suggests that patterns of conjoint behavioral risk among bisexual adolescents can be classified into six subtypes: Low Risk (38%), Alcohol Use (20%), Peer-victimization (14%), Sexually Active (11%), Syndemic (11%), and Risk-taking (7%). The Syndemic and Peer-victimization classes were most at risk for suicidality, and girls and behaviorally bisexual adolescents were overrepresented in the riskier classes. Findings highlight the need for refined assessment and targeted intervention for hidden subgroups of bisexual adolescents that are most vulnerable to compounded behavioral risks and associated mortality.
Keywords: adolescent; adolescent behavior; adolescent health; adult; alcohol consumption; article; bisexuality; cyberbullying; ethnicity; female; health disparity; high risk behavior; high school; human; latent class analysis; low risk population; major clinical study; male; partner violence; peer pressure; race difference; risk factor; sex difference; sexual and gender minority; sexual behavior; social psychology; substance use; suicidal behavior; syndemic; young adult

Hormone therapy for trans and gender diverse patients in the general practice setting - Cundill, P. (Australian journal of general practice, 2020)
BACKGROUND: In recent years there has been a significant increase in the number of trans, gender diverse and non-binary (TGDNB) people accessing healthcare. For many of these individuals the first port of call will be to their local general practitioner (GP). The TGDNB community is a high-priority population with the highest suicide rates of any population group in Australia. There is evidence that mental health outcomes improve significantly when individuals are able to access gender-affirming hormones. OBJECTIVE: The aim of this article is to provide GPs working in Australia with a practical guide to prescribe gender-affirming hormone therapy to TGDNB patients. DISCUSSION: GPs are ideally placed to provide care for TGDNB patients in the primary care setting. Gender incongruence is no longer viewed as a mental health disorder. In recent years there has been a move away from mandatory psychiatric assessment to more contemporary patient-centred models of care.
Keywords: adult; article; Australia; female; gender; general practice; hormonal therapy; human; male; mental disease; mental disease assessment; primary medical care; hormone

Bisexual mental health and gender diversity: Findings from the 'Who I Am' study - Taylor, J.; Power, J.; Smith, E.; Rathbone, M. (Australian journal of general practice, 2020)
BACKGROUND AND OBJECTIVES: People who identify as bisexual, transgender or gender diverse report poorer mental health than their homosexual and cisgender counterparts. The aim of this article is to shed light on the mental health experiences of gender diverse bisexual people and the reasons for poor mental health in this group. METHOD: This article reports on a subset of a large cross-sectional survey of bisexual Australians (n = 2651), examining predictors of poor mental health among the 19% (n = 474) of respondents who identified as transgender or gender diverse. RESULTS: Very high rates of psychological distress, mental illness and suicidality were reported by participants who identified as transgender and gender diverse. Higher levels of internalised biphobia and less participation in lesbian, gay, bisexual, transgender and intersex community events predicted higher psychological distress (P <0.05). DISCUSSION: The high rates of mental health problems among transgender and gender diverse bisexual Australians mean it is essential that general practitioners and those on the frontline of mental healthcare provision recognise the need to engage with these groups. This research provides new insights to support and inform this engagement.
Keywords: adult; article; Australian; female; general practitioner; human; LGBTQIA+ people; major clinical study; male; mental disease; mental stress; suicidal behavior

Grazoprevir/elbasvir for the immediate treatment of recently acquired HCV genotype 1 or 4 infection in MSM - Boyd, A.; Miailhes, P.; Chas, J.; Valantin, M.-A.; Yazdanpanah, Y.; Rosenthal, E.; Chevaliez, S.; Piroth, L.; Rougier, H.; Peytavin, G.; Pialoux, G.; Girard, P.-M.; et al. (Journal of Antimicrobial Chemotherapy, 2020)
In Europe, increases in HCV infection have been observed over the last two decades in MSM, making them a key population for recently acquired HCV. Alternative combinations of direct-acting antiviral agents against early HCV infection need to be assessed. Patients and methods: In this pilot trial, MSM with recently acquired genotype 1 or 4 HCV infection were prospectively included and received 8 weeks of oral grazoprevir 100 mg and elbasvir 50 mg in a fixed-dose combination administered once daily. The primary endpoint was sustained virological response evaluated 12 weeks after the end of treatment (EOT) (SVR12). Secondary endpoints were the virological characterization of failures, the quality of life before, during and after treatment and the rate of reinfection. Results: In a 15 month period, 30 patients were enrolled, all of whom were MSM. Of the 29 patients completing follow-up, 28 (96%, 95% CI = 82%-99%) achieved SVR12. One patient interrupted follow-up (suicide) but had undetectable plasma HCV RNA at EOT. One patient with suboptimal adherence confirmed by plasma drug monitoring relapsed and developed NS3, NS5A and NS5B resistance-associated substitutions (V36M, M28V and S556G). The most common adverse events related to study drug were diarrhoea (n = 4, 13%), insomnia (n = 2, 7%) and fatigue (n = 2, 7%), although no patient discontinued treatment. No HIV RNA breakthrough was reported in the 28 patients with HIV coinfection. At Week 48, reinfection was diagnosed in three patients. Conclusions: Our data support the use of grazoprevir/elbasvir for immediate treatment against HCV in order to reduce HCV transmission in MSM.
Keywords: NCT02886624; cobicistat plus elvitegravir plus emtricitabine plus tenofovir alafenamide; dolutegravir; elbasvir; emtricitabine; grazoprevir; nonstructural protein 3; nonstructural protein 5A; nonstructural protein 5B; raltegravir; tenofovir disoproxil; virus RNA; abdominal distension; adult; antiviral therapy; article; binge eating disorder; CD4 CD8 ratio; CD4+ T lymphocyte; CD8+ T lymphocyte; clinical article; creatinine clearance; diarrhea; drug blood level; drug efficacy; drug safety; dysgeusia; fatigue; follow up; hand osteoarthritis; hepatitis C; Hepatitis C virus genotype 1; Hepatitis C virus genotype 4; human; Human immunodeficiency virus infected patient; Human immunodeficiency virus infection; hyperhidrosis; insomnia; knee osteoarthritis; male; medication compliance; men who have sex with men; mixed infection; myalgia; panic; patient compliance; phylogeny; pilot study; prospective study; quality of life; reinfection; Short Form 12; side effect; stomach spasm; suicidal ideation; suicide; sustained virologic response; virus load; virus transmission; xerostomia

Characteristics of offending and non-offending CSA helpline users explored - Wilpert, J.; Janssen, E. (Journal of Forensic Practice, 2020)
Purpose: This study aims to exploratively compare several characteristics of 330 offending and non-offending Dutch subjects, seeking advice/help from child sexual abuse (CSA) prevention helpline Stop it Now!-The Netherlands (SiN-NL). Design/methodology/approach: With a retrospective cross-sectional design, SiN-NL contact logs between March 2012 and June 2016 were investigated. Findings: Results revealed a few interesting differences and similarities. Contrary to earlier findings, attraction to minors and especially boys did not distinguish offenders and non-offenders. However, intimate partner status, suicidal tendencies and expectation of the helpline differed significantly between the study samples. Also, the relevance of several self-reported CSA promoting and impeding factors varied between groups. The non-offender group more often indicated fear of consequences and avoidance of risk situations to be constraining factors, whilst the offender group more frequently suggested benefiting from professional help and social support. Practical implications: The results of this study might inform different forms of prevention and treatment programs aimed at similar help-seeking individuals. Because of their perceived CSA promoting potential by help seekers, access to children and substance abuse are important topics to address by operators and taken into account when assessing offending risk. In contrast to earlier findings, sexual orientation did not differentiate offenders from non-offenders and might play a less significant role. Higher rates of suicidal tendencies and need for help and therapy could imply that, compared to non-offenders, offenders require a more cautious approach and additional care. Originality/value: To our knowledge this is the first study to investigate self-reports of offending and non-offending subjects, seeking advice/help from a CSA prevention helpline.
Keywords: article; avoidance behavior; case report; child; child sexual abuse; clinical article; cross-sectional study; Dutchman; expectation; fear; human; male; Netherlands; offender; risk assessment; self report; sexual orientation; social support; substance abuse

Queering gendered disabilities - Jones, C.E. (Journal of lesbian studies, 2020)
This project defines gendered disabilities broadly, including chronic illnesses that involve the uterus, ovaries, and other body parts traditionally classified as "female." I interrogate the usage of language such as women's health and gynecological using endometriosis, a common chronic illness that can cause severe pain, fatigue, system-wide effects, and infertility. It affects at least ten percent of cisgender women as well as unmeasured numbers of cisgender men and transgender and gender nonconforming people, occurring more commonly than migraines or Crohn's disease. Endometriosis symptoms are often debilitating and can lead to un-/under-employment, reduced quality of life, and even suicide. Once nearly invisible, endometriosis has enjoyed recent public discussion, as major news outlets have reported the individual and social costs of endometriosis, and public figures have spoken out about their experiences. However, increased public spotlight has led to the proliferation of a narrative that endo is primarily a reproductive disease, a myth begun in medical literature nearly a century ago, which overlooks significant medical evidence and drives interventions that have high rates of failure and often cause further impairment. This paper examines locations where queerness meets gendered ableism, arguing that imagining endo as a gendered disability would be a first step toward decoupling compulsory heterosexuality from compulsory able-bodiedness. I also articulate gender-neutral ways to discuss endo and recommendations for more inclusive and accurate language and practices.
Keywords: adult; article; body regions; cell proliferation; chronic disease; controlled study; Crohn disease; disability; employment; endometriosis; fatigue; female; gender; gynecology; heterosexuality; human; infertility; language; male; medical literature; migraine; narrative; ovary; public figure; quality of life; suicide; transgender; uterus; women's health

Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk - Horwitz, A.G.; McGuire, T.; Busby, D.R.; Eisenberg, D.; Zheng, K.; Pistorello, J.; Albucher, R.; Coryell, W.; King, C.A. (Journal of Affective Disorders, 2020)
Background: College student mental health (MH) problems and suicide risk have steadily increased over the past decade and a significant number of students with MH problems do not seek treatment. While some barriers to mental health care service utilization (MHSU) have been identified, very little is known regarding how these barriers differ among sociodemographic subgroups of students. Method: Participants were 3,358 college students from four US universities who screened positive for elevated suicide risk (defined as 2 or more of: depression, alcohol misuse, suicidal ideation, suicide attempt) and were not actively receiving MH services. Reported barriers to MHSU were categorized into: Low perceived need, privacy/stigma concerns, questioning helpfulness of treatment, logistics, time constraints, finances, and cultural issues. Results: Adjusted odds ratios indicated that finances were a greater barrier for women, sexual and gender minority students, and Black and Hispanic students. Privacy/stigma concerns were more prominent for men and young undergraduate students. White students and older undergraduate and graduate students were more likely to report a lack of time, and cultural sensitivity issues were significant barriers for sexual and gender minority, and racial/ethnic minority, students. Limitations: Participating sites were not nationally representative. The barriers assessment did not examine the degree to which a specific barrier contributed to lack of MHSU relative to others. Conclusions: In light of the significant variation in barriers based on age, gender identity, race/ethnicity, and sexual orientation, efforts to increase MHSU should be tailored to meet the unique needs of specific sociodemographic student subgroups.
Keywords: adult; alcoholism; article; college student; demography; depression; female; health care utilization; human; major clinical study; male; mental health care; minority group; priority journal; sexual and gender minority; suicidal ideation; suicide; suicide attempt; young adult

Methylome profiling of young adults with depression supports a link with immune response and psoriasis - Lapsley, C.R.; Irwin, R.; McLafferty, M.; McLafferty, M.; Thursby, S.J.; O'Neill, S.M.; Bjourson, A.J.; Walsh, C.P.; Murray, E.K. (Clinical Epigenetics, 2020)
Background: Currently the leading cause of global disability, clinical depression is a heterogeneous condition characterised by low mood, anhedonia and cognitive impairments. Its growing incidence among young people, often co-occurring with self-harm, is of particular concern. We recently reported very high rates of depression among first year university students in Northern Ireland, with over 25% meeting the clinical criteria, based on DSM IV. However, the causes of depression in such groups remain unclear, and diagnosis is hampered by a lack of biological markers. The aim of this exploratory study was to examine DNA methylation patterns in saliva samples from individuals with a history of depression and matched healthy controls. Results: From our student subjects who showed evidence of a total lifetime major depressive event (MDE, n = 186) we identified a small but distinct subgroup (n = 30) with higher risk scores on the basis of co-occurrence of self-harm and attempted suicide. Factors conferring elevated risk included being female or non-heterosexual, and intrinsic factors such as emotional suppression and impulsiveness. Saliva samples were collected and a closely matched set of high-risk cases (n = 16) and healthy controls (n = 16) similar in age, gender and smoking status were compared. These showed substantial differences in DNA methylation marks across the genome, specifically in the late cornified envelope (LCE) gene cluster. Gene ontology analysis showed highly significant enrichment for immune response, and in particular genes associated with the inflammatory skin condition psoriasis, which we confirmed using a second bioinformatics approach. We then verified methylation gains at the LCE gene cluster at the epidermal differentiation complex and at MIR4520A/B in our cases in the laboratory, using pyrosequencing. Additionally, we found loss of methylation at the PSORSC13 locus on chromosome 6 by array and pyrosequencing, validating recent findings in brain tissue from people who had died by suicide. Finally, we could show that similar changes in immune gene methylation preceded the onset of depression in an independent cohort of adolescent females. Conclusions: Our data suggests an immune component to the aetiology of depression in at least a small subgroup of cases, consistent with the accumulating evidence supporting a relationship between inflammation and depression. Additionally, DNA methylation changes at key loci, detected in saliva, may represent a valuable tool for identifying at-risk subjects.
Keywords: microRNA; microRNA 4520A; microRNA 4520B; unclassified drug; adult; article; automutilation; bioinformatics; brain tissue; chromosome 6; cohort analysis; controlled study; depression; disease association; disease course; DNA methylation; emotional stress; envelope gene; female; gene; gene cluster; gene locus; gene ontology; genetic association; groups by age; high risk population; human; human tissue; immune response; impulsiveness; longitudinal study; major clinical study; major depression; male; medical history; methylome; observational study; priority journal; psoriasis; PSORSC13 gene; pyrosequencing; saliva analysis; sex ratio; smoking; suicide attempt; young adult

Depression and Suicide Literacy among Canadian Sexual and Gender Minorities - Ferlatte, O.; Salway, T.; Oliffe, J.L.; Rice, S.M.; Gilbert, M.; Young, I.; McDaid, L.; Ogrodniczuk, J.S.; Knight, R. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2020)
The purpose of this study was to examine and compare depression and suicide literacy among Canadian sexual and gender minorities (SGM). Online surveys comprised of the 22-item depression literacy scale (D-LIT) and the 12-item literacy of suicide scale (LOSS) were completed by 2,778 individuals identifying as SGM. Relationships between depression and suicide literacy and demographic characteristics were evaluated using multivariable linear regression. Overall, SGM correctly answered 71.3% of the questions from the D-LIT and 76.5% of the LOSS. D-LIT scores were significantly lower among cisgender men and D-LIT and LOSS scores were lower among transgender women when compared to cisgender women. LOSS and D-LIT scores were significantly lower among SGM without a university degree (compared to those with a university degree) and among SGM from ethnic minority groups (compared to White SGM). D-LIT scores, but not LOSS scores, were significantly lower among Indigenous SGM compared to White SGM. The findings provide evidence of differences in suicide and depression literacy between SGM subgroups along multiple social axes. Interventions to increase depression and suicide literacy should be prioritized as part of a mental health promotion strategy for SGM, targeting subgroups with lower literacy levels, including cisgender men, transgender women, Indigenous people, racialized minorities, and those without a university degree.
Keywords: adult; article; controlled study; demography; depression; ethnic group; female; gender identity; human; indigenous people; linear regression analysis; literacy; major clinical study; male; mental health; sexual orientation; suicide; transgender

Trends and causes of mortality in a population-based cohort of HIV-infected adults in Spain: comparison with the general population - Fontela, C.; Aguinaga, A.; Moreno-Iribas, C.; Repáraz, J.; Rivero, M.; Gracia, M.; Floristán, Y.; Fresán, U.; Miguel, R.S.; Ezpeleta, C.; Castilla, J. (Scientific reports, 2020)
Combination antiretroviral therapy reduces mortality of HIV-infected persons. In Spain, where this therapy is widely available, we aim to evaluate mortality trends and causes of death in HIV-infected adults, and to estimate the excess mortality compared to the general population. From 1999 to 2018 mortality by causes was analyzed in a population-based cohort of adults aged 25 to 74 years diagnosed with HIV infection in Spain. Observed deaths and expected deaths according mortality in the general population of the same sex and age were compared using standardized mortality ratios (SMRs). HIV-infected people increased from 839 in 1999-2003 to 1059 in 2014-2018, median age increased from 37 to 47 years, the annual mortality rate decreased from 33.5 to 20.7 per 1000 person-years and the proportion of HIV-related deaths declined from 64% to 35%. HIV-related mortality declined from 21.4 to 7.3 (p < 0.001), while non-HIV-related mortality remained stable: 12.1 and 13.4 per 1000, respectively. Mortality decreased principally in persons diagnosed with AIDS-defining events. In the last decade, 2009-2018, mortality was still 8.1 times higher among HIV-infected people than in the general population, and even after excluding HIV-related deaths, remained 4.8 times higher. Excess mortality was observed in non-AIDS cancer (SMR = 3.7), cardiovascular disease (SMR = 4.2), respiratory diseases (SMR = 7.9), liver diseases (SMR = 8.8), drug abuse (SMR = 47), suicide (SMR = 5.3) and other external causes (SMR = 6). In conclusion, HIV-related mortality continued to decline, while non-HIV-related mortality remained stable. HIV-infected people maintained important excess mortality. Prevention of HIV infections in the population and promotion of healthy life styles in HIV-infected people must be a priority.
Keywords: adult; aged; case control study; cause of death; epidemiology; female; human; Human immunodeficiency virus infection; male; middle aged; mortality; Spain

Rethinking service design for youth with mental health needs: The development of the Youth Wellness Centre, St. Joseph's Healthcare Hamilton - Wang, A.; Tobon, J.I.; Bieling, P.; Jeffs, L.; Colvin, E.; Zipursky, R.B. (Early Intervention in Psychiatry, 2020)
Aim: This article describes the development and design of the Youth Wellness Centre (YWC), an innovative, youth-friendly centre providing mental health and addiction services for emerging adults aged 17 to 25 in Hamilton, Canada. We also report on demographic and clinical characteristics of clients to evaluate how the YWC is serving populations at increased risk of developing mental disorders. Methods: Data were extracted from clinic databases for 1520 youth at the YWC between March 2015 and 2018 to report on demographic characteristics, clinical profiles, primary presenting problems, service use and overall satisfaction with services. Results: Marginalized groups, particularly street-involved individuals and LGBTQ+ youth, are highly represented at the YWC, keeping with the centre's mandate of reaching at-risk populations. Youth at the YWC carry significant mental health burdens, with 80.8% having a history of suicidal ideation and 32.8% having a history of a substance use disorder. The primary route of referral is self-referral and the number of new clients has increased by nearly 20% in the first 3 years of operations. Overall satisfaction with the centre is on par with or slightly above provincial averages. Conclusions: The YWC was developed to meet the mental health needs of transition-aged youth in Hamilton by providing early intervention, system navigation and transition services. The success of the YWC in reaching high-risk youth is demonstrated by the significant proportion of clients reporting demographic and clinical risk factors associated with increased risk for development of mental disorders. The increasing referrals to the YWC highlight the ongoing need for similar services.
Keywords: adolescent; adult; article; data base; demography; disease burden; drug dependence; female; health care need; health center; human; LGBTQIA+ people; male; medical history; mental disease; mental health service; patient referral; patient satisfaction; priority journal; risk factor; social exclusion; suicidal ideation

Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972–2017) - Wiepjes, C.M.; den Heijer, M.; Bremmer, M.A.; Nota, N.M.; de Blok, C.J.M.; Coumou, B.J.G.; Steensma, T.D. (Acta Psychiatrica Scandinavica, 2020)
Objective: This study explored the overall suicide death rate, the incidence over time, and the stage in transition where suicide deaths were observed in transgender people. Methods: A chart study, including all 8263 referrals to our clinic since 1972. Information on death occurrence, time, and cause of death was obtained from multiple sources. Results: Out of 5107 trans women (median age at first visit 28 years, median follow-up time 10 years) and 3156 trans men (median age at first visit 20 years, median follow-up time 5 years), 41 trans women and 8 trans men died by suicide. In trans women, suicide deaths decreased over time, while it did not change in trans men. Of all suicide deaths, 14 people were no longer in treatment, 35 were in treatment in the previous two years. The mean number of suicides in the years 2013–2017 was higher in the trans population compared with the Dutch population. Conclusions: We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs.
Keywords: antiandrogen; estrogen; testosterone; adolescent; adult; aged; article; cause of death; child; cohort analysis; comparative study; controlled study; female; follow up; gender dysphoria; gender identity; hormonal therapy; human; incidence; major clinical study; male; mortality rate; patient referral; population; premedication; primary prevention; priority journal; retrospective study; risk assessment; risk factor; suicide; time to pregnancy; transgender

Understanding the Mental Health of Transgender and Nonbinary Youth - Price-Feeney, M.; Green, A.E.; Dorison, S. (Journal of Adolescent Health, 2020)
Purpose: Currently, there is a lack of nationwide data examining the mental health of transgender and nonbinary youth. Furthermore, relatively little is known about how the mental health of transgender and nonbinary youth compares to that of their cisgender lesbian, gay, bisexual, queer, and questioning peers or differences within subgroups of transgender and nonbinary youth. The goal of the present study was to better understand the mental health of transgender and nonbinary youth. Methods: We analyzed responses from a national quantitative cross-sectional survey of more than 25,000 lesbian, gay, bisexual, transgender, queer, and questioning youth, aged between 13 and 24 years, in the U.S. Results: Transgender and nonbinary youth were at increased risk of experiencing depressed mood, seriously considering suicide, and attempting suicide compared with cisgender lesbian, gay, bisexual, queer, and questioning youth. Controlling for sexual orientation–based or gender identity–based experiences of perceived discrimination and physical threats or harm reduced the disparities but did not fully account for them. Within-group analyses highlighted particularly increased risk for negative mental health outcomes among transgender males and nonbinary youth assigned female at birth. Conclusions: Findings point to the need to directly address the needs of transgender and nonbinary youth in prevention and intervention programs and to advance policies that reduce discrimination and victimization based on sexual orientation or gender identity.
Keywords: adolescent; adult; article; bisexuality; controlled study; cross-sectional study; depression; female; gender identity; health survey; homosexual female; human; LGBTQIA+ people; major clinical study; male; mental health; priority journal; quantitative analysis; risk factor; sexism; sexual orientation; suicide; transgender

Critical overview of adolescent suicides in India; a public health concern - Mathew, A.; Suja, M.K.; Priya, V. (Indian Journal of Public Health Research and Development, 2020)
Suicide is the second most leading cause of death among the 15-29 age group (adolescent). The World Health Organization statistics indicate that 8, 00,000 people suicide annually. The National Crime Records Bureau records indicates that suicidal deaths in 2014 is 15.8% more than 2004, 17% of the suicides worldwide happens in India. Suicides is a contingency that affects the victim’s family community and nation at large and has a long lasting effect on the people left behind. The adolescents often don’t get help when needed which leads to suicides. Sustainable Development Goals 3 intents to promote healthy lives and promote wellbeing for all. Aim: To understand; 1) the percentage increase of suicide in India, difference between male and female suicides, 2) identify states with maximum number of suicides, 3)identify states with maximum number of student suicides, 4) Major Causes for suicide among adolescent male, female and transgender and to study 5) Major means adopted for suicides in India, 6) Understand the significance promoting wellness addressing adolescent suicides. . Results: there is significant increase in number of suicides form 2013 to 2016 and it affects the nation’s economy. The states with maximum number of adolescent suicides are 1) Maharastra, 2) Tamil Nadu, 3) West Bengal, 4) Madhya Pradesh and 5) Karnataka. The major Causes for suicides among adolescents male, female and transgender were identified. The most common means adopted for suicide among adolescents have been identified and listed. Conclusion: The adolescent and student suicides in the nation are increasing rapidly causing serious economic burden to the nation. Hence a comprehensive suicide prevention plan must be developed, the policy should individually target the states with highest number of adolescent and student suicides, access to the most prominent means of suicides must be limited. A national suicide prevention help line and community based access points could be created to provide mental health first aid to the vulnerable adolescents and students.
Keywords: insecticide; adolescent; adult; article; community mental health; drowning; drug abuse; female; hanging; human; immobilization; India; intoxication; jumping; major clinical study; male; mortality rate; public health; suicide; transgender; unemployment; wellbeing

Disparities in Suicidality by Gender Identity Among Medicare Beneficiaries - Progovac, A.M.; Mullin, B.O.; Dunham, E.; Reisner, S.L.; McDowell, A.; Sanchez Roman, M.J.; Dunn, M.; Telingator, C.J.; Lu, F.Q.; Breslow, A.S.; Forstein, M.; Cook, B.L. (American Journal of Preventive Medicine, 2020)
Introduction: Suicidality is higher for gender minorities than the general population, yet little is known about suicidality in disabled or older adult gender minorities. Methods: This study used 2009–2014 Medicare claims to identify people with gender identity–related diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non–gender minority beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of the 4 participant groups separately, and then disparities within eligibility status (disabled or older adult) were assessed using logistic regression models, adjusting first for age and mental health chronic conditions and then additionally for Medicaid eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses were that gender minority beneficiaries would have higher suicidality but that suicidality disparities would persist after adjusting for covariates. Data were analyzed between 2017 and 2019. Results: Gender minority beneficiaries had higher unadjusted suicidality than non–gender minority beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following: age (except in older adult gender minorities), Medicaid eligibility, depression or behavioral health conditions, avoidable hospitalizations, and violence victimization. In age- and mental health–adjusted logistic regression models, gender minorities had higher odds of suicidality than non–gender minority beneficiaries (disabled, OR=1.95, p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility, race/ethnicity, or region. Conclusions: Heightened suicidality among identified gender minority Medicare beneficiaries highlights a pressing need to identify and reduce barriers to wellness in this population.
Keywords: adult; aged; article; cohort analysis; controlled study; depression; ethnic difference; gender identity; groups by age; health insurance eligibility; hospitalization; human; major clinical study; medicaid; medicare; middle aged; predictor variable; race difference; residential area; risk factor; sexual and gender minority; suicidal behavior; suicidal ideation; suicide attempt; very elderly; violence; young adult

Examining the intersection of race/ethnicity and sexual orientation on suicidal ideation and suicide attempt among adolescents: Findings from the 2017 Youth Risk Behavior Survey - Baiden, P.; LaBrenz, C.A.; Asiedua-Baiden, G.; Muehlenkamp, J.J. (Journal of Psychiatric Research, 2020)
Although some studies have examined factors associated with suicidal behaviors, few studies have examined the intersection of sexual orientation and race/ethnicity on suicidal behaviors among adolescents. The objective of this study is to examine the intersection of sexual orientation and race/ethnicity on suicidal ideation and suicide attempt. We hypothesized that controlling for the effects of known risk factors for suicidal behaviors, there will be an interaction effect between sexual orientation and race/ethnicity on suicidal behaviors. Data for this study came from the 2017 Youth Risk Behavior Surveillance System. A sample of 13,697 adolescents aged 14–18 years (51.8% female) was analyzed using binary logistic regression. Of the 13,697 adolescents, 17.7% reported suicidal ideation and 7.7% made at least one suicide attempt during the past 12 months. In the multivariate logistic regression models, non-White sexual minority adolescents are less likely to report suicidal ideation. However, Hispanic lesbian/gay adolescents had 1.71 times higher odds of making a suicide attempt. Odds of suicide attempt are 1.2 times higher for Black or African American bisexual adolescents and American Indian/Native Hawaiian/Pacific Islander bisexual adolescents had 2.44 times higher odds of making a suicide attempt. Other significant predictors of suicidal behaviors include a history of sexual assault, a victim of bullying, depression, cigarette smoking, misuse of prescription pain medication, and illicit drug use. The findings of the present study extend past research on the intersection of sexual orientation and race/ethnicity on mental health problems among adolescents including suicidal behaviors.
Keywords: illicit drug; adolescent; adolescent disease; adult; African American; American Indian; article; bisexuality; Black person; bullying; cigarette smoking; depression; drug abuse; ethnic difference; female; Hispanic; homosexual female; homosexual male; human; major clinical study; male; medical history; Native Hawaiian; prescription drug misuse; priority journal; race difference; sexual and gender minority; sexual assault; sexual orientation; suicidal ideation; suicide attempt; young adult

Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study - Bórquez, A.; Rich, K.; Farrell, M.; Degenhardt, L.; McKetin, R.; Tran, L.T.; Cepeda, J.; Silva-Santisteban, A.; Konda, K.; Cáceres, C.F.; Kelly, S.; Altice, F.L.; et al. (Journal of the International AIDS Society, 2020)
Introduction: Among men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre-exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants. Methods: We adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01-2020/01-2021). We also investigated the 10-year impact (01-2020/01-2030) of: (1) PrEP prioritization for stimulant-using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant-associated risk. Results: MSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant-associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade. Conclusions: MSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.
Keywords: cocaine; psychostimulant agent; anal intercourse; article; cardiovascular disease; cardiovascular mortality; comparative study; death; disease burden; epidemic; gender identity; harm reduction; health hazard; high risk behavior; high risk population; human; Human immunodeficiency virus infection; incidence; infection prevention; infection risk; integrated health care system; major clinical study; male; male to female transgender; mathematical model; men who have sex with men; mortality rate; patient harm; personal experience; Peru; pre-exposure prophylaxis; priority journal; risk reduction; scale up; sensitivity analysis; sexual behavior; substance use; suicide; systematic review (topic); unprotected sex; virus transmission

Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers - van der Miesen, A.I.R.; Steensma, T.D.; de Vries, A.L.C.; Bos, H.; Popma, A. (Journal of Adolescent Health, 2020)
Purpose: Transgender adolescents are at risk for internalizing and externalizing problems, along with high suicidality rates, and poor peer relations. The present study compared transgender adolescents before and after gender-affirmative care with a sample of nonclinical age-equivalent cisgender adolescents from the general population on psychological well-being and aimed to investigate the possible effect of transgender care involving puberty suppression. Methods: In this cross-sectional study, emotional and behavioral problems were assessed by the Youth Self-Report in a sample of 272 adolescents referred to a specialized gender identity clinic who did not yet receive any affirmative medical treatment and compared with 178 transgender adolescents receiving affirmative care consisting of puberty suppression and compared with 651 Dutch high school cisgender adolescents from the general population. Results: Before medical treatment, clinic-referred adolescents showed more internalizing problems and reported increased self-harm/suicidality and poorer peer relations compared with their age-equivalent peers. Transgender adolescents receiving puberty suppression had fewer emotional and behavioral problems than the group that had just been referred to transgender care and had similar or fewer problems than their same-age cisgender peers on the Youth Self-Report domains. Conclusions: Transgender adolescents show poorer psychological well-being before treatment but show similar or better psychological functioning compared with cisgender peers from the general population after the start of specialized transgender care involving puberty suppression.
Keywords: adolescent; affirmative care; age; article; automutilation; care and caring; child psychiatry; child psychology; cisgender; comparative study; controlled study; cross-sectional study; Dutchman; emotional disorder; female; gender identity; groups by sex; high school; human; individual behavior assessment; major clinical study; male; medical care; patient referral; peer group; post hoc analysis; priority journal; problem behavior; psychological well-being; puberty; self report; sex difference; sexual and gender minority; social psychology; suicidal behavior; transgender; Youth Self Report

Depression and suicidal behavior in LGB and heterosexual populations in Serbia and their differences: Cross-sectional study - Janković, J.; Slijepčević, V.; Miletić, V. (PLoS ONE, 2020)
Background Sexual identity is a significant risk factor for triggering symptoms of depression, as well as for suicide attempts in lesbian, gay and bisexual (LGB) population compared to the heterosexual population. To the best of our knowledge, data on the mental health of LGB persons in Serbia are lacking, and this is the first study to address this problem. The aim of the study was to examine the association between selected determinants and depression, and selected determinants and suicide attempts in LGB and heterosexual populations in the Republic of Serbia, as well as, their differences. Methods We conducted a cross-sectional study in 2015 of 264 heterosexual and LGB respondents using the "snowball sampling" method. We used linear regression analyses to investigate the relationship between socio-demographic variables and different sexual identity categories with PHQ-9 scores. We assessed associations between suicide attempts, and socio-demographic characteristics, sexual identity, depression, and suicidal thoughts using logistic regression. Results Depression symptoms were higher in female relative to male participants, in participants who were single, divorced or widowed in comparison to currently married, among people with a middle level of education compared to highly educated, and in respondents identified as bisexual or homosexual in comparison to heterosexual. Homosexual and bisexual participants reported suicidal attempts 27 [Odds Ratio (OR) = 27.31] and six times (OR = 6.40) more often than did heterosexual respondents, respectively. Suicide attempts were less frequently reported by single, divorced or widowed participants in comparison to married (OR = 0.25) and those with middle education (OR = 0.38) compared to highly educated. Conclusions The present study showed that LGB persons in Serbia have significantly more symptoms of depression and suicide attempts compared to heterosexuals. Public health interventions should focus on the early detection of depression and on overcoming prejudicial and discriminatory attitudes. Also, intervention should emphasize that homosexuality and bisexuality are normal, equal and morally acceptable expressions of human sexuality.
Keywords: adult; article; cross-sectional study; demography; depression; divorce; educational status; employment status; female; gender identity; heterosexuality; human; LGBT people; linear regression analysis; major clinical study; male; marriage; Patient Health Questionnaire 9; Serbia; sex difference; single (marital status); snowball sample; social status; suicidal behavior; suicidal ideation; suicide attempt

Mental health care for LGBT youths - Lothwell, L.E.; Libby, N.; Adelson, S.L. (Focus (United States), 2020)
Lesbian, gay, bisexual, and transgender (LGBT) youths comprise a diverse population with unique developmental experiences and needs. Many experience some form of anti-LGBT stigma. Although most LGBT youths cope well and are free from mental illness, they are at increased risk for a number of psychiatric and other health problems compared with the general population. These problems include depression, anxiety, suicidality, tobacco and substance use, and disordered eating. These disorders are significant sources of morbidity and mortality and are risk factors for other health problems, including HIV and other sexually transmitted infections. Preliminary evidence suggests the same is true for gender dysphoric youths. The minority stress hypothesis holds that exposure to LGBT-specific stigma causes these disparities among LGBT youth. During the past decade, increasing attention has been devoted to developing evidence-based practice guidelines to address the mental health needs of LGBT youths, with an emphasis on core clinical competencies for practitioners working with this population. This review addresses key principles for mental health promotion and care of LGBT youths. Key resources for clinicians and two clinical vignettes are included.
Keywords: anxiety; article; child psychiatry; coping behavior; depression; distress syndrome; family decision making; gender dysphoria; gender identity; health care organization; health disparity; health promotion; high risk behavior; homosexual female; human; intersectoral collaboration; juvenile; LGBT people; major depression; mental health care; mental health care personnel; pediatrician; peer rejection; personal experience; prepuberty; priority journal; psychosexual development; psychotherapy; risk factor; separation anxiety; sexual and gender minority; sexual orientation; sexually transmitted disease; social support; stigma; physiological stress; suicidal behavior; therapeutic alliance; transgender; vignette; World Health Organization

Sexual orientation and mental health over the life course in a birth cohort - Spittlehouse, J.K.; Boden, J.M.; Horwood, L.J. (Psychological medicine, 2020)
BACKGROUND: Sexual minority individuals consistently report higher rates of mental disorder than heterosexuals. However, much of the research has methodological limitations related to the classification of sexuality, the use of cross-sectional data and problematic sampling procedures such as using convenience samples. METHODS: We used longitudinal data from a birth cohort enrolled in the Christchurch Health and Development Study (n = 1040). Latent class analysis was used to classify participants sexuality based on self-report data of sexual behaviour, attraction, identity and fantasy, gathered over five assessments between the ages of 18 and 35 years. Mental health and substance use outcome data were gathered at four assessments between the ages of 21 and 35 years. Potential covariate variables were collected during childhood. RESULTS: The latent class analysis identified four groups interpreted as: 'heterosexual' 82%, 'mostly heterosexual' 12.6%, 'bisexual' 3.5% and 'gay/lesbian' 1.9%. In the sexual minority groups, women outnumbered men by at least 2:1. Pooled rates for mental health disorders of depression, anxiety disorders, suicidal ideation, cannabis abuse and total disorders, after adjustment for childhood covariate variables, were significantly higher in the sexual minority groups (p < 0.01). The strength of association between sexuality group and mental health outcomes did not differ according to sex. Fluidity in sexuality reports appeared unrelated to risk of mental health outcomes. CONCLUSIONS: Over the life course, membership of a sexual minority group is clearly associated with mental health problems of depression, anxiety and suicidal ideation regardless of the age when same-sex attraction, behaviour, identity or fantasy is expressed.
Keywords: anxiety disorder; article; bisexuality; cannabis addiction; child; cohort analysis; controlled study; depression; fantasy; female; heterosexuality; homosexual female; human; identity; latent class analysis; longitudinal study; major clinical study; male; mental disease; mental health; outcome assessment; self report; sexual behavior; substance use; suicidal ideation

Sexual violence and safety: the narratives of transwomen in online forums - Noack-Lundberg, K.; Liamputtong, P.; Marjadi, B.; Ussher, J.; Perz, J.; Schmied, V.; Dune, T.; Brook, E. (Culture, health & sexuality, 2020)
An online forum analysis was conducted to explore experiences of sexual violence and safety among transwomen, with a particular focus on transwomen of colour. Four online forums were chosen for the analysis. Three key themes were identified: dating and violence in intimate relationships; fear of violence and safety strategies; and coping after sexual assault. Forum posters faced heightened gender policing and scrutiny, due to not conforming to normative ideals of femininity. Femininity was also predicated on white, middle-class status, and associated with domesticity and romance. As a result, expressions of femininity from non-white backgrounds could be read as deviant or excessive. The intersection of deviation from gender norms and femininity based on whiteness meant that transwomen of colour faced disproportionate levels of violence, both in public and private spaces. Transwomen of colour also faced disadvantage due to participation in higher-risk forms of sex work, low socioeconomic status and employment, and institutional discrimination. Coping mechanisms to deal with cumulative disadvantage included seeking support from health professionals and transgender community networks. However, it also included more harmful forms of self-medicating such as heavy alcohol and drug use, self-harm and suicide attempts.
Keywords: alcohol consumption; article; automutilation; community care; coping behavior; fear; female; femininity; human; male; male to female transgender; narrative; physical violence; sexual assault; social status; suicide attempt; alcohol

Experiences of sexual and gender minorities in an urban enclave of Haiti: despised, beaten, stoned, stabbed, shot and raped - Rahill, G.J.; Joshi, M.; Galea, J.; Ollis, J. (Culture, health & sexuality, 2020)
Studies of sexual and gender minorities in Haiti and globally typically involve HIV research and programming with men who have sex with men. We conducted focus groups with individuals in Haiti's Cité Soleil slum whose assigned gender at birth matched neither their gender identity nor contextual heteronormative constructions of gender roles, i.e. transwomen and transmen. The Yogyakarta Principles provided the study framework. Focus group participants offered emic perspectives on overall well-being, identities, biopsychosocial strengths and HIV-protective and risk factors. We found that gender expression that conflicts with contextual norms evoked recurring, humiliating and intentionally injurious sexual assaults against participants, heightening their HIV risk; participants endured beatings, shootings, stabbings, stonings and socio-political violence. Lack of confidentiality and stigma hinder participants' access to scarce HIV resources. Indistinct boundaries between sexuality, gender identity and gender expression merged with traditional gender-based roles to perpetuate sexual violence towards transwomen by cisgender heterosexual men and by transmen towards cisgender heterosexual women. Despite resignation to omnipresent violence, participants showed resilience regarding gender identity. Needed are integrated socio-behavioural and health programmes to challenge existing gender inequities while providing training on human rights and HIV risk reduction for Haitian sexual and gender minorities.
Keywords: adult; article; confidentiality; controlled study; female; gender based violence; Haiti; health program; heterosexual female; heterosexual male; human; Human immunodeficiency virus; human rights; male; male to female transgender; nonhuman; risk factor; risk reduction; sex role; sexual assault; stigma; wellbeing

Integrating Minority Stress Theory and the Interpersonal Theory of Suicide among Sexual Minority Youth Who Engage Crisis Services - Fulginiti, A.; Goldbach, J.T.; Mamey, M.R.; Rusow, J.; Srivastava, A.; Rhoades, H.; Schrager, S.M.; Bond, D.W.; Marshal, M.P. (Suicide & life-threatening behavior, 2020)
OBJECTIVE: The present study sought to integrate minority stress theory (MST) and the interpersonal theory of suicide (ITS) to better understand high rates of suicide among sexual minority youth (SMY). To date, the ITS and MST have largely advanced independently from one another even though the research base for each theory contains gaps that the other theory may help fill. METHOD: Using data from a national sample of 564 SMY (aged 12-24) recruited from an LGBTQ youth-focused suicide crisis prevention provider, we examined structural equation models to understand how perceived burdensomeness and thwarted belongingness mediate the relationship between minority stress and suicidal ideation and attempt. RESULTS: Sexual minority stress was significantly associated with both perceived burdensomeness and thwarted belongingness in models predicting suicidal ideation and attempt. Moreover, minority stress had a direct effect on suicide attempt and an indirect effect on both suicidal ideation and suicide attempt through burdensomeness. CONCLUSIONS: Given that minority stress is associated with greater thwarted belongingness, perceived burdensomeness, and suicide attempts, there should be greater demand for continuing education centered on sexual minority populations and population-specific services. Identifying burdensomeness as a minority stress-suicide mechanism highlights the potential gains of piloting recently developed burdensomeness interventions among SMY.
Keywords: article; child; continuing education; human; human experiment; juvenile; LGBTQIA+ people; prevention; school child; physiological stress; structural equation modeling; suicidal ideation; suicide attempt; theoretical study

Predictors of Discontinuation of Efavirenz as Treatment for HIV, Due to Neuropsychiatric Side Effects, in a Multi-Ethnic Sample in the United Kingdom - Law, J.K.C.; Butler, L.T.; Hamill, M.M. (AIDS Research and Human Retroviruses, 2020)
Efavirenz (EFV) is one of the most commonly prescribed antiretroviral therapy (ART) medications for human immunodeficiency virus-infected adults because of its favorable pharmacokinetic profile and well-documented efficacy. Nonetheless, neuropsychiatric adverse events (AE) occur in almost half of the EFV users and it is the main reason for treatment discontinuation. To identify the sociodemographic characteristics and reported neuropsychiatric side effects that placed EFV users at an increased risk of discontinuation in a multi-ethnic sample in the United Kingdom. A retrospective medical records analysis of patients prescribed EFV-containing ART in an outpatient sexual health clinic between 2010 and 2016. One hundred forty-nine medical records were reviewed. Fifty-five patients discontinued EFV within the study period. About 55.7% of patients suffered from at least one neuropsychiatric AE, the most commonly recorded symptoms were depression, vivid dreams, dizziness, and sleep disturbance. There was an inverse relationship between number of AE and EFV continuation [adjust odds ratio (OR) = 0.12; confidence interval (95% CI) = 0.03-0.44, p <.05]. Furthermore, neuropsychiatric symptoms, including depression (adjust OR = 3.01; 95% CI = 1.30-6.96, p <.05), sleep disturbance (adjust OR = 3.00; 95% CI = 1.10-8.19, p <.05), and vivid dreams (adjust OR = 2.51; 95% CI = 1.05-6.00, p <.05), were independent predictors of EFV discontinuation. The findings revealed that patients who did not experience any neuropsychiatric side effects were eight times more likely to stay on an EFV-containing regimen than those who suffered from more than three symptoms. Additionally, patients who experienced depression or sleep disturbance were at threefold elevated risk of discontinuing an EFV-based regimen. The implications for clinical practice are discussed.
Keywords: efavirenz; adult; African; aggression; anxiety; article; Asian; bisexuality; Black person; body weight loss; British citizen; Caribbean (person); Caucasian; depression; dizziness; drowsiness; drug withdrawal; dyspnea; ethnicity; fatigue; female; hangover; headache; heterosexuality; homosexuality; human; Human immunodeficiency virus infected patient; Human immunodeficiency virus infection; irritability; life event; loss of appetite; major clinical study; male; medical record review; mental concentration; middle aged; mood disorder; multivariate logistic regression analysis; nausea; odds ratio; prediction; priority journal; psychosocial withdrawal; retrospective study; risk factor; sexual health; sleep disorder; physiological stress; suicidal ideation; sweating; symptom; treatment duration; United Kingdom; vivid dream; young adult

Pilot Results from the First HIV/AIDS Intervention among Transgender Women in the Middle East: Gender Affirmation and Social Support from within Trans Communities in Beirut, Lebanon - Kaplan, R.L.; El Khoury, C.; Wehbe, S.; Lize, N.; Mokhbat, J. (AIDS Research and Human Retroviruses, 2020)
Transgender women are 49 times more likely to become HIV positive than all adults worldwide. Data were unavailable for trans women's sexual and mental health in the Middle East and North Africa until 2015-2016, when HIV prevalence (10%) and suicide attempt (46%) rates were established in Lebanon. Because of the lack of evidence-based interventions for this marginalized group, the purpose of this study was to pilot test an adapted intervention, "Baynetna," to assess preliminary impact on mental and sexual health. Using the gender affirmative model and community connectedness and social cohesion constructs, we pilot tested Baynetna among sixteen trans women, who attended 6 weekly 3-h trans-facilitated group-delivered sessions in Beirut with post-test assessments at 1, 3, and 6 months. Each participant acted as her own control; we used paired t-tests to assess changes at follow-up to evaluate potential differences in outcomes. Positive directionality in intervention impact on gender affirmation satisfaction, community connectedness, and social cohesion was demonstrated. An increase in HIV testing proportion between 6 months before and after enrollment was achieved. Higher social cohesion was associated with less suicidal thoughts (p =.05). There was a significant (p =.019) relationship between more community connectedness and lower depression scores. War event exposure was associated with higher anxiety (p =.02; p =.004). Those who reported never having had a sexually transmitted infection had higher gender affirmation satisfaction scores (7.5, 95% confidence interval: 1.4-13.6) (p =.019). Increases in community connectedness, social cohesion, and gender affirmation satisfaction scores confirm Baynetna's proposed mechanisms of impact. Proportional HIV testing increases demonstrate prevention objectives' progress. The significant results contribute to confidence in Baynetna's mechanisms of action and support the hypothesis that the Gender Affirmation model is applicable to the Lebanese context. We have shown for the first time that the adapted intervention, and its constructs, are applicable in this context outside the United States.
Keywords: HIV test; adult; anxiety disorder; article; clinical article; depression; follow up; health insurance; Hospital Anxiety and Depression Scale; human; Human immunodeficiency virus prevalence; Lebanon; male; male to female transgender; mental health; posttraumatic stress disorder; priority journal; refugee; satisfaction; self esteem; sexual health; sexually transmitted disease; social support; suicidal behavior; suicidal ideation; suicide attempt

Sexual Orientation Disparities in Preconception Health - Limburg, A.; Everett, B.G.; Mollborn, S.; Kominiarek, M.A. (Journal of Women's Health, 2020)
Objective: In the United States, there have been very few improvements in adverse birth outcomes, such as infant mortality, low birthweight, and preterm birth in recent years. Health promotion before pregnancy (e.g., preconception care) has been increasingly recognized as an important strategy by which to improve these reproductive outcomes. As of yet, no research has examined sexual orientation disparities in preconception health which has important implications for birth outcomes in the United States, since sexual minority women (SMW) are more likely to report stillbirths, low birthweight, and preterm infants than heterosexual women. Methods: This study addresses this gap by utilizing data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine sexual orientation disparities in women's preconception health 1 and 3 years before a live birth (n = 3,133). Results: Our findings suggest that, even after controlling for maternal characteristics, SMW are more likely to report adverse health conditions and behaviors before pregnancy relative to heterosexual women 1 year before the survey, including higher odds of binge drinking, other substance use, having a sexually transmitted infection diagnosis, and depression. Conclusions: Despite new public health policies aimed at improved preconception health, our findings suggest that SMW are even more vulnerable to poor preconception health than their heterosexual counterparts, which has important implications for maternal and child health. This study provides important evidence for the need to invest in the reproductive health of SMW, particularly in the context of pregnancy.
Keywords: adult; article; binge drinking; bisexuality; current smoker; depression; eating disorder; ex-smoker; female; gender identity; health disparity; heterosexual female; homosexual female; human; live birth; major clinical study; male; obesity; pregnancy outcome; prepregnancy care; priority journal; reproductive health; sexual and gender minority; sexual orientation; sexually transmitted disease; substance abuse; suicidal ideation; United States; women's health; young adult

Transgenders’ mental experiences of gender duality: A qualitative study in Iran - Farahmand, M.; Danafar, F. (Iranian Journal of Psychiatry and Behavioral Sciences, 2020)
Background: In many societies, transgender is a marginal minority that experience deprivation and isolation in cultural discourse, and find many social and psychological problems. Objectives: The present inquiry aims is to study transgender’s interactive- mental experiences. Methods: A qualitative method is used to study the lived experiences of transgender. Twenty five transgender in the cities of Yazd, Mashhad, and Tehran were selected through snowball sampling for an in-depth interview. The transcripts of interviews were analyzed through theoretical coding. Results: The analysis of interviews showed mental distress as the main phenomenon of transgenders. The results indicated that transgender’s life experiences consisted of gender-mental dimensions (duality of gender self-concept, duality of gender presentation and dual gender performance) and gender-interaction dimension (family, friends, school interaction, and lack of social opportunities). Transgender’s strategies in such situations are often removing sex organs, anonymity, and isolation. Other consequences include sexual abuse, drug addiction, and suicide. Conclusions: In the current research, the constructed meanings of these people suggest that transgender is experiencing complex, insecure, and difficult life world. So educating the families, society, and media can play an effective role in reducing and managing their problems.
Keywords: hormone; adult; anonymization; article; clinical article; controlled study; distress syndrome; drug dependence; female; gender duality; gender identity; grounded theory; human; Iran; male; mental health; personal experience; prescription; qualitative research; self concept; sex reassignment; sexual abuse; social discrimination; social interaction; social isolation; suicide; transgender

Sexual Orientation Change Efforts, Adverse Childhood Experiences, and Suicide Ideation and Attempt Among Sexual Minority Adults, United States, 2016-2018 - Blosnich, J.R.; Henderson, E.R.; Coulter, R.W.S.; Goldbach, J.T.; Meyer, I.H. (American journal of public health, 2020)
Objectives. To examine how sexual orientation change efforts (SOCE) are associated with suicide morbidity after controlling for adverse childhood experiences (ACEs).Methods. Cross-sectional survey data are from the Generations survey, a nationally representative sample of 1518 nontransgender sexual minority adults recruited between March 28, 2016, and March 30, 2018, in the United States. Self-identified transgender individuals were included in a separate, related TransPop study. We used weighted multiple logistic regression analyses to assess the independent association of SOCE with suicidal ideation and suicide attempt while controlling for demographics and ACEs.Results. Approximately 7% experienced SOCE; of them, 80.8% reported SOCE from a religious leader. After adjusting for demographics and ACEs, sexual minorities exposed to SOCE had nearly twice the odds of lifetime suicidal ideation, 75% increased odds of planning to attempt suicide, and 88% increased odds of a suicide attempt with minor injury compared with sexual minorities who did not experience SOCE.Conclusions. Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE.Public Health Implications. Evidence supports minimizing exposure of sexual minorities to SOCE and providing affirming care with SOCE-exposed sexual minorities. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e7. doi:10.2105/AJPH.2020.305637).
Keywords: adult; article; child; childhood adversity; clergy; controlled study; conversion therapy (sexual orientation); demography; female; human; human tissue; injury; major clinical study; male; prevalence; public health; suicidal ideation; suicide attempt; transgender; United States

HIV understanding, experiences and perceptions of HIV-positive men who have sex with men in Amazonian Peru: a qualitative study - Tattsbridge, J.; Wiskin, C.; de Wildt, G.; Clavé Llavall, A.; Ramal-Asayag, C. (BMC public health, 2020)
BACKGROUND: HIV-related incidence and mortality is increasing across Peru, with highest mortality rates recorded in the Amazonian region of Loreto. This epidemic is concentrated in men who have sex with men, a population with 14% HIV treatment adherence despite free national provision. This study investigates barriers and facilitators to following healthcare advice through experiences and perceptions of HIV-positive men who have sex with men and healthcare professionals in Loreto. METHODS: Twenty qualitative interviews with HIV-positive men who have sex with men and one focus group with HIV-specialist healthcare professionals were conducted in Loreto, January-February 2019. Interviews were transcribed per verbatim. Thematic content analysis and deviant case analysis were used. RESULTS: A culture of isolation and discrimination was identified, propagated by poor public knowledge surrounding HIV transmission and treatment. Employment potential was hampered and 7/20 patients had suicidal thoughts post-diagnosis. Barriers to care included: shame, depression, travel cost/times, a preference for traditional plant-based medicine and side-effects of antiretroviral therapy. Facilitators included: education, family and clinic support, disease acceptance and lifestyle changes. CONCLUSION: More effective, focussed community education and workplace discrimination investigations are recommended to reduce stigma and increase adherence to treatment in this population.
Keywords: antiretrovirus agent; adult; attitude to health; health care personnel; human; Human immunodeficiency virus; Human immunodeficiency virus infection; information processing; male; middle aged; Peru; psychology; qualitative research; sexual and gender minority; social stigma

Sexual Minority Status and Psychological Risk for Suicide Attempt: A Serial Multiple Mediation Model of Social Support and Emotion Regulation - Chang, C.J.; Fehling, K.B.; Selby, E.A. (Frontiers in Psychiatry, 2020)
The current study examined the relation between sexual minority status, social support, emotion dysregulation, and suicide attempt in a community sample. A total of 388 community and college adults completed a one-time survey examining self-injury and suicidality. Findings demonstrated that that social support and emotion regulation, independently and in sequence, mediated the relation between sexual minority status and suicide attempt. The reverse mediation model with emotion regulation as the first mediator and social support as the second mediator was also significant. Social support and emotion regulation may both be related and may explain the relation between sexual minority status and suicide attempt. If replicated longitudinally, these findings shed light on specific risk factors and their interrelations, which may have important implications for preventing suicide in sexual minorities.
Keywords: adult; article; automutilation; college student; community; controlled study; Difficulties with Emotion Regulation Scale; disease association; emotion regulation; ethnicity; female; household income; human; male; Multidimensional Scale of Perceived Social Support; psychologic assessment; psychological risk; rating scale; reverse mediation model; risk factor; sexual and gender minority; social support; statistical model; suicide attempt; United States; young adult

Association between insufficient sleep and suicidal ideation among adolescents - Baiden, P.; Tadeo, S.K.; Tonui, B.C.; Seastrunk, J.D.; Boateng, G.O. (Psychiatry Research, 2020)
The objective of this study was to examine the association between insufficient sleep and suicidal ideation among adolescents. Data for this study came from the 2017 Youth Risk Behavior Surveillance System. A sample of 13,659 adolescents aged 14–18 years (51.8% female) were analyzed using logistic regression with suicidal ideation as the outcome variable and insufficient sleep as the main explanatory variable. Of the 13,659 adolescents, 2,409 representing 17.6% experienced suicidal ideation during the past 12 months and three out of four adolescents (75.2%) had insufficient sleep on an average school night. Controlling for all other predictors, the odds of experiencing suicidal ideation were 1.35 times higher for adolescents who had insufficient sleep relative to those who had sufficient sleep on an average school night (AOR = 1.35, 95% CI = 1.16–1.58). Other factors associated with suicidal ideation include female gender, sexual minority, history of traditional bullying and cyberbullying victimization, feeling sad or hopeless, being slightly or very overweight, and substance use. Physical activity was inversely associated with suicidal ideation. School counselors, clinicians, and practitioners should consider adequate sleep as an important intervention in suicide prevention.
Keywords: adolescent; adolescent obesity; adult; article; cyberbullying; female; hopelessness; human; major clinical study; male; night; physical activity; priority journal; sadness; school; sex factor; sexual and gender minority; sleep deprivation; substance use; suicidal ideation; victim

Preferences in information processing, marginalized identity, and non-monogamy: Understanding factors in suicide-related behavior among members of the alternative sexuality community - Cramer, R.J.; Langhinrichsen-Rohling, J.; Kaniuka, A.R.; Wilsey, C.N.; Mennicke, A.; Wright, S.; Montanaro, E.; Bowling, J.; Heron, K.E. (International Journal of Environmental Research and Public Health, 2020)
Suicide-related behavior (SRB) is a mental health disparity experienced by the alternative sexuality community. We assessed mental health, relationship orientation, marginalized identities (i.e., sexual orientation minority, gender minority, racial minority, ethnic minority, and lower education), and preferences in information processing (PIP) as factors differentiating lifetime SRB groups. An online cross-sectional survey study was conducted in 2018. Members of the National Coalition for Sexual Freedom (NCSF; n = 334) took part. Bivariate analyses identified the following SRB risk factors: female and transgender/gender non-binary identity, sexual orientation minority identity, lower education, suicide attempt/death exposure, Need for Affect (NFA) Avoidance, depression, and anxiety. Monogamous relationship orientation was a protective factor. Multi-nomial regression revealed the following: (1) monogamous relationship orientation was a protective factor for suicidal ideation and attempt; (2) lower education was a risk factor for suicide attempt; (3) anxiety was a risk factor for suicide attempt; and (4) depression was a risk factor for suicidal ideation. A two-way interaction showed that elevated NFA Approach buffered the negative impacts of depression. Relationship orientation, several marginalized identities (i.e., based on gender, sexual orientation, and educational level), and PIP all contributed uniquely to SRB. Further study is necessary to understand the role of relationship orientation with suicide. Health education and suicide prevention efforts with NCSF should be tailored to account for marginalized identity, mental health, and NFA factors.
Keywords: anxiety; article; controlled study; cross-sectional study; death; depression; educational status; ethnic group; female; gender identity; human; information processing; major clinical study; male; monogamy; protection; risk factor; sexual and gender minority; sexual orientation; social exclusion; suicidal behavior; suicidal ideation; suicide attempt; transgender

Rates of suicidal ideation among HIV-infected patients in care in the HIV Outpatient Study 2000–2017, USA - Durham, M.D.; Armon, C.; Mahnken, J.D.; Novak, R.M.; Palella, F.J.; Tedaldi, E.; Buchacz, K. (Preventive Medicine, 2020)
Background: Suicidal ideation (SI) refers to an individual thinking about, considering or planning suicide. Identifying and characterizing persons with HIV (PWH) at greater risk for SI may lead to better suicide prevention strategies and quality of life improvement. Methods: Using clinical data gathered from medical chart abstraction for HIV Outpatient Study (HOPS) participants from 2000 to 2017, we assessed SI frequency among PWH in care and explored factors associated with the presence of SI diagnoses using linear mixed models analyses. Results: Among 6706 participants, 224 (3.3%) had a charted diagnosis of SI. Among those with SI, median age (interquartile range [IQR]) was 43.4 years [IQR: 38.7–50.3], median (IQR) CD4+ cell count was 439 cells/mm3 (IQR: 237–686), 71.4% were male, 54% were men who have sex with men (MSM), 25.4% heterosexual, and 13.4% persons who inject drugs. In multivariable analysis, persons at increased risk for SI were more likely to be: <50 years old (adjusted rate ratio [aRR] 1.86, 95% confidence interval [95%CI] 1.36–2.53), non-Hispanic/Latino black (aRR 1.75; 95%CI 1.29–2.38), have CD4+ cell count <350 cells/mm3 (aRR 1.32; 95%CI 1.05–1.65), have a viral load ≥50 copies/mL (aRR 1.49; 95%CI 1.12–1.98), have stopped antiretroviral therapy (aRR 1.46; 95%CI 1.10–1.95), have a history of: alcohol dependence (aRR 2.75; 95%CI 1.67–4.52), and drug overdose (aRR 4.09; 95%CI 2.16–7.71). Conclusion: Routine mental health assessment and monitoring are needed in HIV clinical practice to better understand factors associated with SI and to inform the development of preventive interventions.
Keywords: antidepressant agent; dolutegravir; efavirenz; glucocorticoid; opiate; raltegravir; adult; age; alcoholism; antiretroviral therapy; anxiety; article; bipolar disorder; CD4 lymphocyte count; clinical practice; cohort analysis; controlled study; drug overdose; employment; female; health insurance; heterosexuality; human; human cell; Human immunodeficiency virus infected patient; Human immunodeficiency virus infection; injection drug user; insomnia; major clinical study; male; men who have sex with men; mental health; middle aged; nonhuman; observational study; patient care; priority journal; prospective study; psychosis; race; risk factor; substance use; suicidal ideation; United States; virus load

Research Note on Whether Sexual Minority Individuals Are Over-Represented Among Suicide's Casualties - Feigelman, W.; Plöderl, M.; Rosen, Z.; Cerel, J. (Crisis, 2020)
Background: Past studies have repeatedly shown higher suicidal thoughts and attempts among sexual minority members, yet have remained opaque on whether these groups are more prone to taking their own lives. Aims: This short report focuses on suicide deaths among sexual minority members. Method: We utilized two large-scale surveys: one, among adults, the updated Cumulative General Social Surveys, and the other, among adolescents, The National Longitudinal Study of Adolescent Health (Add Health), where respondents' data were cross-linked to National Death Index death records. Results: Results confirmed pre-existent findings showing elevated suicide rates among sexual minority females but not among sexual minority males. Limitations: The shortfall of female adolescent suicides in the Add Health sample prevented us from examining the question of female sexual minority suicides within this population. Conclusion: Although ample evidence demonstrates higher suicidal thoughts and attempts among sexual minority males, three studies presently do not confirm their greater propensity to die by suicide, compared with heterosexual males; yet, for sexual minority females the evidence is steadily mounting showing their greater suicide risks.
Keywords: bisexuality; female; homosexuality; human; male; odds ratio; sexual and gender minority; suicide attempt

Brief online interventions for LGBTQ young adult mental and behavioral health: A randomized controlled trial in a high-stigma, low-resource context - Pachankis, J.E.; Williams, S.L.; Behari, K.; Job, S.; McConocha, E.M.; Chaudoir, S.R. (Journal of consulting and clinical psychology, 2020)
OBJECTIVE: To identify scalable interventions for improving sexual minority mental health and health-risk behavior, this study tested the efficacy of two self-guided online writing interventions-expressive writing and self-affirmation. To reach sexual minority young adults living in high-stigma, low-resource settings, we developed and tested these interventions in Appalachian Tennessee. METHOD: In consultation with sexual minority young adults (n = 10) and stakeholders (n = 10) living in Appalachian Tennessee, we adapted these two writing interventions that we then delivered to 108 local sexual minority young adults (Mage = 23.68, SD = 3.11). Participants, representing diverse sexual and gender identities and socioeconomic backgrounds, were randomly assigned to participate in a 3-session expressive writing intervention, self-affirmation intervention, or neutral control. Participants completed mental health and health-risk behavior measures at baseline, postintervention, and 3-month follow-up. RESULTS: Compared to the neutral control, expressive writing exerted 3-month improvements in depressive symptoms (d = 0.48) and general psychological distress (d = 0.36) whereas self-affirmation exerted improvement in suicidal ideation (d = 0.62) and drug abuse (d = 0.59). Participants who were exposed to greater contextual minority stressors common in rural regions (i.e., discrimination and victimization) experienced significantly greater 3-month reductions in depression from expressive writing and self-affirmation compared to control. Those who experienced greater discrimination also experienced significantly greater 3-month reductions in suicidality from self-affirmation compared to control. CONCLUSION: Brief writing interventions exert significant impact on the mental health of young adult sexual minorities, especially those exposed to minority stress. Future research can consider strategies for population-level implementation, especially in high-stigma, low-resource settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Keywords: NCT03751020; adult; behavior; controlled study; female; human; male; poverty; psychology; psychotherapy; randomized controlled trial; sexual and gender minority; social stigma; Tennessee; therapy; young adult

Peer Responses to Trans Youth Tweeting About Self-Harm and Suicidality - Simms, D. (Creative nursing, 2020)
BACKGROUND: Transgender youth have been found to be at higher risk of experiencing common mental health problems than their cisgender peers, but there has been little research into the mechanisms of peer support among this group. Research into how young people communicate about self-harm and suicidality on social media has found patterns of behavior in which young people encourage each other's risky and self-injurious actions, but whether this holds true among minority groups such as trans youth has not been established. METHOD: Twitter biographies were searched to find self-identifying trans people aged 14-18 years. The resulting accounts were searched for key words related to common mental health issues. The tweets caught by the search terms and their replies were coded into themes using a combination of inductive and deductive coding. The occurrence of themes were quantified and analyzed using SPSS 24. RESULTS: 1,468 tweets were analyzed from 235 accounts; 133 (56.6%) of the accounts with relevant content received no public replies to tweets mentioning mental health issues. Of the 102 (43.4%) that did receive public replies, 64 (62.7%) received a maximum of two replies. Three themes were found in replies to tweets, Support, Feeling the Same Way, and Advice. Most replies were expressions of support, followed by expressions of feeling the same way; advice was rare. There were no incidents of replies that were dismissive of or encouraged self-injurious behavior. DISCUSSION: Findings differ from existing research on how youth interact with each other online with regard to mental health issues: the trans youth in this study were not found to encourage risky and self-injurious behavior in each other. This has implications for caring for trans youth in mental health settings, where social media use is normally discouraged, as its use may be a protective factor for trans youth specifically.
Keywords: adolescent; adolescent behavior; automutilation; female; human; male; peer group; psychology; social media; suicide; transgender

Behavioral Health Concerns and Eligibility Factors Among Adolescents and Young Adults Seeking Gender-Affirming Masculinizing Top Surgery - Boskey, E.R.; Jolly, D.; Tabaac, A.R.; Ganor, O. (LGBT health, 2020)
Purpose: We evaluated behavioral health histories and eligibility factors for patients seeking chest reconstruction. Methods: One hundred and fifty-eight consecutive transgender patients were seen for initial masculinizing top surgery consults between May 2017 and July 2019. Chart review was used to assess behavioral health and demographic factors, and eligibility factors related to the World Professional Association for Transgender Health (WPATH) Standards of Care. Univariate and age-adjusted regression models were used to examine the relationship between demographic and behavioral health factors and WPATH criteria. Results: The average age of patients at the time of their first consult was 18 (standard deviation = 3.3, range = 14-33). Eighty-five percent had at least one behavioral health diagnosis; 27% had three or more. Sixty-four percent endorsed a history of self-harm or suicidal ideation, 13% within the last 6 months. Thirty-two percent reported a history of marijuana use and 19% a history of nicotine use. For those prescribed testosterone, additional months on testosterone were significantly associated with male (vs. nonbinary) gender (β = 4.64, 95% confidence interval [CI] 0.37-8.90, p = 0.033), age (β = 0.87, 95% CI 0.41-1.34, p < 0.001), living as one's affirmed gender for over 1 year (β = 6.37, 95% CI 1.37-11.37, p = 0.013), history of marijuana use (β = 4.54, 95% CI 1.10-7.98, p = 0.010), and history of nicotine use (β = 6.23, 95% CI 2.22-10.26, p = 0.003). Conclusion: Patients seeking gender-affirming masculinizing top surgery are behaviorally complex, in ways not necessarily associated with surgical eligibility. Involving a behavioral health provider in perioperative assessment can help identify and address potential risks to recovery and outcomes.
Keywords: adolescent health; adult; article; automutilation; cannabis use; controlled study; demography; female; gender; human; major clinical study; male; medical record review; suicidal ideation; thorax; transgender; young adult; nicotine; testosterone

Homicide of Lesbians, Gays, Bisexuals, Travestis, Transexuals, and Transgender people (LGBT) in Brazil: a Spatial Analysis - Mendes, W.G.; Silva, C.M.F.P.D. (Ciencia & saude coletiva, 2020)
Keywords: adult; article; Brazil; cold stress; female; firearm; geographic distribution; government; homicide; homophobia; homosexual male; human; LGBT people; male; public health problem; public policy; respect; spatial analysis; suffocation; victim

Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: Preliminary results - Achille, C.; Taggart, T.; Eaton, N.R.; Osipoff, J.; Tafuri, K.; Lane, A.; Wilson, T.A. (International Journal of Pediatric Endocrinology, 2020)
Background/aims: Transgender youths experience high rates of depression and suicidal ideation compared to cisgender peers. Previous studies indicate that endocrine and/or surgical interventions are associated with improvements to mental health in adult transgender individuals. We examined the associations of endocrine intervention (puberty suppression and/or cross sex hormone therapy) with depression and quality of life scores over time in transgender youths. Methods: At approximately 6-month intervals, participants completed depression and quality of life questionnaires while participating in endocrine intervention. Multiple linear regression and residualized change scores were used to compare outcomes. Results: Between 2013 and 2018, 50 participants (mean age 16.2 + 2.2 yr) who were naïve to endocrine intervention completed 3 waves of questionnaires. Mean depression scores and suicidal ideation decreased over time while mean quality of life scores improved over time. When controlling for psychiatric medications and engagement in counseling, regression analysis suggested improvement with endocrine intervention. This reached significance in male-to-female participants. Conclusion: Endocrine intervention may improve mental health in transgender youths in the US. This effect was observed in both male-to-female and female-to-male youths, but appears stronger in the former.
Keywords: antiandrogen; estrogen; gonadorelin agonist; medroxyprogesterone; sex hormone; testosterone; adolescent; adult; article; child; clinical article; controlled study; depression; female; female to male transgender; gender; gender dysphoria; growth regulation; hormonal therapy; human; longitudinal study; male; male to female transgender; menstruation; multiple linear regression analysis; outcome assessment; patient counseling; priority journal; psychiatric treatment; psychological well-being; quality of life; questionnaire; scoring system; suicidal ideation; treatment response

Suicidality Among Transgender Youth: Elucidating the Role of Interpersonal Risk Factors - Austin, A.; Craig, S.L.; D'Souza, S.; McInroy, L.B. (Journal of interpersonal violence, 2020)
Data indicate that 82% of transgender individuals have considered killing themselves and 40% have attempted suicide, with suicidality highest among transgender youth. Using minority stress theory and the interpersonal theory of suicide, this study aims to better understand suicide risk among transgender youth. The present study examines the influence of intervenable risk factors: interpersonal and environmental microaggressions, internalized self-stigma, and adverse childhood experiences (ACEs), and protective factors: school belonging, family support, and peer support on both lifetime suicide attempts and past 6-month suicidality in a sample of transgender youth (n = 372). SPSS 22 was utilized to examine the impact of the independent variables on both suicidality and lifetime suicide attempt through two separate logistic regressions. Fifty six percent of youth reported a previous suicide attempt and 86% reported suicidality. Logistic regressions indicated that models for both lifetime suicide attempts and suicidality were significant. Interpersonal microaggressions, made a unique, statistically significant contribution to lifetime suicide attempts and emotional neglect by family approached significance. School belonging, emotional neglect by family, and internalized self-stigma made a unique, statistically significant contribution to past 6-month suicidality. Results have significant practice and policy implications. Findings offer guidance for practitioners working with parents and caregivers of trans youth, as well as, for the creation of practices which foster interpersonal belonging for transgender youth.
Keywords: article; caregiver; child; childhood adversity; controlled study; emotional neglect; female; gender identity; human; independent variable; juvenile; major clinical study; male; peer group; physician; risk factor; stigma; physiological stress; suicide attempt; theoretical study; transgender

Minority status, depression and suicidality among counseling center clients - Kalibatseva, Z.; Bathje, G.J.; Wu, I.H.C.; Bluestein, B.M.; Leong, F.T.L.; Collins-Eaglin, J. (Journal of American college health : J of ACH, 2020)
Objective: This study examined race/ethnicity, gender, sexual orientation, and financial stress and their association with depression and suicidality among university counseling center clients. Methods: The sample included 3,189 participants who received services at a university counseling center. Results: Asian American college students reported more depressive symptoms than European American and Hispanic students and were more likely to have a depression diagnosis than European American and African American students. Female and lesbian/gay/bisexual/questioning (LGBQ) individuals had higher depressive symptom scores, were more likely to have a depression diagnosis, and history of suicidal ideation and attempts than male and heterosexual individuals, respectively. Students with high financial stress reported higher depression scores and were more likely to have experienced past and current suicidality. More minority statuses were associated with higher risk for depression and suicidality. Conclusions: Counseling center clients who identified with one or more minority groups had higher risk for depression and suicidality.
Keywords: adult; African American; article; Asian American; bisexuality; college student; controlled study; counseling; depression; ethnicity; European American; female; gender; heterosexuality; Hispanic; homosexual female; human; major clinical study; male; minority group; race; physiological stress; suicidal ideation

Social isolation and connectedness as determinants of well-being: Global evidence mapping focused on LGBTQ youth - Garcia, J.; Vargas, N.; Clark, J.L.; Magaña Álvarez, M.; Nelons, D.A.; Parker, R.G. (Global Public Health, 2020)
Social isolation describes a lack of a sense of belonging, the inability to engage and connect with others, and the neglect or deterioration of social relationships. This conceptual review describes how social isolation and connectedness affect the well-being of LGBTQ youth. Most studies focused on the psychosocial experience of social isolation, which led to suicide attempt, self-harm, sexual risk, and substance use. Scholarly work has drawn from a variety of frameworks, ranging from minority stress theory to positive youth development, to devise interventions that target isolation and connectedness in schools, community-based organisations, and in online environments. Finally, we discuss the importance of addressing social, cultural, and structural dimensions of social isolation in order to foster enabling environments that allow LGBTQ youth to thrive. This conceptual review suggests that individual and social transformations are the result of young people's meaningful participation in shaping their environment, which is made possible when their capabilities are fostered through social well-being. Our findings suggest the need for measures of social isolation among youth in databanks produced by global institutions, such as the World Health Organization.
Keywords: article; automutilation; bullying; high risk behavior; human; juvenile; LGBTQIA+ people; priority journal; sexual behavior; social determinants of health; social isolation; substance use; suicide attempt; wellbeing

Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria - Kaltiala, R.; Heino, E.; Työläjärvi, M.; Suomalainen, L. (Nordic Journal of Psychiatry, 2020)
Purpose: To assess how adolescent development progresses and psychiatric symptoms develop among transsexual adolescents after starting cross-sex hormone treatment. Materials and methods: Retrospective chart review among 52 adolescents who came into gender identity assessment before age 18, were diagnosed with transsexualism and started hormonal gender reassignment. The subjects were followed over the so-called real-life phase of gender reassignment. Results: Those who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life. Those who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life. Conclusion: Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.
Keywords: sex hormone; adolescent; adolescent development; anxiety disorder; article; attention deficit disorder; autism; comorbidity; conduct disorder; depression; eating disorder; female; gender dysphoria; gender identity; health care need; human; major clinical study; male; medical record review; peer group; psychiatric treatment; psychosis; retrospective study; school; sex reassignment; sexual development; sexual intercourse; social psychology; substance abuse; suicidal behavior; transgender; transsexualism

Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults - Kattari, S.K.; Bakko, M.; Hecht, H.K.; Kattari, L. (SSM - Population Health, 2020)
Transgender and nonbinary patients have a wide array of experiences when attempting to access healthcare, including discrimination and having to educate providers about trans people. This study examines the mental health factors connected to transgender and nonbinary patients' experience with providers to determine the likelihood of transgender or nonbinary patients receiving respectful care after a provider knows about the patient's gender identity, and patients' experience of having to educate providers about trans people, controlling for sociodemographic factor. Using data from the 2015 United States Trans Survey (N = 27,715), chi-square tests of independence and multivariate logistic regressions were used to explore the odds of transgender or nonbinary individuals having a positive experience with a doctor or healthcare provider. Of the respondents, 24.31% experienced having to educate a provider about trans people when seeking care, and 62.90% experienced a provider knowing they were transgender or nonbinary and treating them with respect. Those experiencing depression and suicidal thoughts were significantly less likely to have had a provider treat them with respect, and significantly more likely to need to educate their providers. Gender, age, disability status, and educational level were significant across both variables; income was significant regarding having to educate a provider. Healthcare providers need ongoing training and education to improve their care of transgender and nonbinary patients, specifically around acknowledging the multiple backgrounds and experiences of such patients, including those related to mental health, gender, race, age, income, educational level, and disability.
Keywords: adult; age distribution; article; controlled study; demography; depression; disability; doctor patient relationship; educational status; female; gender identity; groups by sex; health care delivery; health care quality; health disparity; health survey; help seeking behavior; human; income; major clinical study; male; medical education; mental health; nonbinary person; patient care; priority journal; race difference; respect; suicidal ideation; transgender; United States

An Investigation of the LGBTQ+ Youth Suicide Disparity Using National Violent Death Reporting System Narrative Data - Ream, G.L. (Journal of Adolescent Health, 2020)
Purpose: This study explored law enforcement and medical examiner reports about adolescent and young adult deaths by suicide for novel and understudied risk factors and described variability by sexual orientation and gender identity in those risk factors' prevalence. It also sought to explain why the suicide disparity between lesbian, gay, bisexual, transgender, queer/questioning, and other sexual/gender minority (LGBTQ+) youth and non-LGBTQ+ youth is wider in adolescence than in young adulthood. Methods: This study involved coding of law enforcement and medical examiner reports from the National Violent Death Reporting System (NVDRS) for all 394 LGBTQ+ youth who died by suicide in NVDRS participating states between 2013 (the year that NVDRS began coding for sexual orientation and transgender status) and 2016 (the latest year of NVDRS available), along with 394 non-LGBTQ+ cases matched with them on dimensions of sex, urbanicity, race, and military service. Results: Fifty-nine percent of 12- to 17-year-old LGBTQ+'s cases mentioned an LGBTQ+-specific contributing circumstance, whereas only 30% of 18- to 29-year-old LGBTQ+'s cases mentioned an LGBTQ+-specific contributing circumstance. However, there were 3.6 times as many cases of LGBTQ+ 18- to 29-year-olds as there were of LGBTQ+ 12- to 17-year-olds. Cases of gay males, bisexual males, and bisexual females were particularly likely to include family/peer rejection and bullying as contributing circumstances, while lesbians' cases more often mentioned romantic breakups. Conclusions: The LGBTQ+/non-LGBTQ+ suicide disparity may be greater for adolescents because LGBTQ+-specific contributing circumstances are more prevalent among adolescents. Prevention efforts should be tailored to clients' age and specific LGBTQ+ subgroup.
Keywords: adult; article; bisexual female; bisexual male; bullying; controlled study; coroner; family conflict; female; health disparity; homosexual female; human; law enforcement; LGBTQIA+ people; major clinical study; male; military service; peer rejection; priority journal; race; sex; sexual orientation; suicide; transgender; young adult

Patterns of Healthcare Discrimination Among Transgender Help-Seekers - Romanelli, M.; Lindsey, M.A. (American Journal of Preventive Medicine, 2020)
Introduction: Affirmative health care is imperative to address health and mental health disparities faced by transgender communities. Yet, transgender help-seekers experience discrimination that precludes their access to and participation in care. This study uses latent class analysis to examine patterns of healthcare discrimination among transgender help-seekers. Predictors of class membership are investigated to identify subpopulations at highest risk for healthcare discrimination. Methods: Data were obtained from the 2015 U.S. Transgender Survey and analyzed in 2019. Ten healthcare experiences were included as latent class indicators. Latent class analysis and regression were performed in Mplus, version 8 to identify latent subgroups and examine the relationship between respondent characteristics and the latent classes. Results: The final sample included 23,541 respondents. A 3-class model fit best: Class 1 experienced overt discrimination and interfaced with providers with limited trans-competence; Class 2 did not experience healthcare discrimination or report issues related to providers’ trans-competence; and Class 3 did not experience discrimination but had providers with low trans-competence. Transmen and respondents who were out as trans to their providers and reported psychological distress, suicidal thoughts, and disabilities were more likely to be members of Class 1 or 3 than Class 2. Conclusions: Experiences of healthcare discrimination are not homogeneous across transgender help-seekers. Predictors of the latent classes indicated that transgender help-seekers holding an additional marginalized identity may be at higher risk for healthcare discrimination or care from providers with limited trans-competence. Targeted engagement and education interventions might improve these transgender help-seekers’ access to and connections with care.
Keywords: adult; article; competence; disability; distress syndrome; female; female to male transgender; health care; health care access; health survey; help seeking behavior; human; male; male to female transgender; nonhuman; race; social discrimination; suicidal ideation; transgender

Co-occurring risk factors among U.S. high school students at risk for suicidal thoughts and behaviors - Flores, J.P.; Swartz, K.L.; Stewart, E.A.; Wilcox, H.C. (Journal of Affective Disorders, 2020)
Background: Suicidal thoughts and behaviors (STBs) are increasing among adolescents in the United States and are challenging to predict and prevent. The current study identifies subtypes of youth at risk for suicidal thoughts and behaviors (STBs) in school-based settings. Method: Data are from the CDC's 2015 and 2017 National Youth Risk Behavior Survey of US high school students. Among students reporting depression symptoms, latent class analysis is used to identify subtypes at risk for STBs based on personal characteristics, risk behaviors and environments. Results: Two distinct subtypes of youth were found to be at high risk for STBs: The first, larger subtype (22%) is predominately females in early high school, many of whom identify as bisexual, experienced past-year bullying, and are likely to have experienced sexual victimization. These students have low levels of externalizing risk behaviors making them difficult to detect. The second high-risk subtype (7%) is characterized by students with significant social integration challenges, with extremely high levels of substance abuse, fighting, physical and sexual victimization and poor academic performance. Many of these students have low English fluency, and identify as sexual minority. Limitations: Due to attrition or language barriers, experiences of some students at high-risk for STBs may not have been captured by this survey. Conclusion: Universal screening in clinical settings, and universally focused suicide prevention programs in school-based settings are needed and should be introduced early on. Interventions should be tailored to reach high-risk students with language, cultural and social integration challenges.
Keywords: cocaine; diamorphine; methamphetamine; midomafetamine; academic achievement; adolescent; article; bullying; cohort analysis; depression; English (language); female; high school student; hopelessness; human; integration; juvenile; major clinical study; male; physical abuse; prescription drug misuse; priority journal; risk factor; sadness; sexual abuse; sexual and gender minority; sexual intercourse; substance abuse; suicidal behavior; suicidal ideation; suicide attempt

Psychometric properties of the psychological strain scales (PSS) in suicide attempters and community controls of rural China - Wei, Y.-X.; Wang, X.-T.; Zhang, J.; Yao, Z.-Y.; Liu, B.-P.; Jia, C.-X. (Journal of Affective Disorders, 2020)
Background: Psychological Strain Scales (PSS) were developed to measure four types of strain comprising value strain, deprivation strain, aspiration strain, and coping strain. This study aimed to evaluate the psychometric properties of the Chinese version of 40-item PSS in suicide attempters and community controls of rural China. Methods: Data of this study came from the investigation of 132 suicide attempters and their paired community controls matched with the same sex, age (±3 years) and residence in five counties in rural Shandong, China. The Chinese version of PSS, the Center for Epidemiologic Studies Depression Scale (CES-D), the Trait Anxiety Inventory (TAI) and the Self-esteem Scale (SES) were administered and reliability test and validity test of the PSS were conducted. Results: Cronbach's α and Guttman Spilt-Half coefficient of PSS was 0.942 and 0.842 for suicide attempters, and 0.950 and 0.874 for community controls. For both suicide attempters and community controls, the Exploratory Factor Analysis indicated a one-factor structure of each strain scale, which accorded with the original factor structure proposed by the authors. The scores of the total PSS and four subscales were positively correlated with the scores of CES-D and TAI; and negatively correlated with the score of SES, which indicated a good performance in convergent validity. Limitations: This study was limited to its generalizability to the Chinese urban population. Conclusions: The Chinese version of the 40-item PSS has satisfactory psychometric properties in terms of reliability and validity in Chinese rural suicide attempters and community controls.
Keywords: adult; anxiety assessment; article; Center for Epidemiological Studies Depression Scale; China; construct validity; controlled study; convergent validity; coping behavior; depression; exploratory factor analysis; face validity; female; human; male; physical disease; priority journal; psychological strain scale; psychometry; reliability; rural area; self esteem; suicide attempt; trait anxiety inventory

Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study - Scheim, A.I.; Perez-Brumer, A.G.; Bauer, G.R. (The Lancet Public Health, 2020)
Background: Transgender (trans) people experience profound mental health disparities compared with the general population, attributable in part to the psychological effects of gender non-affirmation. Despite the barriers to legal gender affirmation for trans people, little is known about its association with mental health. We therefore sought to determine whether having gender-concordant identity documents (IDs) is associated with mental health among trans adults in the USA. We hypothesised that having an ID that reflects one's preferred name and gender marker would be associated with reduced psychological distress and suicide risk. Methods: In this cross-sectional observational study, we obtained data from the 2015 US Transgender Survey, the largest cross-sectional survey of trans adults in the USA, with 27 715 participants. Eligible participants were adults (≥18 years), residing in a US state, territory, or overseas US military base; and considered themselves transgender, trans, genderqueer, non-binary, or similar. We excluded participants not living day-to-day in a different gender to the sex they were assigned at birth, participants who identified as crossdressers, and those missing data. The primary exposure of interest was whether all or some (vs none) of a respondent's IDs reflected their preferred name and gender marker. We examined associations with psychological distress (measured with the Kessler 6 scale) and suicide ideation, planning, and attempts in the past year, which we analysed using linear and modified Poisson regression models to examine associations with respondents' IDs. Findings: Of 22 286 respondents included in our analytic sample, 10 288 (weighted percentage 45·1%) had their preferred name and gender marker on none, 9666 (44·2%) on some, and 2332 (10·7%) on all of their IDs. Compared with those with no gender-concordant ID, respondents for whom all IDs were concordant had lower prevalence of serious psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61–0·76), suicidal ideation (0·78, 0·72–0·85), and suicide planning (0·75, 0·64–0·87), adjusting for potential confounders. Having some versus no concordant ID was generally associated with smaller reductions in distress and suicidality. Gender-concordant ID was not associated with suicide attempts (eg, adjusted prevalence ratio for all vs no IDs was 0·92, 95% CI 0·68–1·24). Interpretation: Possession of gender-concordant IDs might improve mental health among trans persons. Gender recognition policies should be considered structural determinants of transgender health. Funding: None.
Keywords: adult; age distribution; article; cognition; cross-sectional study; disease assessment; distress syndrome; ethnicity; exposure; female; gender; gender identity; health survey; hormonal therapy; human; Kessler 6 scale; major clinical study; male; mental health; prevalence; priority journal; public health; risk factor; social support; suicidal ideation; suicide attempt; transgender

Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy - Kuper, L.E.; Stewart, S.; Preston, S.; Lau, M.; Lopez, X. (Pediatrics, 2020)
OBJECTIVES: Our first aim was to examine baseline differences in body dissatisfaction, depression, and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to test for changes in youth symptoms over the first year of receiving gender-affirming hormone therapy. Our third aim was to examine potential differences in change over time by demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) are also reported. METHODS: Participants (n = 148; ages 9–18 years; mean age 14.9 years) were receiving gender-affirming hormone therapy at a multidisciplinary program in Dallas, Texas (n = 25 puberty suppression only; n = 123 feminizing or masculinizing hormone therapy). Participants completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick Inventory of Depressive Symptoms and collected information on youth experiences of suicidal ideation, suicide attempt, and NSSI. RESULTS: Affirmed males reported greater depression and anxiety at baseline, but these differences were small (P, .01). Youth reported large improvements in body dissatisfaction (P, .001), small to moderate improvements in self-report of depressive symptoms (P, .001), and small improvements in total anxiety symptoms (P, .01). No demographic or treatment-related characteristics were associated with change over time. Lifetime and followup rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively. CONCLUSIONS: Results provide further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction. Modest initial improvements in mental health were also evident.
Keywords: adolescent; age distribution; anxiety disorder; article; automutilation; body dissatisfaction; Body Image Scale; clinician; cohort analysis; controlled study; demography; depression; female; follow up; gender dysphoria; health survey; hormonal therapy; human; interdisciplinary education; longitudinal study; major clinical study; male; mental health; patient participation; personal experience; priority journal; puberty; Quick Inventory of Depressive Symptoms score; scoring system; Screen for Child Anxiety Related Emotional Disorder score; self report; sex difference; suicidal ideation; suicide attempt; Texas

Prevalence of depressive symptoms among Italian medical students: The multicentre cross-sectional “PRIMES” study - Bert, F.; Lo Moro, G.; Corradi, A.; Acampora, A.; Agodi, A.; Brunelli, L.; Chironna, M.; Cocchio, S.; Cofini, V.; D’Errico, M.M.; Marzuillo, C.; Pasquarella, C.; et al. (PLoS ONE, 2020)
Background Four percent of the world’s population suffers from depression, which is a major public health issue. Medical students are at risk, as their depressive symptoms (DS) prevalence is reported to be approximately 27% worldwide. Since few data on Italian medical students exist, this study aimed to estimate their DS prevalence and assess risk and protective factors. Methods The PRIMES was a multicentre cross-sectional study performed in 12 Italian medical schools. Questionnaires were self-reported and included 30 sociodemographic items and the Beck Depression Inventory-II (BDI-II). The primary outcome was the presence of DS (BDI-II score≥14). The main analyses were chi-squared tests and multivariable logistic regressions with a p-value<0.05 considered significant. Results The number of collected questionnaires was 2,513 (117 BDI-II incomplete). Females accounted for 61.3% of the respondents, and the median age was 22 years (IQR = 4). The prevalence of DS was 29.5%. Specifically, 14.0% had mild depression, 11.1% had moderate depression, and 4.5% had severe depression. The main risk factors for DS were age, being female, bisexual/asexual orientation, living with partner/housemates, poor economic status (worsened by living far from home), less than 90 min of weekly exercise, relatives with psychiatric disorders, personal chronic disease, judging medical school choice negatively, unsatisfying friendships with classmates, competitive and hostile climate among classmates, thinking that medical school hinders specific activities and being worried about not measuring up to the profession. Protective factors included family cohesion, hobbies, intellectual curiosity as a career motivation and no worries about the future. Conclusion Italian medical students are at high risk of reporting DS, similar to the global population of medical students’. Medical schools must make efforts to implement preventive and treatment interventions by offering counselling and working on modifiable factors, such as lifestyle and learning climate.
Keywords: central stimulant agent; neuroleptic agent; academic achievement; adult; affect; aging; article; asexuality; Beck Depression Inventory; bisexuality; career; chronic disease; cognition; competition; cross-sectional study; decision making; depression; depressive risk; descriptive research; disease risk assessment; disease severity; drug use; economic status; employment; exercise; family cohesion; family interaction; female; first-degree relative; friendship; health hazard; health survey; high risk population; hostility; human; human relation; intellectual curiosity; Italian (citizen); leisure; living condition; major clinical study; male; medical school; medical school choice; medical student; motivation; multicenter study (topic); patient counseling; personal experience; prediction; prevalence; psychiatrist; psychological resilience; psychologist; questionnaire; residential area; rest; risk factor; second-degree relative; self report; sex difference; sleep; social environment; social status; social support; student attitude; student satisfaction; suicide; suicide attempt

Allowing for Nondisclosure in High Suicide Risk Groups - Podlogar, M.C.; Joiner, T.E. (Assessment, 2020)
Inaccurate disclosure of information is a significant limitation when relying on self-report for suicide risk screening. However, allowing for an explicit nondisclosure response option in screening items (e.g., "prefer not to disclose") may ultimately improve follow-up assessment validity. This study investigated explicit nondisclosure in suicide risk screening among military service members and veterans (n = 135), men older than 50 years, (n = 187), and LGBTQ (lesbian, gay, bisexual, transgender, or queer) young adults (n = 140); all higher risk and lower help-seeking populations. Results indicated that allowing for explicit nondisclosure minimally affected screening sensitivity and specificity. However, its selection was prevalent among higher risk participants, and was associated with experience of past unhelpful reactions and "avoidance of stigmatized consequences." Allowing for nondisclosure creates potential psychometric and classification advantages, and may be a safe and effective way to encourage discussion of barriers, build trust, maximize patient autonomy, and ultimately facilitate accurate risk disclosure to improve assessment validity.
Keywords: adult; article; avoidance behavior; bisexuality; controlled study; female; high risk population; homosexual female; human; major clinical study; male; military service; patient autonomy; risk assessment; sensitivity and specificity; suicide; transgender; trust; validity; veteran; young adult

Associations between negative life experiences and the mental health of trans and gender diverse young people in Australia: findings from Trans Pathways - Strauss, P.; Cook, A.; Winter, S.; Watson, V.; Wright Toussaint, D.; Lin, A. (Psychological medicine, 2020)
BACKGROUND: Trans and gender diverse (TGD) young people worldwide experience high rates of poor mental health; however, these rates were unknown in Australia. In addition, how negative life events affect the mental health of TGD young people has been largely unexplored. METHODS: This paper reports on novel mental health findings of Trans Pathways, the largest study ever conducted in Australia with trans (transgender) and gender diverse young people (N = 859; aged 14-25 years). The study was an anonymous online cross-sectional survey undertaken in 2016. Logistic and linear regression models were used to test associations between mental health outcomes and negative life experiences. RESULTS: TGD young people in Australia experience high levels of mental distress, including self-harming (79.7%), suicidal thoughts (82.4%), and attempting suicide (48.1%). Three in four participants had been diagnosed with depression and/or anxiety (74.6% and 72.2%, respectively). Many TGD young people had been exposed to negative experiences such as peer rejection (89.0%), precarious accommodation (22.0%), bullying (74.0%), and discrimination (68.9%). Most poor mental health outcomes were associated with negative experiences. The strongest associations were found for precarious accommodation and issues within educational settings. For example, participants with a prior suicide attempt were almost six times more likely to have experienced issues with accommodation, including homelessness. CONCLUSIONS: The current results highlight the urgent need for better mental health care and provide insight into areas for targeted mental health interventions. These findings are pertinent for clinicians working with trans young people and wider society.
Keywords: adolescent; anxiety; article; Australia; automutilation; bullying; clinician; controlled study; distress syndrome; female; gender; homelessness; human; linear regression analysis; major clinical study; male; mental health care; outcome assessment; peer rejection; personal experience; suicidal ideation; suicide attempt; transgender

Testing Basic Assumptions of the Interpersonal Needs Questionnaire-15 in a Sample of Clinically Depressed and Suicidal Youth - Hunt, Q.A.; Weiler, L.M.; McGuire, J.; Mendenhall, T.; Kobak, R.; Diamond, G.S. (Suicide & life-threatening behavior, 2020)
OBJECTIVE: Suicide is a leading cause of death in adolescence. The mechanisms of adolescent suicidality, however, are not fully understood. Although the Interpersonal-Psychological Theory of Suicide, as assessed by the Interpersonal Needs Questionnaire-15 (INQ), may be a promising framework, systematic study of its utility during adolescence is lacking. METHOD: To this end, we utilized factor analyses and hierarchical regression analyses to test the factor structure, correlates, and predictive validity of the INQ in a sample of clinically depressed and suicidal adolescents (N = 120, aged 12-18). The sample was mostly female (81.9%), ethnically diverse (68.2% non-White) and with nearly a third identifying as a sexual minority (31.8%). RESULTS: Contrary to studies including adult samples in which a two-factor solution is identified, results within this sample indicated three factors: perceived burdensomeness, thwarted belongingness, and perceived isolation. Perceived burdensomeness and the interaction between perceived burdensomeness and perceived isolation predicted suicide ideation above and beyond depression, but thwarted belongingness and perceived isolation did not. CONCLUSION: Perceived burdensomeness appears to play a role in adolescent suicidality and may be a point of intervention, yet the notable deviation from previous findings and the relative weakness of two of the factors warrant further study.
Keywords: adolescent; adult; article; child; controlled study; factor analysis; female; human; juvenile; major clinical study; predictive validity; questionnaire; school child; sexual and gender minority; suicidal ideation; weakness

Addressing LGBTQ Student Bullying in Massachusetts Schools: Perspectives of LGBTQ Students and School Health Professionals - Reisner, S.L.; Sava, L.M.; Menino, D.D.; Perrotti, J.; Barnes, T.N.; Humphrey, D.L.; Nikitin, R.V.; Earnshaw, V.A. (Prevention science : the official journal of the Society for Prevention Research, 2020)
Lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) youth face disparities in bullying victimization are associated with higher rates of physical injury, psychological distress, and even suicide. Innovative strategies to address bullying victimization are needed to prevent adverse physical and mental health outcomes, including those engaging school health professionals (SHPs; school nurses, psychologists). This mixed-methods study sought to identify factors that facilitate or impede SHPs' reporting and responding to LGBTQ bullying in Massachusetts from the perspectives of LGBTQ students and SHPs. Between August 2017 and July 2018, asynchronous online focus group discussions and a brief survey were conducted separately for 28 LGBTQ students and 19 SHPs in Massachusetts (9-12 participants per group; n = 47 enrolled). Focus groups probed on bullying experiences. Rapid qualitative inquiry was used for thematic coding of facilitators and barriers to address LGBTQ student bullying described by youth and SHPs. Facilitators and barriers largely coalesced around the social ecological model. Youth and SHPs identified factors at multiple levels of the social ecological model: (1) individual (knowledge, skills, attitudes); (2) interpersonal (trust and follow-through, confidentiality and fear of being "outed," close relationships, champion SHPs); and (3) structural (school buy-in, time, reporting and protocols, staff roles, resources, and school culture of inclusivity). LGBTQ students expressed a need for an intersectional lens for SHPs when addressing LGBTQ student bullying. Interventions that help SHPs overcome multilevel barriers and leverage facilitators are needed. Consideration of intersectionality will better equip SHPs to support LGBTQ students and address disparities in LGBTQ student bullying that confer health risks.
Keywords: adult; article; bisexuality; bullying; clinical article; confidentiality; controlled study; fear; female; health hazard; homosexual female; human; injury; juvenile; male; Massachusetts; mental health; mental stress; psychologist; public health; school health nursing; skill; suicide; transgender; trust

Mental Health Issues and Complex Experiences of Abuse Among Trans and Gender Diverse Young People: Findings from Trans Pathways - Strauss, P.; Cook, A.; Winter, S.; Watson, V.; Wright Toussaint, D.; Lin, A. (LGBT health, 2020)
Purpose: Trans and gender diverse (TGD) young people have reported high levels of mental distress in research studies, specifically depression, anxiety, self-harming, and suicidal behaviors. Rates of abuse are also high in TGD populations, but little is known about how this relates to mental health in populations of TGD young people. This study sought to examine associations between experiences of abuse and mental health outcomes. Methods: A cross-sectional study design was used. An anonymous online questionnaire was conducted to determine rates of abuse among Australian TGD young people (N = 859) and the potential association with poor mental health. Primary outcomes of interest were self-reported psychiatric diagnoses, self-harm and suicidal behaviors, and current anxiety and depressive symptoms. Results: Exposures to six forms of abuse are reported in this article: extrafamilial physical abuse, familial physical abuse, extrafamilial sexual abuse, familial sexual abuse, abuse within an intimate relationship, and other familial abuse (including emotional or verbal abuse and neglect). All six forms of abuse measured were associated with poor mental health overall; risk estimates for some forms of abuse were much stronger than others. Conclusion: The current findings have wide-ranging implications for clinical practice. Those working in TGD health care need to be aware of the high prevalence of violence and abuse among TGD young people and the association with poor mental health outcomes. The findings also have implications for broader societal change and interventions targeting increasing parental support to reduce familial violence against TGD young people.
Keywords: adolescent; adult; Australia; cross-sectional study; female; human; male; mental disease; physical abuse; psychology; questionnaire; sexual crime; transgender; young adult

LGBTQ-Related Individual Differences Predict Emotional Reactions to the Pulse Nightclub Shootings - Maduro, R.S.; Sheehan, B.E.; Hitson, P.; Shappie, A.T.; Derlega, V.J. (Violence and victims, 2020)
This study examined, among 232 lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) participants, the association of identity centrality and public regard with negative affect about the Pulse nightclub shootings in Orlando, Florida. Identification with victims and perceived threat to personal safety were sequential mediators. Identity centrality was associated with greater identification with the shooting victims. In turn, identification with the victims was associated with greater perceived threat, followed by more negative affect. Low public regard was associated with greater perceived threat that, in turn, was associated with more negative affect. The results support the notion that LGBTQ-related individual differences increase distress about anti-sexual/gender minority hate crimes, especially for individuals with a strong LGBTQ identity and who believe that the majority, heterosexual society devalues sexual/gender minority persons.
Keywords: bisexuality; female; Florida; human; individuality; lesbianism; male; mass disaster; mental stress; sexual and gender minority; social psychology; transgender; violence

Children and adolescents with gender dysphoria in israel: Increasing referral and fertility preservation rates - Segev-Becker, A.; Israeli, G.; Elkon-Tamir, E.; Perl, L.; Sekler, O.; Amir, H.; Interator, H.; Dayan, S.C.; Chorna, E.; Weintrob, N.; Oren, A. (Endocrine Practice, 2020)
Objective: To describe patient characteristics at presentation, management, and fertility preservation rates among a cohort of Israeli children and adolescents with gender dysphoria (GD). Methods: We performed a retrospective chart review of 106 consecutive children and adolescents with GD (<18 years) referred to and followed at the multidisciplinary Israeli Pediatric Gender Dysphoria Clinic from March 2013 through December 2018. Results: Of the 106 patients, 10 were prepubertal (9 prepubertal transgender females), and 96 were pubertal (38 pubertal transgender females). The GD population increased 11-fold since the establishment of our clinic in 2013. The subject's median age at referral was 15.5 years (range, 4.6 to 18 years). At the time of referral, 91 (95%) of the pubertal group had completed sexual maturation in their assigned gender at birth. Thirteen (13.5%) patients had attempted suicide, and 11 (11.5%) reported having had suicidal thoughts. Fourteen (45%) pubertal transgender females and 3 (6.5%) pubertal transgender males completed fertility preservation. Gonadotropin-releasing hormone analog treatment was prescribed in 77 (80%) patients at a mean age of 15.9 ± 1.6 years. Gender-affirming hormones were prescribed in 61 (64%) patients at a mean age of 16.5 ± 1.3 years. No severe side effects were recorded. Two (2%) of the pubertal group expressed regret about medical treatment. Conclusion: Children and adolescents with GD are presenting for medical attention at increasing rates. Israeli adolescents with GD have high fertility preservation rates, perhaps attributable to cultural perspectives. Taking advantage of the option to preserve fertility can be achieved when proper counseling is both available and promoted by medical personnel.
Keywords: gonadorelin derivative; adolescent; adult; anxiety; article; breast reconstruction; cohort analysis; controlled study; female; fertility preservation; gender dysphoria; hormonal therapy; human; major clinical study; male; morbidity; prepuberty; prescription; retrospective study; sexual maturation; suicidal ideation; suicide; vagina reconstruction

Suicide and the transgender experience: A public health crisis - Dickey, L.M.; Budge, S.L. (The American psychologist, 2020)
Given the rise in the visibility of the trans community, increasing attention has been paid to mental health disparities in trans populations. Specifically, research findings conclude that suicide is considered 1 of the major health disparities in trans populations. Across several studies it has been found that 40% or more of trans people have attempted suicide at least once in their lifetime. There are a multitude of reasons why trans people experience suicidal ideation and attempt suicide, with minority stress being theorized as a primary cause. To address minority stress-focused suicide, a psychologically adapted public health model is proposed. This model includes the following steps for preventing suicidal thoughts and behaviors: (a) defining the issue, (b) identifying causes and risk factors, (c) developing and testing psychological interventions, and (d) implementing psychological interventions. Key components discussed include the evidence and practice for supporting trans people through their social and medical transition processes, which have been demonstrated to improve mental and physical health outcomes. The implications of the prevention model indicate that psychologists play a key role in supporting trans people, regardless of the clinical concerns that bring them to therapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Keywords: adult; epidemiology; health disparity; human; mental stress; minority group; psychology; public health; suicidal ideation; suicide attempt; transgender

Cohort profile: The Brain and Mind Centre Optymise cohort: Tracking multidimensional outcomes in young people presenting for mental healthcare - Carpenter, J.S.; Iorfino, F.; Cross, S.; Nichles, A.; Zmicerevska, N.; Crouse, J.J.; Palmer, J.R.; Whitton, A.E.; White, D.; Naismith, S.L.; Guastella, A.J.; Hermens, D.F.; et al. (BMJ Open, 2020)
Purpose The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course. Participants Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment. Measures Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen. Findings to date There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes. Future plans Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.
Keywords: adolescent; adult; alcohol consumption; alcoholism; anxiety disorder; article; automutilation; bipolar disorder; child; clinical assessment; clinical feature; clinical research; cohort analysis; comorbidity; conduct disorder; depression; disease burden; disease course; disruptive behavior; dissociative disorder; drug dependence; early intervention; eating disorder; family history; female; follow up; gender dysphoria; health; health care utilization; human; impulse control disorder; longitudinal study; major clinical study; male; mental disease; mental health; mental health care; mental health service; mixed anxiety and depression; mood disorder; observational study; obsessive compulsive disorder; personality disorder; posttraumatic stress disorder; psychosis; psychosomatic disorder; register; sleep disorder; Social and Occupational Functioning Assessment Scale; substance use; suicidal behavior; suicidal ideation; suicide attempt

Sexual minorities and teen suicide attempts in a southeastern state with prominent exclusionary policies - Richardson, S.C.; Hales, T.; Meehan, E.; Waters, A. (Death studies, 2020)
This study examines differences in suicide-related behaviors between heterosexual and sexual minority youth in a southeastern state with exclusionary policies. Furthermore, it seeks to further knowledge regarding risk factors for suicide attempts among sexual minority high school students. Utilizing the 2017 Youth Risk Behavior Survey data, descriptive analysis tests, and logistic regression tests were conducted. Findings indicate that sexual minorities were three times as likely to experience suicidal thoughts and plans but four times as likely to attempt suicide. Risk factors were noted for sexual minority youth. Policy advocacy is recommended to decrease suicide-related behaviors among this population.
Keywords: article; female; heterosexuality; high school student; human; juvenile; male; risk factor; sexual and gender minority; suicidal ideation; suicide attempt

Prevalence and Correlates of Sexual Revictimization in Middle and High School Youth - Edwards, K.M.; Banyard, V.L. (Journal of interpersonal violence, 2020)
Research consistently shows that individuals who experience a sexual assault are at an increased risk to experience a subsequent sexual assault, a phenomenon known as sexual revictimization. However, little research has used a longitudinal methodology to examine rates and correlates of peer-to-peer sexual revictimization in middle and high school youth. The purpose of this study was to address this gap in the literature. Participants were 1,706 youth in Grades 7 to 10 (51.3% female) who completed surveys at the beginning and end of an academic year, approximately 6 months apart. Results showed that the vast majority (n = 1561, 90.4%) of youth reported no sexual victimization at either time point, 125 youth (7.2%) reported sexual victimization at one time point, and 40 youth (2.3%) reported sexual victimization at two time points. Among victims (n = 165), about one quarter (n = 40, 24.2%) were victimized at both time points. Binge drinking, depression, and suicidal thoughts were all higher among multiple and singular victims compared with nonvictims and among multiple victims compared with singular victims. Girls and sexual minorities were more likely to be multiple and singular victims compared with nonvictims and multiple victims compared with singular victims. Older youth were more likely to be multiple and singular victims compared with nonvictims. These data underscore the need for programming that concurrently focuses on mental health and sexual assault risk reduction, especially among high-risk youth.
Keywords: article; binge drinking; child; controlled study; domestic violence; female; high school; human; major clinical study; male; mental health; prevalence; risk reduction; sexual and gender minority; sexual assault; suicidal ideation; victim; alcohol

Victimization, depression, and the suicide cascade in sexual minority youth - Turpin, R.E.; Rosario, A.; Wang, M.Q. (Journal of Mental Health, 2020)
Background: Suicidality remains disproportionately prevalent among sexual minority youth, necessitating novel methods of understanding suicide risk in this population. Victimization and depression are especially salient suicide risk factors. Aims: We aimed to test if victimization and depression were associated with suicidality at each step of a suicide cascade: Ideation, planning, and suicide attempts. Method: In sample of sexual minorities from the 2015 and 2017 Youth Risk Behavior Survey, we tested nine measures of victimization and depression associated with three outcomes in succession: Suicidal ideation among the full sample (n = 3357), suicide planning among those with ideation (n = 1475), and suicide attempts among those who planned suicide (n = 1073). Results: Depression was associated with suicidal ideation (aPR = 3.93, 95% CI 3.36–4.60), planning (aPR = 1.38, 95% CI 1.12–1.69), and attempts (aPR = 1.78, 95% CI 1.32–2.41) in successive subsamples. Victimization measures had different associations with suicidality at each successive stage, with the strongest associations observed with suicidal ideation in the general sample and suicide attempts among those who planned suicide. Conclusions: This may have implications for anti-victimization intervention effectiveness at each stage of suicidality. Additional research into this association among transgender and gender non-conforming youth is recommended.
Keywords: adolescent; adult; article; bullying; controlled study; cross-sectional study; depression; female; human; juvenile; major clinical study; male; sexual and gender minority; sexual assault; sexual intercourse; sexual violence; suicidal ideation; suicide attempt; victim; young adult

Transgender Adolescents' Uses of Social Media for Social Support - Selkie, E.; Adkins, V.; Masters, E.; Bajpai, A.; Shumer, D. (Journal of Adolescent Health, 2020)
Purpose: Transgender adolescents are at higher risk for negative mental health outcomes, such as depression, anxiety, and suicidality, compared with cisgender adolescents. Social media may be an effective venue for addressing these health disparities because most adolescents have access to online information and socialization. This study used qualitative inquiry to explore transgender adolescents' uses of social media for social support. Methods: Transgender adolescents between the ages of 15 and 18 years with a social media profile were recruited from a pediatric gender clinic in the Midwestern U.S. A 30- to 60-minute semistructured interview assessed ways participants used social media to access transgender-related support. Thematic analysis was used to develop categories and code the transcripts. Coding discrepancies were resolved by two researchers following initial coding. Results: Results represent data from 25 interviews comprising 13 transmasculine, 11 transfeminine, and one nonbinary participant(s), with 68% of the sample identifying as white, non-Hispanic. Categories emerged regarding forms of support participants received from transgender-related online communities including emotional support through peers and role models, appraisal support for validating their experiences, and informational support for navigating health decisions and educating family and friends. Participants also referenced negative experiences, including harassment and exclusionary behavior online. Conclusions: Social media platforms represent hubs of community for transgender adolescents. These communities provide emotional, appraisal, and informational support that transgender youth may not otherwise be able to access. Future research should use the affordances of social media to identify approaches to addressing health disparities and improving the well-being of transgender adolescents.
Keywords: adolescent; article; child; female; friend; gender; genetic transcription; harassment; health disparity; human; Internet; juvenile; major clinical study; male; mental health; semi structured interview; social media; social support; thematic analysis; transgender; wellbeing

Potential association between type 1 diabetes mellitus and gender dysphoria - Logel, S.N.; Bekx, M.T.; Rehm, J.L. (Pediatric Diabetes, 2020)
Background/Objective: Multiple factors have been proposed to explain the increasing prevalence of type 1 diabetes mellitus (T1DM), including psychological stress. The prevalence of gender dysphoria (GD) in youth is also growing. Identifying environmental triggers, such as psychological minority stress experienced by youth with GD, that may influence the pathogenesis and management of T1DM could have important clinical implications. The objective of this study was to determine the prevalence of concurrent diagnosis of T1DM and GD in adolescents evaluated at a university-based children's hospital. Methods: An electronic data extraction was conducted at the University of Wisconsin Hospital and Clinics from 1 November 2007 to 1 November 2017. Inclusion criteria included age 10 to 21 years and diagnosis of T1DM and/or GD. Prevalence rates were calculated for T1DM and GD. For adolescents with T1DM and GD, information related to diagnosis, treatment, and psychiatric history was collected. Results: The prevalence for T1DM was 2.69 per 1000; the prevalence for GD was 0.42 per 1000. Eight adolescents had T1DM and GD. In adolescents with GD, the prevalence of T1DM was 9.4-fold higher than the prevalence of T1DM alone (24.77 vs 2.68 per 1000). Five adolescents were seen in GD clinic and their glycemic control initially improved after the first GD clinic visit. Conclusions: There was an increased prevalence of a concurrent diagnosis of T1DM in those with GD compared to the general population. Glycemic control improved after the first GD clinic visit in adolescents with T1DM and GD, which may be secondary to stress reduction.
Keywords: article; child; controlled study; disease association; female; gender dysphoria; glycemic control; human; insulin dependent diabetes mellitus; major clinical study; male; mental stress; prevalence; priority journal; school child; suicide attempt

Who attempts suicide among medical students? - Marcon, G.; Massaro Carneiro Monteiro, G.; Ballester, P.; Cassidy, R.M.; Zimerman, A.; Brunoni, A.R.; von Diemen, L.; Hauck, S.; Passos, I.C. (Acta Psychiatrica Scandinavica, 2020)
Objective: To identify factors associated with a history of suicide attempt in medical students. Methods: A Web-based survey was sent out to a sample of medical students. A multi-predictor Poisson regression was performed to identify factors associated with a history of suicide attempt. In addition, an elastic net regularization was used to build a risk calculator to identify students at risk for attempted suicide. Results: A total of 4,840 participants were included in the study. Prevalence of suicide attempts in the sample was 8.94%. Risk factors associated with past suicide attempt in the multi-predictor Poisson regression were as follows: female gender (P < 0.001); homosexuality (P < 0.001); low income (P = 0.026); bullying by university peers (P = 0.006); childhood (P = 0.001) or adult (P = 0.001) trauma; family history of suicide (P = 0.005); suicidal ideation within the last month (P < 0.001); daily tobacco use (P = 0.037); and being at severe risk for alcohol abuse (P = 0.023). Our elastic net model performed well with an AUC of 0.83. Conclusions: This study identifies a number of key factors associated with a history of suicide attempts among medical students. Future longitudinal studies should assess the causal relationship between these factors and suicide attempts. Additionally, these results demonstrate that current available data on suicide attempts among medical students can be used to develop an accurate risk algorithm.
Keywords: adult; alcohol abuse; article; Brazil; bullying; childhood trauma; cross-sectional study; family history; female; homosexuality; human; lowest income group; major clinical study; male; medical student; peer group; prevalence; priority journal; risk factor; suicidal ideation; suicide attempt; tobacco use; undergraduate student; university student; young adult

Predicting suicidal behavior among lesbian, gay, bisexual, and transgender youth receiving psychiatric emergency services - Berona, J.; Horwitz, A.G.; Czyz, E.K.; King, C.A. (Journal of Psychiatric Research, 2020)
Lesbian, gay, bisexual, and transgender (LGBT) youth are at elevated risk for self-injurious thoughts and behaviors (SITBs). However, few studies have comprehensively examined SITBs and their longitudinal course in LGBT youth at high risk for suicide. The aims of the present study were to characterize histories of SITBs among high-risk LGBT youth and to examine prospective associations with suicidal behavior. Participants were 285 youth (41.8% LGBT) ages 13–25 years receiving psychiatric emergency department (ED) services. Post-discharge suicidal behavior was assessed via 4-month phone interviews and 12 month chart reviews. The sample was 42.1% male, 57.9% female, 2.5% gender minority, 41.8% sexual minority. LGBT participants were more likely to have prior psychiatric ED visits and hospitalizations, more frequent past week suicide ideation, and more severe nonsuicidal self-injury (NSSI). We conducted stratified survival analyses to identify predictors of time to suicidal behavior post discharge. The final model for LGBT youth included past week suicide ideation and past month NSSI episodes. Among non-LGBT youth, the final model included number of lifetime NSSI methods and use of a highly lethal suicide attempt method. Within this sample of youth receiving psychiatric emergency services, LGBT youth were overrepresented and had more severe histories of SITBs. Results suggest the importance of assessing both lifetime and recent factors (i.e., past week and month), particularly for LGBT youth. Future research should replicate these findings in larger samples to explore whether there are unique risk factors that can aid in predicting and preventing suicide among LGBT youth.
Keywords: adolescent; adult; article; automutilation; cohort analysis; disease association; disease severity; emergency ward; female; high risk population; hospital discharge; human; lethality; LGBT people; lifespan; longitudinal study; major clinical study; male; medical history; medical record review; predictive value; priority journal; prospective study; psychiatric emergency service; risk factor; sensitivity analysis; sexual and gender minority; suicidal behavior; suicidal ideation; suicide attempt; survival analysis; survival prediction; telephone interview

Suicidal ideation and behavior among sexual minority and heterosexual youth: 1995-2017 - Liu, R.T.; Walsh, R.F.L.; Sheehan, A.E.; Cheek, S.M.; Carter, S.M. (Pediatrics, 2020)
OBJECTIVES: In this study, we determined trends in prevalence of suicidal thoughts and behaviors among lesbian, gay, bisexual, and heterosexual youth from 1995 to 2017 using populationbased surveillance data. METHODS: Data were drawn from the Massachusetts Youth Risk Behavior Survey from 1995 to 2017 (unweighted N = 41 636). The annual percent change (APC) in prevalence of suicidal ideation, plans, and attempts was stratified by sexual orientation as indexed by sexual identity and sexual behavior. RESULTS: Among sexual minority youth, prevalence rates declined over the entire study period for suicidal ideation (APCsexual identity = 21.25; APCsexual behavior = 21.83), plans (APCsexual identity = 21.88; APCsexual behavior = 21.95), and attempts (APCsexual identity = 22.64; APCsexual behavior = 22.47). Among heterosexual youth, prevalence rates declined from 1995 to 2007 for suicidal ideation (APCsexual identity = 26.67; APCsexual behavior = 26.77) and plans (APCsexual identity = 25.73; APCsexual behavior = 26.25). These declines in ideation and plans were steeper than those for sexual minority youth. Prevalence of suicide attempts declined across the entire study period among heterosexual youth (APCsexual identity = 23.66; APCsexual behavior = 24.01). Prevalence of all 3 outcomes remained markedly high among sexual minority youth across the 23-year study period. CONCLUSIONS: Although suicidal thoughts and behavior have generally declined among sexual minority and heterosexual youth, disparities in these outcomes persist, and their prevalence among sexual minority youth has remained consistently elevated. Prioritized screening for risk for suicidal thoughts and behaviors in this vulnerable population is imperative to reduce disparities and prevalence of these outcomes.
Keywords: adolescence; adolescent; article; bisexuality; female; gender identity; heterosexuality; homosexual female; homosexual male; human; major clinical study; male; prevalence; priority journal; sexual and gender minority; sexual behavior; suicidal behavior; suicidal ideation; suicide attempt; trend study

Sexual orientation and suicide attempt disparities among US adolescents: 2009-2017 - Raifman, J.; Charlton, B.M.; Arrington-Sanders, R.; Chan, P.A.; Rusley, J.; Mayer, K.H.; Stein, M.D.; Austin, S.B.; McConnell, M. (Pediatrics, 2020)
BACKGROUND: Sexual minority adolescents face mental health disparities relative to heterosexual adolescents. We evaluated temporal changes in US adolescent reported sexual orientation and suicide attempts by sexual orientation. METHODS: We used Youth Risk Behavioral Surveillance data from 6 states that collected data on sexual orientation identity and 4 states that collected data on sex of sexual contacts continuously between 2009 and 2017. We estimated odds ratios using logistic regression models to evaluate changes in reported sexual orientation identity, sex of consensual sexual contacts, and suicide attempts over time and calculated marginal effects (MEs). RESULTS: The proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017 (ME: 0.8 percentage points [pp] per year; 95% confidence interval [CI]: 0.6 to 0.9 pp). The proportion of adolescents reporting any same-sex sexual contact increased by 70%, from 7.7% in 2009 to 13.1% in 2017 (ME: 0.6 pp per year; 95% CI: 0.4 to 0.8 pp). Although suicide attempts declined among students identifying as sexual minorities (ME: -0.8 pp per year; 95% CI:-1.4 to -0.2 pp), these students remained <3 times more likely to attempt suicide relative to heterosexual students in 2017. Sexual minority adolescents accounted for an increasing proportion of all adolescent suicide attempts. CONCLUSIONS: The proportion of adolescents reporting sexual minority identity and same-sex sexual contacts increased between 2009 and 2017. Disparities in suicide attempts persist. Developing and implementing approaches to reducing sexual minority youth suicide is critically important.
Keywords: adolescent; adult; article; controlled study; female; gender identity; health disparity; heterosexuality; human; logistic regression analysis; major clinical study; male; priority journal; risk assessment; sexual and gender minority; sexual behavior; sexual intercourse; sexual orientation; statistical model; student; suicide attempt; United States

Chemsex-related drug use and its association with health outcomes in men who have sex with men: A cross-sectional analysis of Antidote clinic service data - Stevens, O.; Moncrieff, M.; Gafos, M. (Sexually Transmitted Infections, 2020)
Purpose Chemsex-related drug use (CDU) is an escalating public health issue among men who have sex with men (MSM), associated with significant physical, biomedical and psychosocial harm. Few interventions exist to help MSM engaging in chemsex and little data exist on which to build. This cross-sectional analysis, using data from Antidote, the UK's only lesbian, gay, bisexual, and transgender specialist drug service, aims to remedy this paucity of data. Methods Modified Poisson regression was used to assess associations between CDU and a range of health outcomes; CDU+ subanalysis disaggregated MSM by primary chemsex drug of concern; and HIV+ subanalysis investigated whether CDU was associated with self-reported treatment adherence, HIV seroconversion and other HIV-specific issues. Findings Compared with CDU- MSM, MSM presenting for CDU were more likely to be HIV+, current or previous injectors, to have used postexposure prophylaxis in the last year, and have had ≥6 sexual partners in the last 90 days, though less likely to be hazardous alcohol consumers or to have experienced previous suicidal ideation (all p<0.0005). CDU+ subanalysis revealed health outcome differences - those selecting mephedrone were less likely to be hepatitis C+, HIV+, current or previous injectors, or to have experienced previous suicidal ideation (all p<0.0005), whereas those selecting methamphetamine were more likely (all p<0.0005, except suicidal ideation p=0.009). Implications This analysis shows MSM presenting for CDU are a heterogeneous high-risk population with unmet health needs. There is a need for standardised chemsex surveillance and for improved intersectorial working between sexual health and drug treatment services. Future research should investigate typological differences between MSM presenting for CDU. Originality/value To date, this is the world's largest analysis of MSM seeking treatment for CDU. Further, the publication of € real-world' service data is a valuable addition to the literature alongside surveys and recruited studies.
Keywords: 4' methylmethcathinone; methamphetamine; alcohol consumption; article; chemsex related drug use; cross-sectional study; disease association; drug use; female; hepatitis C; high risk population; human; Human immunodeficiency virus infection; LGBT people; major clinical study; male; men who have sex with men; methamphetamine dependence; patient compliance; patient-reported outcome; post exposure prophylaxis; priority journal; public health problem; sexuality; suicidal ideation

Exploring substance use and mental health for minority transgender youth: Implications for advanced practice nurses - Raynor, P.A.; Nation, A.; Outlaw, F. (Journal of the American Association of Nurse Practitioners, 2020)
BACKGROUND: Transgender youth, particularly if they are transgender female and of a minority racial or ethnic group (i.e., minority transgender youth [MTY]), are known to have higher incidence of new HIV infections, substance abuse, and suicidality when compared with cisgender youth. Mental health disparities and substance use among MTY, between the ages of 13-24 years, have been underexplored in the United States, although they have serious public health concerns contributing to morbidity and mortality. OBJECTIVES: To examine the US literature to discover what is known about the intersection of substance use, mental health disorders, and associated health risks for MTY. DATA SOURCES: An integrative review exploring experimental and nonexperimental research was conducted from 2010 to 2018 using Cumulative Index for Nursing and Allied Health (CINAHL), PsycINFO, and PubMed. Articles were selected if the research identified MTY, mental health and/or substance use risks, data-driven outcomes, or considerations that could potentially influence MTY outcomes. Ten articles were included in the final selection. CONCLUSIONS: All studies addressed mental health, substance use, and/or health risks, although many of the articles explored all transgender youth outcomes without a particular focus on MTY. Identified factors linked to poor health outcomes included socioeconomic vulnerability, substance use, mood disorders, self-harm, and risky sexual behaviors. IMPLICATIONS FOR PRACTICE: The authors have provided recommendations regarding culturally appropriate, compassionate, evidence-informed practices for engaging MTY and their families to promote greater well-being for all youth, regardless of gender identity.
Keywords: adolescent; advanced practice nursing; child; drug dependence; female; gender identity; high risk behavior; human; male; mental disease; minority group; psychology; transgender; United States; young adult

Trans adolescents' perceptions and experiences of their parents' supportive and rejecting behaviors - Johnson, K.C.; LeBlanc, A.J.; Sterzing, P.R.; Deardorff, J.; Antin, T.; Bockting, W.O. (Journal of counseling psychology, 2020)
Transgender (trans) adolescents consistently report higher rates of adverse mental health outcomes compared to their cisgender peers. Parental support is a recognized adolescent protective factor; however, little is known about the specific parental behaviors that trans adolescents perceive as most or least supportive. To address this gap, we analyzed data from qualitative interviews conducted with an ethnically diverse, urban-based sample of trans adolescents (N = 24; 16-20 years old) to describe (a) the spectrum of specific parental behaviors across 3 categories-rejecting, supportive, and mixed (i.e., simultaneous supportive and rejecting behaviors)-and (b) the perceived psychosocial consequences across these 3 categories of parental behaviors. Qualitative data were gathered through lifeline interviews (i.e., visual representations from birth to present) and photo elicitation (i.e., photographs representing parental support and/or rejection). Supportive behaviors included instances where parents made independent efforts to learn about trans issues or help their child obtain gender-affirming health care. Rejecting behaviors included instances when parents refused to use their child's name or pronouns or failed to show empathy when their child struggled with gender-identity-related challenges. Mixed behaviors included examples when parents expressed support of their child's gender identity, but not of their sexual orientation (or vice versa). Overall, participants reported that rejecting and mixed parental behaviors contributed to a range of psychosocial problems (e.g., depression and suicidal ideation), while supportive behaviors increased positive wellbeing. These findings expand upon descriptions of parental support and rejection within the trans adolescent literature and can help practitioners target specific behaviors for interventions. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Keywords: adolescent; child parent relation; female; gender identity; human; male; peer group; psychology; transgender; young adult

Documentation Practices for Transgender Youth Admitted to an Inpatient Psychiatric Unit - Bieber, E.D.; Vande Voort, J.L.; Croarkin, P.E.; VON Drehle, C.T.; Simon, S.M.; Hopp, B.N.; Heil, H.M.; Romanowicz, M. (Journal of psychiatric practice, 2020)
BACKGROUND: Population-based surveys estimate that 0.7% of youth (13 to 17 y of age) in the United States identifies as transgender. Transgender youth are at an increased risk of anxiety, depression, and suicide attempts that often require inpatient care. Unfortunately, because of perceived insensitivity to gender identity from their providers, which includes incorrect use of names and/or pronouns, they may delay seeking necessary care. To date, there have been no specific documentation practice guidelines published by the International Association of Child and Adolescent Psychiatry and Allied Professions, American Academy of Child and Adolescent Psychiatry (AACAP), or other professional associations. The main goal of this study was to review documentation practices among multidisciplinary teams caring for hospitalized transgender youth on a child and adolescent inpatient psychiatry unit. METHODS: Retrospective chart reviews were completed for 44 transgender patients who were hospitalized between 2008 and 2017. The charts were reviewed for consistency in the documentation of name and gender by the multidisciplinary team. Members included child and adolescent staff psychiatrists, residents, fellows, nurses, nurse practitioners, physician assistants, and social workers. Inconsistency was defined as at least 2 members of the team referring to a patient by a different name and/or gender pronoun in separate notes or >2 interchanges of name and/or gender pronoun in a single note. Kappa coefficient was calculated between each team member role to estimate exact agreement statistics. RESULTS: In 43.2% (n=19) of cases, team members did not have a consistent approach to documenting a patient's name and/or gender pronoun and 18% (n=8) of discharge summaries were also inconsistent in this documentation. The greatest agreement in documentation practices was noted between the team and the staff psychiatrist (κ=0.446). CONCLUSIONS: Findings from this study suggest that inpatient treatment teams show inconsistency in documentation practices for youth transgender inpatients. Further work is necessary to understand the implications of these findings for patient satisfaction and clinical outcomes.
Keywords: adolescent; article; care behavior; child; child psychiatry; clinical article; clinical outcome; controlled study; documentation; female; gender; hospital patient; human; juvenile; kappa statistics; male; medical record review; multidisciplinary team; nurse practitioner; occupation; outcome assessment; patient satisfaction; physician assistant; practice guideline; psychiatric department; resident; social worker; transgender

Health Disparities Among Transgender Adults in South Korea - Lee, H.; Operario, D.; van den Berg, J.J.; Yi, H.; Choo, S.; Kim, S.-S. (Asia-Pacific journal of public health, 2020)
This study aims to identify health disparities among transgender adults in South Korea (hereafter Korea), where they widely experience social stigma. We assessed prevalence of nine health indicators using a nationwide cross-sectional survey of 255 Korean transgender adults in 2017. Standardized prevalence ratios of these indicators were estimated using four nationally representative surveys in Korea that included the same health measures. Overall, transgender adults had a significantly higher risk of adverse health outcomes than the general population in Korea. Specifically, disparities in mental health outcomes between transgender adults and the general population were statistically significant. The prevalence of depressive symptoms was 6.44 and 9.71 times higher among transgender adults than women and men in the general population, respectively. For suicidal ideation, transgender adults reported 6.49 and 18.83 times greater risk than women and men in the general population, respectively. Our findings indicate that Korean transgender adults are at a higher risk of negative health outcomes than the general population.
Keywords: adult; cross-sectional study; depression; female; health disparity; human; male; middle aged; prevalence; psychology; risk assessment; social stigma; South Korea; suicidal ideation; transgender; young adult

Self-reported history of concussions is associated with risk factors for suicide completion among high school students - Mantey, D.S.; Omega-Njemnobi, O.; Barroso, C.S.; Kelder, S.H. (Journal of Affective Disorders, 2020)
Background: Suicide is the third leading cause of death among adolescents. While research has found concussions to be a risk factor for suicide in adults, this relationship is not well studied in nationally representative samples of youth. This study examines the relationship between self-reported history of sports-related concussion and five risk factors for suicide completion. Methods: Data were obtained from the 2017 Youth Risk Behavior Surveillance Survey (n=13,353). Multivariate logistic regression models assessed the relationship between self-reported, sports-related concussion and five risk factors for suicide completion. Analyses controlled for sex, race/ethnicity, grade, bullying victimization, and sexual orientation. Subsample analyses were conducted stratified by sex. Interaction models examined biological sex as a possible effect modifier. Results: Overall, 15.0% of high school students reported a sports-related concussion in the past 12-months. Self-reported, sports-related concussion was significantly associated with greater odds of feeling sad/hopeless (Adj OR: 1.20; 95% CI:1.02–1.42), suicidal ideations (Adj OR: 1.25; 95% CI:1.02–1.55), suicide attempt (Adj OR: 1.60; 95% CI:1.31–1.96), and suicide attempt treated by a doctor/nurse (Adj OR: 2.35; 95% CI:1.68–3.29), adjusting for covariates. Stratified analyses demonstrated differences by sex, however, no direct evidence of effect modification was observed in interaction models. Limitations: Data are cross-sectional, prohibiting causal inferences. Measures were assessed via self-report. No pre-concussion measures of mental health. Conclusion: Self-reported sports-related concussion was associated with risk factors for suicide completion. No direct evidence of effect modification was observed but stratified analyses suggest biological sex may impact the observed relationship.
Keywords: adolescent; article; concussion; female; high school student; hopelessness; human; major clinical study; male; medical history; priority journal; risk factor; sadness; self report; sex difference; sport injury; suicidal ideation; suicide; suicide attempt

Understanding suicide risk and eating disorders in college student populations: Results from a National Study - Lipson, S.K.; Sonneville, K.R. (International Journal of Eating Disorders, 2020)
Objective: To examine suicide risk by eating disorder severity and symptom presentation in a nationwide sample of college students. Method: The Healthy Minds Study is the largest mental health survey of college populations in the United States. We analyzed the most recent available data (2015–2017) with 71,712 randomly selected students from 77 campuses. We estimated associations between two measures of suicidality (ideation and attempts) and three validated measures of eating disorder symptoms (the SCOFF, weight concerns scale, and the eating disorder examination questionnaire binge and purge items). Importantly, we also controlled for co-occurring symptoms of depression and anxiety, based on validated screening tools. The large, diverse sample provided a unique opportunity to assess whether certain individual characteristics were associated with increased risk. Results: Eating disorder symptoms, even at subthreshold levels, were highly predictive of suicidality. Relative to students with no apparent eating disorder symptoms, students with the highest symptom levels (a SCOFF score of 5) had 11 times higher odds of attempting suicide, while those with subthreshold symptoms had two times higher odds. We also observed a strong association between suicide attempts and eating disorder presentations that included purging. Students from marginalized backgrounds, particularly gender and sexual minorities, were at increased risk for suicide and eating disorders. Discussion: In the largest known study to date, findings suggest that eating disorders should be a priority within broader campus suicide prevention efforts, should be assessed along a continuum of severity and symptom presentation, and should focus on reaching vulnerable students.
Keywords: adult; anxiety disorder; article; binge eating disorder; college student; depression; eating disorder; female; human; major clinical study; male; priority journal; purging disorder; risk factor; suicidal ideation; suicide; suicide attempt; young adult

Association between perceived public stigma and suicidal behaviors among college students of color in the U.S. - Goodwill, J.R.; Zhou, S. (Journal of Affective Disorders, 2020)
Background: Suicide is the 2nd leading cause of death among college students and 10 to 34-year-olds in the U.S. While rates of suicide among young people of color have increased, less is known about factors that contribute to suicidality among racial minority students who are sorely underrepresented within existing research. Thus, we sought to explore the association between perceived public stigma of receiving mental health treatment and suicidality among Black, Asian Domestic, Asian International, Latinx, Multiracial, Arab/Arab American, American Indian/Alaska Native, and White college students. Methods: We analyzed cross-sectional survey responses from racially diverse sample of 153, 635 college students who participated in the Healthy Minds Study from years 2007–2018. Multivariable logistic regression was used to examine associations between perceived public stigma and suicide ideation, suicide planning, and suicide attempt. Results: Perceived public stigma was significantly associated with greater odds of suicide ideation, planning, and attempt. Odds of having attempted suicide within the past year were significantly greater among Asian International and Black college students. Sexual minority students broadly, and bisexual students specifically, were also at elevated risk for suicidal behavior. Limitations: Cross-sectional survey responses were assessed and causality cannot be determined. Conclusions: Students who endorsed more perceived public stigma also reported significantly greater odds of having experienced suicide ideation, planning, and attempt within the past 12 months. Subsequent interventions should account for concerns surrounding public perceptions of stigma when working to prevent suicide among students of color.
Keywords: adult; article; bisexuality; college student; cross-sectional study; cultural diversity; depression; female; human; major clinical study; male; Patient Health Questionnaire 9; perception; priority journal; risk factor; sexual and gender minority; sexual orientation; social stigma; suicidal behavior; suicidal ideation; suicide attempt; suicide planning

Associations of perceived socially unfavorable attitudes toward homosexuality and same-sex marriage with suicidal ideation in Taiwanese people before and after same-sex marriage referendums - Ko, N.-Y.; Lin, I.-H.; Huang, Y.-T.; Chen, M.-H.; Lu, W.-H.; Yen, C.-F. (International Journal of Environmental Research and Public Health, 2020)
This study examined the associations of perceived socially unfavorable attitudes toward homosexuality and same-sex marriage with suicidal ideation in non-heterosexual and heterosexual participants from first (Wave 1, 23 months prior to same-sex marriage referendums) and second (Wave 2, one week after the referendums) wave surveys in Taiwan. Data provided by 3239 participants in Wave 1 and 1337 participants in Wave 2 who were recruited through a Facebook advertisement were analyzed. Participants completed an online questionnaire assessing suicidal ideation and perceived unfavorable attitudes toward homosexuality and same-sex marriage from Taiwanese society, heterosexual friends, and family members. The results indicate that perceived unfavorable attitudes toward homosexuality from Taiwanese society, heterosexual friends, and family members were positively associated with suicidal ideation among non-heterosexual individuals in the first but not the second survey. In addition, among non-heterosexual individuals, such attitudes toward same-sex marriage in family members and in heterosexual friends were positively associated with suicidal ideation in the Wave 1 and Wave 2 surveys, respectively. Perceived unfavorable attitudes toward homosexuality and same-sex marriage in heterosexual friends were associated with suicidal ideation in heterosexual participants with a favorable attitude but not in those individuals with an unfavorable attitude toward homosexuality, in both surveys. Perceived socially unfavorable attitudes toward homosexuality and same-sex marriage were significantly associated with suicidal ideation before and after same-sex marriage referendums; however, the associations varied between non-heterosexual and heterosexual individuals.
Keywords: adult; article; attitude; bisexuality; controlled study; female; heterosexuality; homosexual female; homosexuality; human; major clinical study; male; mental health; questionnaire; risk factor; same-sex marriage; sexual and gender minority; sexual orientation; suicidal behavior; suicidal ideation; Taiwan; Taiwanese

Sexual orientation differences in non-suicidal self-injury, suicidality, and psychosocial factors among an inpatient psychiatric sample of adolescents - Peters, J.R.; Mereish, E.H.; Krek, M.A.; Chuong, A.; Ranney, M.L.; Solomon, J.; Spirito, A.; Yen, S. (Psychiatry Research, 2020)
Within broader community samples, sexual minority adolescents (SMA, e.g., lesbian, gay, bisexual, queer) are at greater risk than their heterosexual counterparts for nonsuicidal self-injury (NSSI) and suicidal thoughts and behaviors. The present study investigated whether sexual minority orientation continues to confer additional risk for these behaviors in an already higher-risk sample of youth. Frequency and function of NSSI, suicidal behavior, and psychosocial factors were assessed in a sample of 52 adolescents (aged 12–18 years) admitted to an inpatient psychiatric unit due to suicide risk; 27 of them identified as SMA, and 25 as heterosexual (HA). Greater proportions of SMA reported engaging in lifetime NSSI, compared to HA, with a greater variety and frequency of NSSI behaviors and greater endorsement of intrapersonal NSSI functions. SMA reported higher levels of suicide ideation than HA, but not suicidal behavior. Group differences in NSSI and SI persisted when controlling for the greater prevalence of abuse and levels of peer-victimization reported by SMA. In inpatient clinical settings, SMA may be more likely than heterosexual youth to engage in NSSI, including more severe forms, and to experience suicide ideation. Providing alternative coping mechanisms may serve as treatment goals for reducing NSSI in SMA.
Keywords: adolescent; adult; article; automutilation; child; child psychiatry; clinical assessment; controlled study; emotion regulation; female; heterosexuality; high risk behavior; high risk population; hospital patient; human; major clinical study; male; mental patient; peer review; prevalence; priority journal; sex difference; sexual and gender minority; sexual orientation; social psychology; suicidal behavior; suicidal ideation

Suicide risk among gender and sexual minority college students: The roles of victimization, discrimination, connectedness, and identity affirmation - Busby, D.R.; Horwitz, A.G.; Zheng, K.; Eisenberg, D.; Harper, G.W.; Albucher, R.C.; Roberts, L.W.; Coryell, W.; Pistorello, J.; King, C.A. (Journal of Psychiatric Research, 2020)
Background: Little is known about how victimization and discrimination relate to suicide risk among sexual and gender minority (SGM) college students, or what is protective for these students. The current study will: 1.) determine the extent to which interpersonal victimization, discrimination, identity affirmation, and social connectedness are associated with suicide risk characteristics, and if race and/or ethnicity moderates this association; 2.) examine whether identity affirmation and social connectedness are protective against associations between victimization or discrimination and suicide risk characteristics. Method: Participants were 868 students (63.6% female) from four United States universities who completed an online screening survey and met the following study inclusion criteria: self-identification as gender and/or sexual minority, endorsement of at least one suicide risk characteristic and no current use of mental health services. Participants also completed measures that assessed demographics, non-suicidal self-injury (NSSI), victimization, discrimination, connectedness, and LGBTQ identity affirmation. Results: Victimization was positively associated with depression severity, suicidal ideation, alcohol misuse, suicide attempt history, and NSSI. Discrimination was positively associated with depression severity, suicide attempt history, and NSSI. Connectedness was inversely associated with depression severity, suicidal ideation severity, suicide attempt history, and NSSI, and moderated the association between victimization and suicide attempt history. LGBTQ identity affirmation moderated the link between victimization and depression. Conclusions: Results suggest efforts to decrease victimization and discrimination and increase connectedness may decrease depressive morbidity and risks for self-harm among SGM college students. Further, increasing LGBTQ identity affirmation may buffer the impact of victimization on depression.
Keywords: adult; alcohol abuse; article; automutilation; college student; depression; disease severity; female; gender identity; human; identity; LGBT people; major clinical study; male; medical history; priority journal; risk factor; sexual and gender minority; social discrimination; suicidal ideation; suicide; suicide attempt; United States; university student; victim; young adult

Pubertal suppression for transgender youth and risk of suicidal ideation - Turban, J.L.; King, D.; Carswell, J.M.; Keuroghlian, A.S. (Pediatrics, 2020)
BACKGROUND AND OBJECTIVES: Gonadotropin-releasing hormone analogues are commonly prescribed to suppress endogenous puberty for transgender adolescents. There are limited data regarding the mental health benefits of this treatment. Our objective for this study was to examine associations between access to pubertal suppression during adolescence and adult mental health outcomes. METHODS: Using a cross-sectional survey of 20 619 transgender adults aged 18 to 36 years, we examined self-reported history of pubertal suppression during adolescence. Using multivariable logistic regression, we examined associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality. RESULTS: Of the sample, 16.9% reported that they ever wanted pubertal suppression as part of their gender-related care. Their mean age was 23.4 years, and 45.2% were assigned male sex at birth. Of them, 2.5% received pubertal suppression. After adjustment for demographic variables and level of family support for gender identity, those who received treatment with pubertal suppression, when compared with those who wanted pubertal suppression but did not receive it, had lower odds of lifetime suicidal ideation (adjusted odds ratio = 0.3; 95% confidence interval = 0.2–0.6). CONCLUSIONS: This is the first study in which associations between access to pubertal suppression and suicidality are examined. There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment. These results align with past literature, suggesting that pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.
Keywords: adult; article; binge drinking; clinician; cross-sectional study; demography; distress syndrome; female; gender identity; groups by age; health care access; health survey; hormonal therapy; human; LGBT people; male; mental health; priority journal; risk factor; self report; suicidal behavior; suicidal ideation

Long-term puberty suppression for a nonbinary teenager - Pang, K.C.; Notini, L.; McDougall, R.; Gillam, L.; Savulescu, J.; Wilkinson, D.; Clark, B.A.; Olson-Kennedy, J.; Telfer, M.M.; Lantos, J.D. (Pediatrics, 2020)
Many transgender and gender-diverse people have a gender identity that does not conform to the binary categories of male or female; they have a nonbinary gender. Some nonbinary individuals are most comfortable with an androgynous gender expression. For those who have not yet fully progressed through puberty, puberty suppression with gonadotrophin-releasing hormone agonists can support an androgynous appearance. Although such treatment is shown to ameliorate the gender dysphoria and serious mental health issues commonly seen in transgender and gender-diverse young people, long-term use of puberty-suppressing medications carries physical health risks and raises various ethical dilemmas. In this Ethics Rounds, we analyze a case that raised issues about prolonged pubertal suppression for a patient with a nonbinary gender.
Keywords: gonadorelin; selective estrogen receptor modulator; tamoxifen; adolescent; anxiety disorder; article; automutilation; bone density; breast cancer; case report; clinical article; cognitive development; decision making; falling; fertility; gender dysphoria; gender identity; health hazard; health promotion; hot flush; human; male; medical ethics; mental health; osteoporosis; patient autonomy; phenotype; priority journal; psychological well-being; psychosocial care; puberty; social support; suicide attempt; transgender

Adolescent Homelessness and Associated Features: Prevalence and Risk Across Eight States - Cutuli, J.J.; Treglia, D.; Herbers, J.E. (Child psychiatry and human development, 2020)
This study utilizes data from the Youth Risk Behavior Survey to estimate the prevalence of adolescent homelessness and relations to five indicators of poor functioning among students attending public high school in eight states. About 3.27% of students experienced homelessness, and nearly 7% of teens who identified as lesbian, gay, or bisexual (LGB) experienced homelessness. Homelessness was related to higher rates of sexual/dating violence as well as having been bullied and feeling unsafe at school. Homelessness and LGB identification predicted higher rates of more-severe problems with alcohol, hard drug use, poor grades, suicidality, and risky sexual behavior, controlling for other factors. There was no interaction effect between homelessness and LGB status, suggesting that these risks are additive.
Keywords: adolescent; article; bisexuality; clinical article; dating violence; female; high school; homelessness; homosexual female; human; human experiment; juvenile; male; prevalence; sexual behavior; student; substance use; suicidal ideation; alcohol

The Link between Discrimination and Worst Point Suicidal Ideation among Sexual and Gender Minority Adults - Salentine, C.M.; Hilt, L.M.; Muehlenkamp, J.J.; Ehlinger, P.P. (Suicide & life-threatening behavior, 2020)
OBJECTIVE: Sexual and gender minority (SGM) adults often report a disproportionately high rate of suicidal ideation compared to their heterosexual and cisgender counterparts. The current study aimed to understand the relationship between discrimination for one's sexual orientation or gender identity and suicidal ideation. We hypothesized that discrimination would be associated with suicidal ideation at one's worst point through the indirect effects of hopelessness regarding thwarted belongingness and perceived burdensomeness. METHOD: A sample of 178 SGM adults (M age = 30.34, range 18-69; 76% white) completed an online questionnaire assessing minority-specific stressors and suicide-related thoughts and behaviors. RESULTS: A mediation model with bootstrapping indicated that greater discrimination was associated with more frequent suicidal ideation at one's worst point through the indirect effect of hopelessness regarding thwarted belongingness. CONCLUSIONS: The current study provides evidence that the pathway between discrimination and worst point suicidal ideation may be partially explained by the perception that one will never belong. These findings support the utility of an understudied Interpersonal Theory of Suicide hypothesis for research among SGM adults.
Keywords: adolescent; adult; aged; female; human; human relation; male; middle aged; psychology; questionnaire; risk factor; self concept; sexual and gender minority; social discrimination; suicidal ideation; young adult

God Bless You? The Association of Religion and Spirituality with Reduction of Suicide Ideation and Length of Hospital Stay among Psychiatric Patients at Risk for Suicide - Plöderl, M.; Kunrath, S.; Fartacek, C. (Suicide & life-threatening behavior, 2020)
OBJECTIVE: Religion and spirituality (R&S) were protective against suicidal behavior in the majority of studies. In prospective studies, R&S were associated with improved outcome for patients with depression, a main risk factor for suicide. Thus, R&S may also improve recovery from suicidal crisis, but related data is lacking. METHOD: We explored how aspects of R&S were associated with reduction of suicide ideation and length of hospital stay among 351 patients admitted to a psychiatric crisis intervention ward specialized in suicide prevention. We analyzed the results separately by gender and sexual orientation due to the known specific effects of R&S in these groups. RESULTS: Overall, there were only small and non-significant associations between R&S and reduction of suicide ideation and length of hospital stay. For heterosexual men, some R&S variables were associated with less optimal outcome. Contrary to our hypothesis, R&S were not less or even more beneficial for sexual minority than heterosexual patients. CONCLUSIONS: Religion and spirituality were not or only weakly associated with improvement of suicide ideation and shorter hospital stay. Further studies are needed to account for selection biases and other limitations in our study. Based on our findings, R&S may not be major sources to recover from suicidal crisis in a psychiatric setting.
Keywords: adult; depression; female; human; length of stay; male; mental disease; middle aged; prospective study; psychology; religion; risk factor; sexual and gender minority; suicidal ideation; suicide attempt

High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults - Newcomb, M.E.; Hill, R.; Buehler, K.; Ryan, D.T.; Whitton, S.W.; Mustanski, B. (Archives of sexual behavior, 2020)
Transgender and gender diverse (TGD) people are disproportionately impacted by various health issues and associated risk factors, but little is known about differences in these outcomes between gender identities within the TGD population. This study characterized the health of a diverse sample of TGD youth and young adults. Data were taken from the baseline visit of two longitudinal studies in the Chicago area, RADAR (N = 1079, M age = 20.8 years) and FAB 400 (N = 488, M age = 19.57 years), which are cohorts of young sexual and gender minorities assigned male at birth (AMAB) and assigned female at birth (AFAB), respectively. There was a combined sample of 214 TGD (128 AFAB, 86 AMAB) individuals across cohorts. We examined differences between gender identities in self-reported health and related psychosocial variables, and compared TGD youth and their cisgender sexual minority peers from their cohort of origin on all variables. Among TGD youth, we found high rates of depression and suicidality (ideation, plan, attempt), violence (trauma, victimization, childhood sexual abuse), and substance use (cigarette, alcohol, illicit drug use). With the exception of depression, transgender women and non-binary AMAB youth reported worse health outcomes than transgender men and non-binary AFAB youth. Non-binary AMAB youth reported the highest rates of certain outcomes, including traumatic experiences and suicidal ideation. TGD youth generally reported worse outcomes than cisgender sexual minority youth; these differences were less pronounced among AFAB youth. Findings point to the diversity of experiences within the TGD population and critical needs for intervention approaches to mitigate health disparities.
Keywords: adult; cohort analysis; drug dependence; female; gender identity; human; male; mental health; procedures; psychology; risk factor; transgender; violence; young adult

Interpersonal Psychotherapy for Gender Dysphoria in a Transgender Woman - Barbisan, G.K.; Moura, D.H.; Lobato, M.I.R.; da Rocha, N.S. (Archives of sexual behavior, 2020)
We present a case of a 32-year-old natal male seeking medical follow-up care, due to gender dysphoria (GD) along with other complaints (depressive symptoms, anxiety, and suicidal ideation). The attending team chose interpersonal psychotherapy (IPT), with a focus on role transition in order to help her. The patient presented a favorable trajectory throughout treatment and demonstrated personal growth one year after treatment. To our knowledge, little was found in the literature on the use of IPT in the treatment of those with GD; we also did not find any other publication or case report using IPT exclusively to treat the problems accompanying role transition. Psychotherapy was not intended to change the gender identity of this individual. However, further studies will be required to explore possible benefits of IPT for GD treatment.
Keywords: adult; gender dysphoria; gender identity; human; male; procedures; transgender

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation - Liu, R.T.; Bettis, A.H.; Burke, T.A. (Psychological medicine, 2020)
BACKGROUND: Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear. METHODS: We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO. RESULTS: A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons. CONCLUSIONS: Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.
Keywords: comorbidity; human; mental disease; meta analysis; prevalence; risk factor; suicidal ideation; suicide attempt

Women With Amenorrhea and Men With Menstruation: The Qualitative Experiences of People With Disorders of Sex Development in Nigeria - Sani, A.M.; Arif, I.I.; Arshad, M.M.; Mungadi, I.A.; Soh, K.G.; Soh, K.L. (The journal of nursing research : JNR, 2020)
BACKGROUND: Disorders of sex development (DSD) affect the quality of life of people who live with this condition. In developing countries, diagnoses of DSD are associated with a delay in presentation until the patients developed ambiguous physical traits and features. PURPOSE: This study explores the menstrual experiences of people with DSD and sex reassignment in Nigeria. METHODS: A qualitative approach with a phenomenological study design was employed in this study to explore and describe the experiences of people with DSD at the Usmanu Danfodiyo University Teaching Hospital in Sokoto, Nigeria. The data were collected using face-to-face interviews, transcribed verbatim, and analyzed using NVivo software. RESULTS: The findings show that the participants experienced menstrual problems: men with menstruation and women with amenorrhea. The female participants generally described amenorrhea as a disappointment and linked menstruation with womanhood. Amenorrhea evinced both emotional and psychological effects. However, some of the female participants considered amenorrhea in a positive light and were happy with their lives without menstruation. The menstrual experiences of male participants included menarche, lower abdominal pain, regular monthly bleeding, and ovulation. The male participants described menstruation as a disaster in their lives and a source of anxiety, suicidal ideation, and depression. Menstruation negatively affected their psychosocial well-being. CONCLUSIONS: The menstrual experience of individuals with DSD negatively affects their quality of life. The women with DSD in this study showed a generally poor knowledge of menarche, menstruation, and puberty, indicating that their parents had ignored the initial symptoms of DSD. DSD were only recognized at puberty because of the development of ambiguous physical traits and of the onset of menstruation in men and the confirmation of amenorrhea in women.
Keywords: adolescent; adult; amenorrhea; child; complication; disorder of sex development; female; human; interview; male; menstruation disorder; Nigeria; procedures; psychology; qualitative research; quality of life

Violence and substance use in sexual minorities: Data from the Second Brazilian National Alcohol and Drugs Survey (II BNADS) - Diehl, A.; Pillon, S.C.; Caetano, R.; Madruga, C.S.; Wagstaff, C.; Laranjeira, R. (Archives of psychiatric nursing, 2020)
OBJECTIVE: To describe the prevalence of substance use and the associations between adverse early life experiences, sexual behaviour and violence in sexual minority (SM) individuals. METHODS: The Brazilian National Alcohol and Drugs Survey is a probabilistic household survey performed in 2012, collecting data from 4067 Brazilians aged 14 years and older. RESULTS: 3.4% of the sample declared themselves as sexual minorities, 53.8% female, 66.5% single, mean age of 29.5 years (standard deviation 16.0 years). A high prevalence of alcohol dependence (15.2%) and binge drinking (22.2%) was identified in the SM group. Respondents were more likely to use crack cocaine and hallucinogens, to have been involved in child prostitution, child sexual abuse and to report suicidal ideation in the previous year. Respondents were also more likely to engage in unprotected sex compared to non-sexual minorities. Nearly one-third referred to having suffered homophobic discrimination in their lives. Respondents also reported higher rates of domestic violence (18.9%) and urban violence (18%) among the SM. CONCLUSION: The findings reinforce that violence directed at individuals in the Brazilian SM community begins early in life and persists into adulthood when compared to non-sexual minorities. This population is also more exposed to substance use disorders.
Keywords: adult; Brazil; child; child sexual abuse; drug dependence; female; human; male; prevalence; questionnaire; sexual and gender minority; sexual behavior; suicidal ideation

Life satisfaction and mental health among transgender students in Norway - Anderssen, N.; Sivertsen, B.; Lønning, K.J.; Malterud, K. (BMC public health, 2020)
BACKGROUND: Social attitudes to transgender persons and other gender minorities vary around the world, and in many cultures, prejudices and social stigma are common. Consequently, transgender persons face challenges related to discrimination and negative attitudes among the public. The purpose of this study was to compare life satisfaction, loneliness, mental health, and suicidal behavior among transgender students with cisgender students' experiences in a nationwide sample of Norwegian students pursuing higher education. METHODS: In total,50,054 full-time Norwegian students completed an online questionnaire (response rate 30.8%), of whom 15,399 were cisgender males, 34,437 cisgender females, 28 individuals who reported being binary transgender (12 transwomen and 16 transmen), and 69 individuals non-binary transgender persons. The measures included questions concerning gender identity, life satisfaction (Satisfaction With Life Scale), loneliness (The Three-Item Loneliness Scale), mental health problems (Hopkins Symptoms Check List), mental disorders, and suicidal ideation, suicidal behavior, and self-harm. Chi-square tests, Independent-Samples Kruskal-Wallis tests, and logistic regression analyses were used to examine differences between gender identities. RESULTS: Transgender students reported significantly more psychosocial burdens on all measures. There were no significant differences in any of the measures between the binary and non-binary transgender students. CONCLUSION: The findings call for increased awareness about welfare and health for transgender students in Norway. Higher education institutions need to consider measures at various levels to establish a learning environment that is more inclusive for gender minorities.
Keywords: adult; female; human; loneliness; male; mental disease; Norway; psychology; questionnaire; satisfaction; student; suicidal ideation; transgender; university; young adult

Association Between Overt and Subtle Experiences of Discrimination and Violence and Mental Health in Homosexual and Bisexual Men in Mexico - Mendoza-Perez, J.C.; Ortiz-Hernandez, L. (Journal of interpersonal violence, 2020)
The aim of this study was to determine whether the experiences of direct or subtle forms of discrimination and violence are associated with mental health in Mexican gay, homosexual, and bisexual (GHB) men. A cross-sectional survey was conducted online; the sample consisted of 4,827 GHB men. Ten forms of overt and subtle sexual orientation-based discrimination and violence (SO-DV) were assessed. Linear and logistic regression models were used to evaluate the association between SO-DV experiences and mental health outcomes. Physical violence was reported less frequently than the other forms of SO-DV. As the number of settings in which SO-DV were experienced increased, a stronger association with negative mental health outcomes was observed. Experiences of subtle SO-DV were associated with increased distress, lower vitality, and increased risk of suicidal ideation. Disapproval of gender nonconformity was associated with negative mental health outcomes independently of violence based on sexual orientation. Subtle forms of SO-DV are more common than direct and overt forms. Both types of SO-DV could negatively affect mental health. Studies investigating these negative experiences are required to gain an understanding of the health inequalities faced by non-heterosexual populations.
Keywords: adult; article; bisexual male; distress syndrome; female; gender; homophobia; homosexuality; human; human experiment; male; mental health; mental stress; Mexico; outcome assessment; physical violence; suicidal ideation

Psychosocial mediators of perceived stigma and suicidal ideation among transgender women - Kota, K.K.; Salazar, L.F.; Culbreth, R.E.; Crosby, R.A.; Jones, J. (BMC public health, 2020)
BACKGROUND: Transgender women (TGW) in the U.S. experience high rates of stigma, depression, and elevated rates of suicide. This study examined correlates of suicidal ideation and estimated the conditional indirect effects of perceived stigma and psychosocial mediators on suicidal ideation. METHODS: Using a cross-sectional study design, TGW (N = 92) were recruited through snowball sampling in Atlanta, Georgia. Structured interviews were conducted. Suicidal ideation was assessed by combining two variables that measured suicidal thoughts. Logistic regression models were performed to identify the potential risk and protective factors for suicidal ideation. We examined hypothesized psychosocial factors, including anxiety, depression, psychosocial impact of gender minority status, and substance use behaviors as potential mediators for the relationship between perceived stigma and suicidal ideation. All models were controlled for age, race, education, and homelessness. RESULTS: Suicidal ideation was reported by 33% (N = 30) of the study participants. In multivariable analysis, suicidal ideation was associated with sexual abuse (AOR = 3.17, 95% CI = 1.10-9.30), anxiety (AOR = 1.74, 95% CI = 1.10-2.73), family verbal abuse (AOR = 2.99, 95% CI = 1.10-8.40), stranger verbal abuse (AOR = 3.21, 95% CI = 1.02-10.08), and psychosocial impact of gender minority status (AOR = 3.42, 95% CI = 1.81-6.46). Partner support was found to be the protective factor for suicidal ideation (AOR = 0.34, 95% CI = 0.13-0.90). In the mediation analysis, the psychosocial impact of gender minority status mediated the relationship between perceived stigma and suicidal ideation. The estimated conditional indirect effect was 0.46, (95% CI = 0.12-1.11). CONCLUSION: Interventions that aim to reduce suicidal behaviors among TGW should address stigma, psychosocial impact of gender minority status, and different forms of violence and abuse.
Keywords: adolescent; adult; aged; cross-sectional study; female; human; male; middle aged; psychology; risk factor; social stigma; suicidal ideation; transgender; young adult

Inequality and mental healthcare utilisation among first-year university students in South Africa - Bantjes, J.; Saal, W.; Lochner, C.; Roos, J.; Auerbach, R.P.; Mortier, P.; Bruffaerts, R.; Kessler, R.C.; Stein, D.J. (International Journal of Mental Health Systems, 2020)
Background: Addressing inequalities in mental healthcare utilisation among university students is important for socio-political transformation, particularly in countries with a history of educational exclusion. Methods: As part of the WHO World Mental Health International College Student Initiative, we investigated inequalities in mental healthcare utilisation among first-year students at two historically "White" universities in South Africa. Data were collected via a web-based survey from first-year university students (n = 1402) to assess 12-month mental healthcare utilisation, common mental disorders, and suicidality. Multivariate logistic regression models were used to estimate associations between sociodemographic variables and mental healthcare utilisation, controlling for common mental disorders and suicidality. Results: A total of 18.1% of students utilised mental healthcare in the past 12 months, with only 28.9% of students with mental disorders receiving treatment (ranging from 28.1% for ADHD to 64.3% for bipolar spectrum disorder). Of those receiving treatment, 52.0% used psychotropic medication, 47.3% received psychotherapy, and 5.4% consulted a traditional healer. Treatment rates for suicidal ideation, plan and attempt were 25.4%, 41.6% and 52.9%, respectively. In multivariate regression models that control for the main effects of mental health variables and all possible joint effects of sociodemographic variables, the likelihood of treatment was lower among males (aOR = 0.57) and Black students (aOR = 0.52). An interaction was observed between sexual orientation and first generation status; among second-generation students, the odds of treatment were higher for students reporting an atypical sexual orientation (aOR = 1.55), while among students with atypical sexual orientations, the likelihood of mental healthcare utilisation was lower for first-generation students (aOR = 0.29). Odds of treatment were significantly elevated among students with major depressive disorder (aOR = 1.88), generalised anxiety disorder (aOR = 2.34), bipolar spectrum disorder (aOR = 4.07), drug use disorder (aOR = 3.45), suicidal ideation (without plan or attempt) (aOR = 2.00), suicide plan (without attempt) (aOR = 3.64) and suicide attempt (aOR = 4.57). Likelihood of treatment increased with level of suicidality, but not number of mental disorders. Conclusion: We found very low mental healthcare treatment utilisation among first-year university students in South Africa, with enduring disparities among historically marginalised groups. Campus-based interventions are needed to promote mental healthcare utilisation by first-year students in South Africa, especially among male and Black students and first-generation students with atypical sexual orientations.
Keywords: psychotropic agent; adult; article; attention deficit disorder; bipolar disorder; Black person; cross-sectional study; disease association; disease surveillance; drug dependence; female; generalized anxiety disorder; health care disparity; health care survey; health care utilization; human; major clinical study; major depression; male; mental disease; mental health service; prevalence; priority journal; psychotherapy; sex difference; sexual orientation; South Africa; suicidal behavior; suicidal ideation; suicide attempt; traditional healer; university student; young adult

Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health - Butkus, R.; Rapp, K.; Cooney, T.G.; Engel, L.S. (Annals of Internal Medicine, 2020)
The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.
Keywords: electronic cigarette; nicotine; article; climate change; death; drug dependence; environmental health; ethnic or racial aspects; gender; general practitioner; gunshot injury; health care access; health care system; health hazard; health workforce; human; intellectual impairment; LGBTQIA+ people; maternal mortality; nutrition; physical disability; priority journal; social determinants of health; tobacco dependence; tobacco use; United States

Assessing the Well-being of Sexual Minority Soldiers at a Military Academic Institution - McDonald, J.L.; Ganulin, M.L.; Dretsch, M.N.; Taylor, M.R.; Cabrera, O.A. (Military medicine, 2020)
INTRODUCTION: The goal of the present study was to characterize behavioral health rates, behavioral health care utilization, loneliness, and perceived prejudice and support among sexual minority soldiers. MATERIALS AND METHODS: Cross-sectional survey data were obtained from 640 active-duty U.S. soldiers enrolled in an academic training institute who provided information on their sexual orientation. Survey topics included demographics, behavioral health, behavioral health care utilization, and mitigating factors (eg, perceived prejudice, perceived support, and loneliness). Chi-square analyses were utilized to determine any differences between groups for behavioral health rates and behavioral health care utilization. Robust regression was used for analysis of self-reported loneliness. RESULTS: A higher proportion of lesbian, gay, bisexual (LGB) soldiers than heterosexual soldiers screened positive for anxiety, post-traumatic stress disorder, and suicidality. No between-group differences in behavioral health care utilization were found; however, a higher proportion of LGB soldiers sought help from military family life counselors. No between-group differences for loneliness were found. Finally, perceived prejudice was higher for LGB soldiers and perceived support was lower. CONCLUSION: Organizational barriers, such as perceived prejudice and lack of support, appear to still exist for sexual minority soldiers. Increasing organizational support and implementing training and education for health care providers in order to better support the LGB soldier community may mitigate these barriers.
Keywords: adolescent; adult; anxiety; cross-sectional study; depression; devices; female; human; male; mass screening; military personnel; posttraumatic stress disorder; procedures; psychology; questionnaire; sexual and gender minority; sexual behavior

Psychotic experiences and suicidal outcomes in a general population sample - Narita, Z.; Wilcox, H.C.; DeVylder, J. (Schizophrenia Research, 2020)
Psychotic experiences (PEs) are associated with suicidal ideation and attempts. However, studies examining the role of potential psychosocial confounders in these associations have yielded variable and inconclusive results. In the current study, data from 974 participants in a general population sample were analyzed. We fitted four regression models to examine the associations between PEs vs. suicidal ideation and attempts, using hierarchical adjustments for sociodemographic factors and psychosocial risk factors. After adjustment for sociodemographic factors and psychosocial factors, PEs were associated with increased odds of suicidal ideation (odds ratio (OR) = 1.89, 95% CI = 1.12–3.22) and suicide attempts (OR = 4.33, 95% CI = 1.77–10.60). For both suicidal ideation and attempts, the association was attenuated but remained statistically significant, even at the highest level of adjustment. Sociodemographic factors and psychosocial factors substantially confound the association between PEs and suicidal ideation and attempts. When adjusting for these confounders, PEs remain independently associated with both suicidal ideation and attempts.
Keywords: adult; article; comorbidity; controlled study; cross-sectional study; disease association; distress syndrome; female; human; major clinical study; male; mental health; priority journal; psychosis; risk factor; self report; sexual orientation; social psychology; suicidal behavior; suicidal ideation; suicide attempt; United States

Methylsulfonylmethane inhibits cortisol-induced stress through p53-mediated SDHA/HPRT1 expression in racehorse skeletal muscle cells: A primary step against exercise stress - Sp, N.; Kang, D.Y.; Kim, D.H.; Lee, H.G.; Park, Y.-M.; Kim, I.H.; Lee, H.K.; Cho, B.-W.; Jang, K.-J.; Yang, Y.M. (Experimental and Therapeutic Medicine, 2020)
Cortisol is a hormone involved in stress during exercise. The application of natural compounds is a new potential approach for controlling cortisol-induced stress. Tumour suppressor protein p53 is activated during cellular stress. Succinate dehydrogenase complex subunit A (SDHA) and hypoxanthine phosphoribosyl transferase 1 (HPRT1) are considered to be two of the most stable reference genes when measuring stress during exercise in horses. In the present study cells were considered to be in a 'stressed state. if the levels of these stable genes and the highly stress responsive gene p53 were altered. It was hypothesized that a natural organic sulphur-containing compound, methylsulfonylmethane (MSM), could inhibit cortisol-induced stress in racing horse skeletal muscle cells by regulating SDHA, HPRT1 and p53 expression. After assessing cell viability using MTT assays, 20 μg/ml cortisol and 50 mM MSM were applied to horse skeletal muscle cell cultures. Reverse transcription.quantitative PCR and western blot analysis demonstrated increases in SDHA, HPRT1 and p53 expression in cells in response to cortisol treatment, which was inhibited or normalized by MSM treatment. To determine the relationship between p53 and SDHA/HPRT1 expression at a transcriptional level, horse gene sequences of SDHA and HPRT1 were probed to identify novel binding sites for p53 in the gene promoters, which were confirmed using a chromatin immunoprecipitation assay. The relationship between p53 and SDHA/HPRT1 expression was confirmed using western blot analysis following the application of pifithrin-α, a p53 inhibitor. These results suggested that MSM is a potential candidate drug for the inhibition of cortisol.induced stress in racehorse skeletal muscle cells.
Keywords: dimethyl sulfone; hydrocortisone; hypoxanthine phosphoribosyltransferase; peptides and proteins; protein p53; succinate dehydrogenase complex a; unclassified drug; animal cell; article; binding site; cell viability; chromatin immunoprecipitation; controlled study; exercise; gene expression; gene sequence; male; MTT assay; nonhuman; promoter region; protein DNA binding; real time polymerase chain reaction; physiological stress; Thoroughbred horse; Western blotting

Research round-up - Kang, S. (The Lancet Psychiatry, 2020)
Keywords: alcohol metabolism; anxiety; article; autism; automutilation; bipolar disorder; cognitive behavioral therapy; histone acetylation; human; male; medical literature; medical research; mental health; posttraumatic stress disorder; priority journal; sexual and gender minority; sleep; stellate ganglion block; suicide

Home-based HIV testing: Using different strategies among transgender women in Argentina - Frola, C.E.; Zalazar, V.; Cardozo, N.; Vázquez, M.L.; Arístegui, I.; Lucas, M.; Gun, A.; Cahn, P.; Sued, O. (PLoS ONE, 2020)
Background In Argentina, HIV prevalence among transgender women (TGW) has been reported at 34%. The stigma is one of the most important factors limiting their access to healthcare services. The aims of this study were to compare different HIV testing methodologies, to determine the factors associated with HIV diagnosis and to determine the feasibility of a home-based HIV testing service for TGW. Methods A multidisciplinary team performed home-based HIV testing interventions in four cities of Argentina. Participants self-identified as TGW, older than 14 years and with a negative or unknown HIV status. Blood samples were screened by two rapid tests (RT), one based on antibodies (Determine™ HIV-1/2) and the other on antigen and antibodies (Determine™ HIV-1/2 Combo), and the subsequent blood processing via 4th generation ELISA (VIDAS HIV DUO). All reactive samples were confirmed with a viral load (VL). We compared the results of both RT with the ELISA. Samples were pooled in groups of 6 and a VL (Abbott Real Time) performed to identify acute HIV infections. Factors associated with HIV infection were evaluated with multivariate logistic regression analysis. Results A total of 260 TGW were tested, 51 tested positive (HIV prevalence 19.6%). There were no discordant results between both RTs nor between RTs and 4th generation ELISA, therefore the correlation was 100%. The VL identified 2 additional positive samples. The final analytic sample for positive cases consisted of 53 TGW. In the multivariate analysis, factors associated with a positive HIV result were history of other sexually transmitted infections (STIs) and not being previously tested for HIV. TGW tested for the first time were at 4 times greater risk of being HIV positive compared to those that were tested previously. Conclusions A multidisciplinary home-based HIV testing service among TGW is feasible and effective to detect cases of HIV infection. The testing algorithm should start with an RT followed by molecular diagnosis. The history of STIs and never having been tested for HIV were the factors associated with HIV-positive results and should determine efforts to reach this population. Home-based testing reaches individuals that were not tested before and who have more risk of acquiring HIV.
Keywords: Abbott Real Time HIV-1 m2000rt; Determine HIV-1/2 Combo; ELISA kit; HIV rapid test; HIV test; home based HIV test; polymerase chain reaction system; VIDAS HIV DUO; adult; algorithm; antibody detection; antigen detection; Argentina; article; blood sampling; controlled study; enzyme linked immunosorbent assay; feasibility study; human; human cell; Human immunodeficiency virus infection; infection risk; major clinical study; male; male to female transgender; multidisciplinary team; sexually transmitted disease; virus load; Abbott Real Time HIV-1 m2000rt; Determine HIV-1/2; Determine HIV-1/2 Combo; VIDAS HIV DUO

Examination of multilevel domains of minority stress: Implications for drug use and mental and physical health among Latina women who have sex with women and men - Cepeda, A.; Nowotny, K.M.; Frankeberger, J.; Ramirez, E.; Rodriguez, V.E.; Perdue, T.; Valdez, A. (PLoS ONE, 2020)
There has recently been growing attention and concern in the U.S. on the detrimental drug use and related health conditions impacting diverse sexual minority populations. While some evidence indicates that bisexual women are at increased risk of substance use, little attention has been given to disadvantaged and racial/ethnic minority bisexual women, who are particularly vulnerable to a complexity of stressors and risk. Using data from a 15-year longitudinal study in San Antonio, Texas, the current study examines drug use, incarceration histories, stressful life events, and infections among 206 young adult Mexican-American women who report engaging in sex with both men and women (WSWM) (n = 61) and those indicating having exclusively male sex partners (WSM) (n = 145). A bivariate analysis finds that WSWM experienced more frequent (p = 0.001) and longer total time incarcerated (p = 0.001), as well as exposure to more stressful life events (p = 0.003). WSWM also have higher rates of past 30 day injection drug use (p = 0.026) and related Hepatitis C Virus (HCV) infection (p = 0.001), as well as greater symptomatology associated with depression (p = 0.014), PTSD (p = 0.005), and suicidal ideation (p = 0.036). Findings indicate a significantly elevated risk profile for socio-economically marginalized WSWM. This knowledge is timely and central to policy discourse to develop interventions and health campaigns aimed at reducing and/or preventing further health disparities among this highly susceptible population of minority women.
Keywords: adolescent; adult; article; cohort analysis; controlled study; depression; drug use; female; follow up; health care policy; health disparity; hepatitis C; human; intervention study; interview; Mexican American; minority group; population research; risk factor; sexual orientation; physiological stress; suicidal ideation; Texas; women who have sex with women and men

A rare cause of female gender dysphoria: Report of three cases with low percentage of turner mosaicism - Erişen Karaca, S.; Eröz, R.; Arslanoğlu, İ. (Duzce Medical Journal, 2020)
Gender dysphoria is a condition caused by a mismatch between the gender assigned at birth and gender identity. Gender development disorders include situations where congenital chromosomal, gonadal, or anatomically gender-related physical features are atypical. In the studies conducted mostly by karyotype analysis, it is reported that the rate of chromosomal abnormality is very low in people with gender dysphoria. In Turner mosaicism, gender dysphoria is not a common finding. In this case series, we examined the phenotype and genotype characteristics of the three cases identified as Turner mosaicism, who applied with gender dysphoria. The patients’ complaints were feeling like a male, negative thoughts about being a female, being uncomfortable with feminine body image, wanting to have a male body. None of our 3 cases had Turner stigmata however their chromosomal or FISH analyses showed that one of them was 45,X/46 XX/47,XXX and two of them were 45 X/46 XX karyotype.
Keywords: estradiol; luteinizing hormone; testosterone; adolescent; article; body height; body image; body mass; body weight; breast development; case report; chromosome aberration; chromosome analysis; clinical article; echocardiography; echography; female; fluorescence in situ hybridization; gender dysphoria; gene mutation; genotype; hirsutism; human; karyotyping; menarche; menstrual irregularity; mosaicism; ovary polycystic disease; phenotype; precocious puberty; suicide attempt; thyroid function; Turner syndrome

Salvage multivisceral abdominal surgery after caustic ingestion: Case report - Maggioni, C.; Voltolini, L.; Bongiolatti, S.; Cianchi, F.; Coratti, F. (International Journal of Surgery Case Reports, 2020)
Introduction: Ingestion of caustic substances is a life-threatening medical emergency with high morbidity and mortality rate. Case report: We present a case report of young patient who presents to our department secondary to ingestion of caustic substances was submitted to multi-visceral resection surgery having saved his life after a long and complex multidisciplinary management. Conclusion: An aggressive surgical approach allows successful initial treatment of extended caustic injuries. Early surgical treatment is essential to improve the prognosis in these patients and refer the patient to large and experienced hospital represents the main goal to guarantee a surviving chance.
Keywords: caustic agent; infusion fluid; piperacillin plus tazobactam; surgical glue; abdominal surgery; adult; article; bile flow; case report; clinical article; emergency ward; esophagobronchial fistula; esophagus reconstruction; hepatojejunostomy; human; ingestion; male; nausea and vomiting; operation duration; pancreatic duct; pancreaticoduodenectomy; priority journal; respiratory distress; salvage multivisceral abdominal surgery; salvage therapy; stomach fundus; stomach perforation; suicide; surgical technique; total stomach resection; transgender; young adult

“Straight Sex is Complicated Enough!”: The Lived Experiences of Autistics Who are Gay, Lesbian, Bisexual, Asexual, or Other Sexual Orientations - Lewis, L.F.; Ward, C.; Jarvis, N.; Cawley, E. (Journal of Autism and Developmental Disorders, 2020)
Autistics are more likely than neurotypicals to be gay, lesbian, bisexual, asexual, and other sexual orientations. Autistics and sexual minorities represent populations at high risk for depression, anxiety, and suicidality. Little is known about the experiences of individuals living at this intersection. In this phenomenology, 67 individuals who identified as autistic sexual minorities participated in online interviews to describe the meaning of their experiences. Six themes emerged, including: self-acceptance is a journey; autistic traits complicate self-identification of sexual orientation; social and sensory stressors affect sexual expression; feeling misunderstood and isolated; challenges finding mutually satisfying relationships; and difficulty recognizing and communicating sexual needs. Autistic sexual minorities experience a “double minority” status that complicates identity formation and increases vulnerability in sexual relationships.
Keywords: adult; article; autism; controlled study; female; human; interview; intimacy; LGBTQIA+ people; major clinical study; male; personal experience; phenomenology

The impact of adverse childhood experiences (Aces) on suicidal ideation and suicide attempts in an inpatient adolescent sample - Benczkowski, T.; Kostoroski, C.; Stabile, M.; Holler, K. (Adolescent Psychiatry, 2020)
Background: Suicidal ideation (SI) and suicide attempts (SAs) among adolescents are a significant public health concern worldwide. The current study extends previous research by exploring the association between adverse childhood experiences (ACEs) and SI and SAs in a sample of inpatient adolescents as well as identifying specific predictors for increased risk of SI and SAs. Methods: Associations between ACE scores and self-reported SI and SAs were explored in a sample of 154 inpatient adolescents via clinical interview and by analyzing the association between cumulative ACE scores and scores on the Suicidal Tendency scale of a larger personality measure. We also tested for independent relationships between 19 ACEs and SI and SAs to determine unique predictors for suicidality. Results: One-way ANOVA analyses revealed that those who attempted suicide reported significantly more ACEs compared to those who did not attempt suicide. Witnessing violence in the home, school, or neighborhood and experiences of discrimination increased one’s likelihood to attempt suicide by two to threefold, while sexual abuse, neglect, and physical abuse increased this likelihood by three-to-fourfold. Stepwise linear regression analyses demonstrated that emotional abuse, living with someone who had mental health problems or attempted suicide were most associated with elevated Suicidal Tendency scores on a personality measure. Conclusion: Early identification, education and intervention are imperative to limit or eliminate ACEs from occurring. The impact of cumulative as well as specific ACEs on suicide risk should be closely considered as areas for such intervention. Areas for future research include extending to include more diverse populations such as the LGBTQ community as well as more ethnically and racially diverse populations.
Keywords: adolescent; adulthood; Adverse Childhood Experiences Questionnaire; analysis of variance; article; child; childhood trauma; controlled study; education; emotional abuse; female; hospital patient; human; interview; LGBTQIA+ people; linear regression analysis; major clinical study; male; neglect; neighborhood; personality; physical abuse; sexual abuse; suicidal ideation; suicide attempt

Suicidality in clinic-referred transgender adolescents - de Graaf, N.M.; Steensma, T.D.; Carmichael, P.; VanderLaan, D.P.; Aitken, M.; Cohen-Kettenis, P.T.; de Vries, A.L.C.; Kreukels, B.P.C.; Wasserman, L.; Wood, H.; Zucker, K.J. (European Child and Adolescent Psychiatry, 2020)
Gender and sexually diverse adolescents have been reported to be at an elevated risk for suicidal thoughts and behaviors. For transgender adolescents, there has been variation in source of ascertainment and how suicidality was measured, including the time-frame (e.g., past 6 months, lifetime). In studies of clinic-referred samples of transgender adolescents, none utilized any type of comparison or control group. The present study examined suicidality in transgender adolescents (M age, 15.99 years) seen at specialty clinics in Toronto, Canada, Amsterdam, the Netherlands, and London, UK (total N = 2771). Suicidality was measured using two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). The CBCL/YSR referred and non-referred standardization samples from both the U.S. and the Netherlands were used for comparative purposes. Multiple linear regression analyses showed that there was significant between-clinic variation in suicidality on both the CBCL and the YSR; in addition, suicidality was consistently higher among birth-assigned females and strongly associated with degree of general behavioral and emotional problems. Compared to the U.S. and Dutch CBCL/YSR standardization samples, the relative risk of suicidality was somewhat higher than referred adolescents but substantially higher than non-referred adolescents. The results were discussed in relation to both gender identity specific and more general risk factors for suicidality.
Keywords: adolescent; article; Canada; checklist; Child Behavior Checklist; controlled study; Dutchman; England; female; gender dysphoria; human; juvenile; major clinical study; male; Netherlands; risk factor; self report; standardization; suicidal behavior; transgender

Clinical characteristics of 172 children and adolescents with body dysmorphic disorder - Rautio, D.; Jassi, A.; Krebs, G.; Andrén, P.; Monzani, B.; Gumpert, M.; Lewis, A.; Peile, L.; Sevilla-Cermeño, L.; Jansson-Fröjmark, M.; Lundgren, T.; Hillborg, M.; et al. (European Child and Adolescent Psychiatry, 2020)
Body dysmorphic disorder (BDD) often starts in childhood, with most cases developing symptoms before age 18. Yet, BDD research has primarily focused on adults. We report the clinical characteristics of the world’s largest cohort of carefully diagnosed youths with BDD and focus on previously unexplored sex and age differences. We systematically collected clinical data from 172 young people with BDD consecutively referred to 2 specialist pediatric obsessive–compulsive and related disorders outpatient clinics in Stockholm, Sweden and in London, England. A series of clinician-, self-, and parent-reported measures were administered. The cohort consisted of 136 girls, 32 boys, and 4 transgender individuals (age range 10–19 years). The mean severity of BDD symptoms was in the moderate to severe range, with more than one third presenting with severe symptoms and more than half showing poor or absent insight/delusional beliefs. We observed high rates of current psychiatric comorbidity (71.5%), past or current self-harm (52.1%), suicide attempts (11.0%), current desire for cosmetic procedures (53.7%), and complete school dropout (32.4%). Compared to boys, girls had significantly more severe self-reported BDD symptoms, depression, suicidal thoughts, and self-harm. Compared to the younger participants (14 or younger), older participants had significantly more severe compulsions and were more likely to report a desire for conducting cosmetic procedures. Adolescent BDD can be a severe and disabling disorder associated with significant risks and substantial functional impairment. The clinical presentation of the disorder is largely similar across sexes and age groups, indicating the importance of early detection and treatment. More research is needed specifically focusing on boys and pre-pubertal individuals with BDD.
Keywords: adolescent; adult; article; automutilation; body dysmorphic disorder; child; clinical feature; comorbidity; compulsion; controlled study; depression; England; female; functional disease; human; major clinical study; male; outpatient; school child; school dropout; suicidal ideation; suicide attempt; Sweden; transgender

Options and realities for trans and gender diverse young people receiving care in Australia’s mental health system: findings from Trans Pathways - Strauss, P.; Lin, A.; Winter, S.; Waters, Z.; Watson, V.; Wright Toussaint, D.; Cook, A. (Australian and New Zealand Journal of Psychiatry, 2020)
Objective: Trans and gender diverse young people experience mental health difficulties self-harm and suicidality at markedly higher rates than the general population, yet they often feel isolated from mental health services. There is little qualitative research on the experiences of trans and gender diverse young people accessing mental health support in Australia. The objective of this study was to comprehensively explore the experiences of trans and gender diverse young people in Australia who have sought mental health support from therapists, counsellors, psychiatrists and/or inpatient care providers. Methods: We report on findings from the Trans Pathways study, which was a mixed-methods study to evaluate the experiences of trans and gender diverse young people accessing mental health services: specifically, therapy and counselling services, psychiatric services and mental health inpatient services. Results: A total of 859 trans and gender diverse young people aged 14–25 years across Australia completed an anonymous online questionnaire. Therapy and/or counselling services (64.4%) were most frequently sought by trans and gender diverse young people in this study, followed by psychiatric services (43.0%) and mental health inpatient services (12.3%). The findings demonstrated that many mental health professionals lacked expertise in gender diversity, and that trans and gender diverse young people found it difficult to locate mental health professionals who were able to meet their needs in a timely manner. Conclusion: These findings indicate that training is necessary for all mental health professionals to improve their knowledge of gender diversity, enhance the support provided to trans and gender diverse young people and help to address the high rates of poor mental health. The findings outlined here provide insight into the areas in which clinicians could optimise their care of trans and gender diverse young people.
Keywords: adolescent; adult; article; Australia; counseling; counselor; female; gender; hospital patient; human; male; mental health care personnel; mental health service; psychiatrist; questionnaire; transgender

Syndemic statuses: Intersectionality and mobilizing for LGBTQ+ Latinx health equity after the Pulse shooting - Kline, N. (Social Science and Medicine, 2020)
As a theoretical framework, syndemics offers a way to examine interactions between two or more pathogens or social phenomena that interact synergistically to exacerbate poor health. The concept allows for interrogating the social, political, and economic circumstances responsible for disease clusters, but it insufficiently considers how social factors themselves interrelate to create complex forms of social subjugation. Failing to examine intersecting inequalities that produce the social contexts in which syndemic interactions occur will inhibit efforts to correct the root causes of poor health. To address this shortcoming, I argue there is a need for research on syndemics to be informed by intersectionality—a framework that considers how multiple interlocking types of oppression create distinct structural inequalities and life experiences. Advancing this argument, I draw from ethnographic fieldwork in Orlando, Florida, following the Pulse nightclub shooting, which disproportionately affected LGBTQ+ Latinx individuals who experience intersecting forms of social marginalization and are part of a population at risk for an HIV and psychopathology syndemic. Key informant interviews (n = 13) revealed how LGBTQ+ Latinx organizations emerged after the shooting to mobilize for greater health equity and health programs that directly respond to populations who experience unique inequalities related to their intersecting LGBTQ+ and Latinx identities. Findings from this article show how attention to intersectionality can inform efforts to mitigate existing syndemics and prevent future syndemics. Such efforts are needed to adequately examine the social contexts in which syndemics arise and to respond to the social and political phenomena that interact to inform health-related vulnerability.
Keywords: adult; article; attention; clinical article; female; field work; Florida; health equity; health program; human; Human immunodeficiency virus; interview; LGBTQIA+ people; male; mental disease; nonhuman; organization; personal experience; social environment; social exclusion; syndemic

A survey of negative mental health outcomes, workplace and school climate, and identity disclosure for lesbian, gay, bisexual, transgender, queer, questioning, and asexual veterinary professionals and students in the United States and United Kingdom - Witte, T.K.; Kramper, S.; Carmichael, K.P.; Chaddock, M.; Gorczyca, K. (Journal of the American Veterinary Medical Association, 2020)
OBJECTIVE To compare the prevalence of negative mental health outcomes among lesbian, gay, bisexual, transgender, queer, questioning, and asexual (LGBTQ+) veterinary professionals and students with the prevalence reported in a previous study of veterinarians; compare LGBTQ+ veterinary professionals and students in regard to access to LGBTQ+ policies and resources, workplace or school climate, and identity disclosure; and examine whether these variables were associated with mental health (eg, psychological distress) or work- and school-related (eg, emotional labor) outcomes. SAMPLE 440 LGBTQ+ veterinary professionals and students in the United States and United Kingdom. PROCEDURES Between July and December 2016, a web-based questionnaire was distributed through email messages to members of LGBTQ+ veterinary groups and announcements at general veterinary and LGBTQ+-focused conferences and in newsletters. RESULTS Nonheterosexual cis men, nonheterosexual cis women, and transgender and nonbinary individuals all had higher lifetime prevalences of suicidal ideation and attempted suicide, compared with previously reported prevalences for male and female veterinarians in general. Professionals reported more welcoming climates than did students (eg, lower frequency of exposure to homophobic language and more supportive environments) and greater identity disclosure; however, students reported greater access to institutional resources and policies. Climate variables had a more robust relationship with negative outcomes than did access to LGBTQ+ policies or identity disclosure variables. CONCLUSIONS AND CLINICAL RELEVANCE Comparatively high rates of suicidal ideation and suicide attempts among LGBTQ+ professionals and students and the relationship between climate variables and negative mental health outcomes suggested enhanced efforts are needed to improve the climates in veterinary workplaces and colleges.
Keywords: adult; aged; article; controlled study; cross-sectional study; depression; distress syndrome; emotional stress; female; gender identity; human; identity disclosure; job satisfaction; job stress; LGBTQIA+ people; male; paraveterinary worker; prevalence; questionnaire; school; school climate; school stress; sexual orientation; social behavior; suicidal ideation; suicide attempt; United Kingdom; United States; veterinarian; veterinary student; workplace

Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings From the Trans Youth Care Study - Chen, D.; Abrams, M.; Clark, L.; Ehrensaft, D.; Tishelman, A.C.; Chan, Y.-M.; Garofalo, R.; Olson-Kennedy, J.; Rosenthal, S.M.; Hidalgo, M.A. (Journal of Adolescent Health, 2020)
Purpose: This study aimed to characterize two developmental cohorts of transgender and nonbinary youth enrolled in the Trans Youth Care Network Study and describe their gender identity–related milestones and baseline mental health and psychosocial functioning. Methods: Trans Youth Care participants were recruited from four pediatric academic medical centers in the U.S. before initiating medical treatment for gender dysphoria either with gonadotropin-releasing hormone agonists (GnRHa) or gender-affirming hormones (GAH). GnRHa cohort data were collected from youth and a parent; GAH cohort data were collected from youth only. Results: A total of 95 youth were enrolled in the GnRHa cohort. Mean age was 11.22 years (standard deviation = 1.46), and the majority were white (52.6%) and designated male at birth (51.6%). Elevated depression symptoms were endorsed by 28.6% of GnRHa cohort youth, and 22.1% endorsed clinically significant anxiety. Approximately one fourth (23.6%) endorsed lifetime suicidal ideation, with 7.9% reporting a past suicide attempt. A total of 316 youth were enrolled in the GAH cohort. The mean age was 16.0 years (standard deviation = 1.88), and the majority were white (62%) and designated female at birth (64.9%). Elevated depression symptoms were endorsed by 51.3% of the GAH cohort, and 57.3% endorsed clinically significant anxiety. Two-thirds (66.6%) endorsed lifetime suicidal ideation, with 24.6% reporting a past suicide attempt. Life satisfaction was lower among both cohorts compared with population-based norms. Conclusions: GnRHa cohort youth appear to be functioning better from a psychosocial standpoint than GAH cohort youth, pointing to possible benefits of accessing gender-affirming treatment earlier in life.
Keywords: adolescent; anxiety; article; case report; child; clinical article; drug therapy; female; gender dysphoria; human; juvenile; LGBTQIA+ people; life satisfaction; male; mental health; multicenter study; school child; social psychology; suicidal ideation; suicide attempt; university hospital; endogenous compound; gonadorelin; gonadorelin agonist; hormone

Self-injurious and suicidal behaviour in a transsexual adolescent and young adult population, treated at a specialised gender identity unit in Spain - Modrego Pardo, I.; Gómez Balaguer, M.; Hurtado Murillo, F.; Cuñat Navarro, E.; Solá Izquierdo, E.; Morillas Ariño, C. (Endocrinologia, Diabetes y Nutricion, 2020)
Introduction: Nonsuicidal self-injury (NSSI) and suicidal behavior (SB) have a significant prevalence in transsexual people. The published data is confusing as it does not distinguish between ideation and realization, age groups, gender, or the degree of medical intervention. Their actual prevalence in Spain is unknown. Objective: Our objective was to investigate the prevalence of NSSI behavior and SB in adolescents and young transsexual adults, differentiating between ideation and consummated behavior, prior to their receiving any type of gender-affirming medical treatment. Material and methods: We retrospectively reviewed the medical history of a cohort of transsexual people aged between 10 and 35 years, treated at the Gender Identity Unit of the Valencian Community. We analyzed the data collected regarding the presence of four variables: NSSI ideation, NSSI behavior, ideas of suicide and suicide attempts, as well as differences according to age group and gender. Results: The final sample consisted of 110 transsexual men and 90 transsexual women. Of these, 21% had made a suicide attempt, 50% had had suicidal ideas, 31% had a history of NSSI behavior and 35% had had NSSI ideas. No differences were found based on gender. Regarding age, subjects under 20 years of age presented a significantly higher prevalence regarding suicidal ideas compared to young adults (43% vs. 25%), while in the remaining variables, no statistically significant differences were found. Conclusions: The prevalence of a history of suicidal ideas and behavior in the Spanish adolescent and young transsexual population is significant and does not differ according to gender or age range. The prevalence of NSSI ideas and behavior differs and is more frequent in adolescent transsexuals.
Keywords: adolescent; adult; article; automutilation; child; controlled study; female; gender dysphoria; human; human tissue; major clinical study; male; medical history; prevalence; retrospective study; Spaniard; suicide attempt; transgender; transsexuality; Valencian Community; young adult

“This Could Mean Death for My Child”: Parent Perspectives on Laws Banning Gender-Affirming Care for Transgender Adolescents - Kidd, K.M.; Sequeira, G.M.; Paglisotti, T.; Katz-Wise, S.L.; Kazmerski, T.M.; Hillier, A.; Miller, E.; Dowshen, N. (Journal of Adolescent Health, 2020)
Objectives: Numerous U.S. state legislatures have proposed bills to ban gender-affirming medical interventions for minors. Parents and caregivers play a critical role in advocating for and supporting their transgender and gender-diverse youth (TGDY). We aimed to understand parent and caregiver perspectives about this potential legislation and perceived effects on their TGDY's mental health. Methods: We developed and launched a social-media based, anonymous online survey in February 2020 to assess parent and caregiver perspectives on proposed laws to ban gender-affirming medical interventions for minors. Participants were asked to respond to two open-ended questions about these laws; responses were coded to identify key themes. Results: We analyzed responses from 273 participants from 43 states. Most identified as white (86.4%) female (90.0%) mothers (93.8%), and 83.6% of their TGDY had received gender-affirming medical interventions before age 18 years. The most salient theme, which appeared in the majority of responses, described parent and caregiver fears that these laws would lead to worsening mental health and suicide for their TGDY. Additional themes included a fear that their TGDY would face increased discrimination, lose access to gender-affirming medical interventions, and lose autonomy over medical decision-making due to government overreach. Conclusions: In this convenience sample, parents and caregivers overwhelmingly expressed fear that the proposed legislation will lead to worsening mental health and increased suicidal ideation for their TGDY. They implored lawmakers to hear their stories and to leave critical decisions about gender-affirming medical interventions to families and their medical providers.
Keywords: adolescent; article; caregiver; child; controlled study; convenience sample; fear; female; gender; government; human; juvenile; law; major clinical study; male; medical decision making; mother; social media; suicidal ideation; transgender

Impact of Bathroom Discrimination on Mental Health Among Transgender and Nonbinary Youth - Price-Feeney, M.; Green, A.E.; Dorison, S.H. (Journal of Adolescent Health, 2020)
Purpose: Nascent research has found that transgender and/or nonbinary (TGNB) youths experience higher rates of poor mental health outcomes than cisgender youths. The minority stress model highlights experiences of rejection and discrimination on mental health disparities for TGNB individuals. Methods: Using data from a quantitative cross-sectional survey of TGNB youth aged 13–24 years, we examined the association between experiencing bathroom discrimination and depressive mood, seriously considering suicide, and attempting suicide. Results: Overall, 58% of TGNB youths in this sample reported being prevented or discouraged from using a bathroom that corresponds to their gender identity. Among the TGNB youth who experienced bathroom discrimination, 85% reported depressive mood and 60% seriously considered suicide. Furthermore, 1 in three TGNB youths who experienced bathroom discrimination reported a past-year suicide attempt, with 1 in five reporting multiple suicide attempts. After adjusting for demographic variables and general discrimination due to one's gender identity, bathroom discrimination significantly increased the odds of reporting depressive mood (adjusted odds ratio [aOR] = 1.34), seriously considering suicide (aOR = 1.40), a suicide attempt (aOR = 1.66), and multiple suicide attempts (aOR = 1.71). Conclusions: These findings suggest that preventing TGNB youths from accessing appropriate bathrooms is associated with harmful mental health indicators. Addressing the suicide disparities for TGNB youths requires structural change. Policies and procedures need to be in place to ensure that all youths have equal access to appropriate bathrooms.
Keywords: adolescent; article; bath; case report; clinical article; demography; depression; female; gender identity; human; juvenile; male; mental health; quantitative analysis; suicide attempt; transgender

Association Among Maltreatment, Bullying and Mental Health, Risk Behavior and Sexual Attraction in Chinese Students - Zhao, M.; Xiao, D.; Wang, W.; Wu, R.; Zhang, W.; Guo, L.; Lu, C. (Academic Pediatrics, 2020)
Objective: To identify the association between sexual attraction, childhood maltreatment and bullying victimization, and mental and behavioral health problems among Chinese adolescents. Methods: A cross-sectional study among Chinese high school students by multistage stratified cluster sampling was conducted using a self-reported questionnaire. Participants who were same- or both-sex attracted were identified as sexual minorities, and those who were opposite-sex attracted were identified as heterosexuals. Childhood maltreatment was assessed as physical, emotional, and sexual abuse, and bullying was assessed as traditional and cyberbullying. Psychological distress was assessed as depressive and anxiety symptoms, and self-destructive behavior was assessed as suicidal behavior and nonsuicidal self-injury. Logistic regression and path analysis were conducted to analyze the data. Results: There were 1360 sexual minority and 15,020 heterosexual respondents. Sexual minority status was associated with increased risk of maltreatment (adjusted odds ratio [AOR] range: 1.25–2.46) and bullying (AOR range: 1.38–1.77) victimization, and a series of health problems (AOR range: 1.85–3.69). Furthermore, childhood maltreatment could partially explain the association of sexual minority status with psychological distress (indirect effect: β = 0.026 for boys; β = 0.086 for girls) and self-destructive behavior (β = 0.056 for boys; β = 0.125 for girls), and bullying could partially explain the association between sexual minority status and psychological distress (β = 0.040 for boys; β = 0.031 for girls). Conclusions: Sexual minority adolescents were more likely than heterosexuals to experience different forms of childhood victimization, which may put them at higher risk for mental and behavioral health problems. Interventions based on both family and school are essential.
Keywords: adolescent; anxiety; article; automutilation; child; child abuse; Chinese; controlled study; cross-sectional study; cyberbullying; depression; emotional abuse; female; heterosexuality; high school student; human; major clinical study; male; mental health; mental stress; path analysis; physical abuse; problem behavior; questionnaire; sexual abuse; sexual and gender minority; suicidal behavior

Female-to-male gender-confirming drainless mastectomy may be safe in obese males - Pittelkow, E.M.; Duquette, S.P.; Rhamani, F.; Rogers, C.; Gallagher, S. (Aesthetic Surgery Journal, 2020)
Background: Gender dysphoria is a medical condition associated with suicidality. Transgender men who have undergone female-to-male (FTM) chest reconstruction report higher quality of life and reduced gender dysphoria. It has been reported that transgender men are at higher risk of obesity. Objectives: The objective of this study was to compare perioperative outcomes and complications between different classes of obesity in FTM transgender patients who underwent chest masculoplasty. Methods: A retrospective review of 145 consecutive patients who underwent mastectomy with free nipple graft was conducted. Postoperative outcomes and complications were collected. Patients were divided into nonobese (body mass index [BMI] <30 kg/m2), obese (BMI 30-39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), and super obese (BMI >50 kg/ m2) groups. Results: Sixty-six of the 145 patients were not obese, 52 were obese, 22 were morbidly obese, and 5 were super obese. There was a statistically significant increase in amount of breast tissue resected between each of the 4 groups (866.8 g vs 1672.4 g vs 3157.1 g vs 4827.6 g; P ≤ 0.0005) as BMI increased, respectively. There was a significant difference in operative time between the nonobese and obese groups (128.7 vs 134.6 vs 150.5 vs 171 minutes; P = 0.026). A significant increase in postoperative infections was observed between the morbidly obese, super obese, and the nonobese group (P = 0.048). Conclusions: Chest wall reconstruction in FTM and nonbinary transgender people is important in relieving gender dysphoria. Postoperative complications were not significantly increased in obese patients (30-39.9 kg/m2). Delaying surgery for weight loss may not be necessary unless patients are morbidly obese.
Keywords: adult; article; body mass; body weight loss; breast tissue; complication; controlled study; female; female to male transgender; gender dysphoria; human; major clinical study; male; mastectomy; nipple; obese patient; postoperative infection; retrospective study; surgery; thorax wall reconstruction

Sexual Orientation-Based Depression and Suicidality Health Disparities: The Protective Role of School-Based Health Centers - Zhang, L.; Finan, L.J.; Bersamin, M.; Fisher, D.A. (Journal of research on adolescence : the official journal of the Society for Research on Adolescence, 2020)
This study's purpose was to examine whether school-based health centers (SBHCs) support mental health indicators among sexual minority youth (SMY). Data came from the 2015 Oregon Healthy Teens Survey with 13,608 11th graders in 137 public high schools in Oregon. Regression results revealed significant SBHC by SMY status interactions indicating relative reductions in likelihood of depressive episodes (30%), suicidal ideation (34%), and suicide attempts (43%) among SMY in schools with SBHCs. SMY students in SBHC schools reported lower likelihood of a past-year depressive episode, suicidal ideation, and suicide attempt versus those attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY by SBHC status. SBHCs may help reduce mental health disparities among SMY, a marginalized, underserved population.
Keywords: article; controlled study; depression; health center; health disparity; high school; human; juvenile; mental health; Oregon; sexual and gender minority; sexual orientation; student; suicidal ideation; suicide attempt

Comparison of Perceived Burdensomeness, Thwarted Belongingness, Capability for Suicide, and Suicidal Ideation among Heterosexual and Sexual Minority Individuals in Mississippi - Pate, A.R.; Anestis, M.D. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2020)
This study sought to compare risk factors for suicidal ideation among heterosexual and sexual minority college students from a previously understudied conservative region of the United States. Suicidal ideation, thwarted belongingness (TB), perceived burdensomeness (PB), and capability for suicide were examined. It was found that PB was significantly higher among sexual minorities than heterosexual individuals, TB and capability were not significantly different, and suicidal ideation was not significantly different when controlling for depression but was significant when depression was not a covariate. Additionally, among sexual minorities and heterosexuals, TB and PB were correlated with ideation and that the strength of the relationship between PB and ideation was dependent on how much TB the individual is experiencing. Sexual minorities, when compared to heterosexual individuals, do not have higher TB or capability, but do have higher levels of PB and suicidal ideation.
Keywords: adult; article; college student; controlled study; female; heterosexuality; human; male; Mississippi; risk factor; sexual and gender minority; suicidal ideation

Experiences of Suicide in Transgender Youth: A Qualitative, Community-Based Study - Hunt, Q.A.; Morrow, Q.J.; McGuire, J.K. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2020)
Objective: The aim was to develop understanding around the experience of suicide in transgender youth. Method: Qualitative analysis with 85 interviews with transgender youth about their histories with suicidality was performed. Participants were recruited from community clinics in three counties (United States, Canada, and Ireland) between 2010 and 2014. Results: Factors that precipitated participants' suicide attempts included rejection based on gender identity and gender dysphoria. Participants demonstrated resilience by attempting to connect with loved ones for support and through self-awareness of mental states, including by regulating behaviors they perceived to adversely affect their mental health. Conclusions: Transgender youth may fear seeking health care due to health professionals' lack of understanding of transgender issues and fear of further victimization. Reframing suicidality as a rational decision-making process in response to stress may further understanding of why people attempt suicide and provide new avenues for intervention.
Keywords: adult; article; automutilation; awareness; Canada; decision making; fear; female; gender dysphoria; human; interview; Ireland; juvenile; male; mental health; multicenter study; qualitative analysis; physiological stress; suicidal ideation; suicide attempt; transgender; United States

Suicide ideation among Southern U.S. Sexual minority college students - Wolford-Clevenger, C.; Frantell, K.A.; Brem, M.J.; Garner, A.; Rae Florimbio, A.; Grigorian, H.; Shorey, R.C.; Stuart, G.L. (Death studies, 2020)
Sexual minority individuals are at higher risk for suicide ideation compared with heterosexual individuals. We tested whether the interpersonal-psychological theory of suicide explains increased suicide ideation among sexual minority college students living in the southeastern region of the United States. The cross-sectional study assessed correlates of suicide ideation in a convenience sample (n = 82) of sexual minority college students. Perceived burdensomeness and thwarted belongingness correlated with suicide ideation. However, only perceived burdensomeness correlated with suicide ideation while controlling for depressive symptoms. Pending replication, perceived burdensomeness may be a target for suicide prevention and intervention among sexual minority college students.
Keywords: adolescent; adult; cross-sectional study; epidemiology; female; human; male; psychological theory; psychology; sexual and gender minority; student; suicidal ideation; United States; university; young adult

Untethered lives: barriers to societal integration as predictors of the sexual orientation disparity in suicidality - Bränström, R.; van der Star, A.; Pachankis, J.E. (Social psychiatry and psychiatric epidemiology, 2020)
PURPOSE: Despite increasing legal protections and supportive attitudes toward sexual minorities (e.g., those who identify as lesbian, gay, and bisexual [LGB]) in recent decades, suicidality remains more common among this population than among heterosexuals. While barriers to societal integration-or a lack of meaning, purpose, and belonging as derived from societal norms, goals, and attachment-have been widely theorized as determinants of suicidality for the general population, they have not been comprehensively explored to explain the sexual orientation disparity in suicidality. The aim of this study was to examine differences in suicidal ideation and attempts between LGB and heterosexual individuals in a nationally representative sample, and to examine barriers to societal integration as a potential explanation for any observed disparities over-and-above the influence of established contributors to sexual orientation disparity in suicidality. METHODS: Data come from the cross-sectional Swedish National Public Health Survey, which collected data from unrestricted random samples of individuals (16-84 years of age) living in Sweden, annually from 2010 to 2015 (n = 57,840 individuals [response rates: 48.1-51.3%]; 1281 (2.2%) self-identified as LGB). Analyses examined sexual orientation differences in suicidality (i.e., past-12-month ideation and attempts), and explored the role of barriers to societal integration (i.e., not living with a partner or children, unemployment, and lack of societal trust) in explaining this disparity over-and-above more commonly explored psychological (e.g., depression, substance use) and interpersonal (e.g., discrimination, victimization, lack of social support) suicidality risk factors. RESULTS: Compared to heterosexuals, suicidal ideation and attempts were more common among both gay men/lesbians (adjusted odds ratio [AOR] for suicide ideation: 2.69; 95% confidence intervals [CI]: 2.09, 3.47; AOR for suicide attempts: 5.50; 95% CI: 3.42, 8.83), and bisexuals (AOR for suicide ideation: 3.83; 95% CI: 3.26, 4.51; AOR suicide attempts: 6.78; 95% CI: 4.97, 9.24). Barriers to societal integration mediated the association between sexual orientation and suicidality even in models adjusting for established risk factors for suicidality. CONCLUSION: Our results suggest that previously under-examined factors, namely the disproportionate barriers to societal integration that LGB individuals experience, are important contributors to the substantially elevated risk of suicidality among sexual minorities. Preventive interventions should consider innovative ways to foster societal integration within sexual minority populations and to adjust hetero-centric social institutions to better include sexual minority individuals.
Keywords: adolescent; adult; aged; child; community integration; cross-sectional study; depression; drug dependence; female; health disparity; heterosexuality; human; male; middle aged; odds ratio; psychology; risk factor; sexual and gender minority; sexual behavior; social support; suicidal ideation; suicide attempt; Sweden; very elderly; young adult

Association between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts among Transgender Adults - Turban, J.L.; Beckwith, N.; Reisner, S.L.; Keuroghlian, A.S. (JAMA Psychiatry, 2020)
Importance: Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown. Objective: To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes. Design, Setting, and Participants: In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019. Exposure: Recalled exposure to GICE. Main Outcomes and Measures: Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization. Results: Of 27715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11857 (42.8%) were assigned male sex at birth. Among the 19741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P <.001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P <.001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P <.001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors. Conclusions and Relevance: The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice.
Keywords: adult; American Samoa; article; counselor; cross-sectional study; distress syndrome; District of Columbia; exposure; female; gender identity; gender identity conversion effort; Guam; hospitalization; human; lifespan; major clinical study; male; mental health; psychological and psychiatric procedures; psychologist; Puerto Rico; religious personnel; suicidal ideation; suicide attempt; transgender

Longitudinal predictors of self-injurious thoughts and behaviors in sexual and gender minority adolescents - Smith, D.M.; Wang, S.B.; Carter, M.L.; Fox, K.R.; Hooley, J.M. (Journal of Abnormal Psychology, 2020)
Sexual and gender minority (SGM) populations are at increased risk for several negative psychological outcomes, including self-injury. Although correlates of self-injurious thoughts and behaviors (SITBs) have been identified, it is unclear which factors are prospective predictors of SITB engagement in SGM youth. The current study investigated an online sample of 252 SGM adolescents over a 6-month period. Participants reported attitudes based on SGM identity, depression, self-criticism, body image, family support and family strain, friend NSSI engagement, and experiences of everyday discrimination. Lasso and elastic net regularized logistic regressions were used to examine which baseline variables were associated with SITB engagement at follow-up. Models resulted in excellent predictive accuracy of nonsuicidal self-injury and suicidal ideation (mean Area Under the Receiving Operating Characteristics Curve [AUC] of 0.90 and 0.91), good predictive accuracy for suicide plans (mean AUC = 0.85), and fair predictive accuracy for suicidal behaviors (mean AUC = 0.78). Several variables emerged as prospectively related to SITB risk, with varied associations across different SITBs. Results suggest that minority-specific factors may predict SITBs in SGM adolescents.
Keywords: adolescent; adolescent behavior; article; automutilation; bisexual female; female; homosexual female; human; longitudinal study; major clinical study; prediction; sexual and gender minority

Suicide among persons who entered same-sex and opposite-sex marriage in Denmark and Sweden, 1989-2016: a binational, register-based cohort study - Erlangsen, A.; Drefahl, S.; Haas, A.; Bjorkenstam, C.; Nordentoft, M.; Andersson, G. (Journal of epidemiology and community health, 2020)
BACKGROUND: People belonging to sexual minority groups have higher levels of suicidality than heterosexuals. However, findings regarding suicide death are sparse. Using unique national data from two countries, we investigated whether individuals entering a same-sex marriage (SSM), a proxy group of sexual minority individuals, had higher suicide rates than those entering opposite-sex marriage (OSM). METHODS: A cohort study of all males and females who entered an SSM (n=28 649) or OSM (n=3 918 617) in Denmark and Sweden during 1989-2016 was conducted. Incidence rate ratios (IRRs) for suicide were calculated using adjusted Poisson regression models. RESULTS: In total, 97 suicides occurred among individuals who had entered an SSM compared with 6074 among those who entered an OSM, corresponding to an adjusted IRR of 2.3 (95% CI 1.9 to 2.8). For people who entered SSM, a 46% decline was noted over time from an IRR of 2.8 (95% CI 1.9 to 4.0) during 1989-2002 to 1.5 (95% CI 1.2 to 1.9) during 2003-2016. The excess suicide mortality was present in all age groups but most pronounced among younger individuals aged 18-34 years of age (IRR 2.7, 95% CI 1.5 to 4.8) and females (IRR 2.7, 95% CI 1.8 to 3.9). CONCLUSION: This large register-based study found higher suicide rates among individuals who entered an SSM, compared with those who entered an OSM. A lower suicide rate was noted for individuals in SSMs in recent years. More research is needed to identify the unique suicide risk and protective factors for sexual minority people.
Keywords: adolescent; adult; cohort analysis; Denmark; epidemiology; family size; female; heterosexuality; homosexuality; human; male; marriage; middle aged; psychology; questionnaire; sexual behavior; suicide; suicide attempt; Sweden; young adult

Parent-Initiated Sexual Orientation Change Efforts With LGBT Adolescents: Implications for Young Adult Mental Health and Adjustment - Ryan, C.; Toomey, R.B.; Diaz, R.M.; Russell, S.T. (Journal of homosexuality, 2020)
Studies of adults who experienced sexual orientation change efforts (SOCE) have documented a range of health risks. To date, there is little research on SOCE among adolescents and no known studies of parents' role related to SOCE with adolescents. In a cross-sectional study of 245 LGBT White and Latino young adults (ages 21-25), we measured parent-initiated SOCE during adolescence and its relationship to mental health and adjustment in young adulthood. Measures include being sent to therapists and religious leaders for conversion interventions as well as parental/caregiver efforts to change their child's sexual orientation during adolescence. Attempts by parents/caregivers and being sent to therapists and religious leaders for conversion interventions were associated with depression, suicidal thoughts, suicidal attempts, less educational attainment, and less weekly income. Associations between SOCE, health, and adjustment were much stronger and more frequent for those reporting both attempts by parents and being sent to therapists and religious leaders, underscoring the need for parental education and guidance.
Keywords: adult; child parent relation; cross-sectional study; depression; family relation; female; homosexuality; human; male; mental health; psychology; sexual and gender minority; sexual behavior; suicidal ideation; suicide attempt; young adult

A Critical Review of Current Evidence on Multiple Types of Discrimination and Mental Health - Vargas, S.M.; Huey, S.J.; Miranda, J. (American Journal of Orthopsychiatry, 2020)
Little is known about people who experience multiple types of discrimination (e.g., racism and heterosexism). While some work suggests that multiply discriminated groups are at higher risk for poor mental health, other studies propose that they may develop resilience against additional kinds of discrimination. We conducted a review of published studies on the relationship between multiple types of discrimination and mental health to critically examine evidence in support of broad risk and resilience models. Using PRISMA guidelines, we identified 40 studies that met our inclusion criteria. Typically, studies examined either whether experiencing multiple discrimination was related to poorer mental health, or whether one kind of discrimination was more predictive of poor mental health. Studies generally showed support for the risk model, with multiple forms of discrimination associated with higher risk for depression symptoms. Furthermore, both racism and heterosexism uniquely predicted symptoms of depression, although initial evidence suggested that only heterosexism predicted suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ) racial/ethnic minorities. Findings on multiple discrimination and other mental health problems (e.g., anxiety, posttraumatic stress disorder [PTSD], distress, and substance use) were mixed. The current evidence suggests that multiply discriminated groups exhibit higher risk for some mental health problems, particularly depression symptoms. However, methodological problems abound in this literature (e.g., correspondence between study sample and types of discrimination assessed), which limits our ability to draw clear conclusions about multiple discrimination. We propose that to further our understanding of how multiple kinds of discrimination may affect mental health, studies must remedy these and other issues.
Keywords: anxiety disorder; article; controlled study; depression; distress syndrome; ethnic group; female; human; LGBTQIA+ people; male; mental disease; posttraumatic stress disorder; Preferred Reporting Items for Systematic Reviews and Meta-Analyses; racism; risk assessment; substance use; suicidal behavior; writing

Mental Health Among Sexual and Gender Minority Adolescents: Examining Interactions With Race and Ethnicity - Fox, K.R.; Choukas-Bradley, S.; Salk, R.H.; Marshal, M.P.; Thoma, B.C. (Journal of Consulting and Clinical Psychology, 2020)
Objective: Sexual and gender minority (SGM) adolescents report elevated risk for psychopathology. Identifying as a racial/ethnic minority and sexual minority (SM) or gender minority (GM) may lead to greater stress/discrimination and psychopathology. We examined nonsuicidal self-injury, suicide ideation, and suicide attempts (i.e., self-injurious thoughts and behaviors [SITBs]) and depressive symptoms across intersections of sexual orientation, gender, and race/ethnicity. Method: Study participants consisted of a large (n = 2,948; 59% GM) sample of adolescents aged 14-18 who were recruited online to complete a cross-sectional survey. SGM status, race/ethnicity, and their interactions were used to predict depressive symptoms and SITBs. Associations among race/ethnicity and GM-specific psychosocial factors were assessed. Results: SM (B = 3.75) and GM (B = 8.81) participants reported higher depressive symptoms and SITB histories (odds ratios [ORs] from 1.92 to 2.43 and 2.87 to 5.44, respectively). Asian participants were less likely to report nonsuicidal self-injury (OR = 0.45), and Latinx participants were more likely to report suicide attempts (OR = 1.50). Although omnibus tests of interactions were largely insignificant, exploratory analyses revealed fewer depressive symptoms (B=-8.40) and SITBs (ORs from -0.95 to -2.05) among Black SM participants and, at times, Black GM participants. This protective effect may relate to lower self-reported expectations of rejection due to gender. Conclusions: GM participants reported the highest risk for depressive symptoms and SITBs. Contrary to hypotheses, multiple minority identification was not associated with greater psychopathology. Future research, assessing specific sexual and gender identities across diverse samples, is needed to highlight how race affects psychopathology risk across these identities.
Keywords: adolescence; adolescent; adult; article; Asian; automutilation; controlled study; depression; ethnicity; expectation; exploratory research; female; gender identity; human; major clinical study; male; mental disease; race; risk assessment; sexual and gender minority; sexual orientation; suicidal ideation; suicide attempt

Psychological Correlates of Self-Harm within Gay, Lesbian and Bisexual UK University Students - Taylor, P.J.; Dhingra, K.; Dickson, J.M.; McDermott, E. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2020)
This study explores the association between lesbian, gay or bisexual (LGB) status and self-harm in UK higher education students. There is currently limited data on this association, and the role psychological variables have in potentially explaining this link, in UK students. We examine whether LGB status is associated with self-harm (both non-suicidal self-injury [NSSI] and suicide attempts [SA]), and whether 4 psychological variables (depression, anxiety, belongingness, self-esteem) mediate this association. A cross-sectional survey was used. UK university students (n = 707) completed an online survey including measures of self-harm, affective symptoms, belongingness, and self-esteem. Latent Variable Modelling (LVM) was used to test our hypotheses. LGB status remained associated with an elevated risk of NSSI and SA even after accounting for mediating factors. Self-esteem and (in the case of SA but not NSSI) thwarted belongingness, did, however, explain some of this association and were correlated with self-harm risk. The findings suggest that psychological factors may account for the association between LGB status and self-harm and, as such, prevention and intervention efforts directed at these psychological mediators may help to reduce self-harm risk in this population.
Keywords: anxiety; article; automutilation; bisexuality; controlled study; depression; education; emotional disorder; female; homosexual female; human; major clinical study; male; psychological aspect; self esteem; suicide attempt; university student

Prevalence of depression, anxiety and suicide among men who have sex with men in China: A systematic review and meta-analysis - Wei, D.; Wang, X.; You, X.; Luo, X.; Luo, X.; Hao, C.; Hao, C.; Gu, J.; Gu, J.; Peng, S.; Yang, X.; Hao, Y.; et al. (Epidemiology and Psychiatric Sciences, 2020)
AimsChinese men who have sex with men (MSM) are at high risk for depression, anxiety and suicide. The estimated prevalence of these problems is essential to guide public health policy, but published results vary. This meta-analysis aimed to estimate the prevalence of depressive symptoms, anxiety symptoms and suicide among Chinese MSM.MethodsSystematic searches of EMBASE, MEDLINE, PsycINFO, PubMed, CNKI and Wanfang databases with languages restricted to Chinese and English for studies published before 10 September 2019 on the prevalence of depressive symptoms, anxiety symptoms, suicidal ideation, suicide plans and suicide attempts among Chinese MSM. Studies that were published in the peer-reviewed journals and used validated instruments to assess depression and anxiety were included. The characteristics of studies and the prevalence of depression and anxiety symptoms, suicidal ideation, suicide plans and suicide attempts were independently extracted by authors. Random-effects modelling was used to estimate the pooled rates. Subgroup analysis and univariate meta-regression were conducted to explore potential sources of heterogeneity. This study followed the PRISMA and MOOSE.ResultsSixty-seven studies were included. Fifty-two studies reported the prevalence of depressive symptoms, with a combined sample of 37 376 people, of whom 12 887 [43.2%; 95% confidence interval (CI), 38.9-47.5] reported depressive symptoms. Twenty-seven studies reported the prevalence of anxiety symptoms, with a combined sample of 10 531 people, of whom 3187 (32.2%; 95% CI, 28.3-36.6) reported anxiety symptoms. Twenty-three studies reported the prevalence of suicidal ideation, with a combined sample of 15 034 people, of whom 3416 (21.2%; 95% CI, 18.3-24.5) had suicidal ideation. Nine studies reported the prevalence of suicide plans, with a combined sample of 5271 people, of whom 401 (6.2%; 95% CI, 3.9-8.6) had suicide plans. Finally, 19 studies reported the prevalence of suicide attempts, with a combined sample of 27 936 people, of whom 1829 (7.3%; 95% CI, 5.6-9.0) had attempted suicide.ConclusionsThe mental health of Chinese MSM is poor compared with the general population. Efforts are warranted to develop interventions to prevent and alleviate mental health problems among this vulnerable population.
Keywords: adult; anxiety; article; China; depression; Embase; human; language; male; Medline; men who have sex with men; mental disease; meta analysis; moose; nonhuman; prevalence; PsycINFO; suicidal ideation; suicide attempt; systematic review; vulnerable population; WanFang Database

Knowledge and confidence of clinicians in Irish CAMHS when working with transgender youth; and the factors clinicians report will assist them in this work - Hodgins, S.; Byrne, T.; Spies, M.; Madigan, K. (Irish Journal of Psychological Medicine, 2020)
Objectives: The Health Service Executive (HSE) Quality Improvement Division (2016) report states that young people who identify as transgender are one of the highest risk groups for suicidal ideation, self-harm, and completed suicides and may require significant input in Irish Child and Adolescent Mental Health Services (CAMHS). This research represents the first exploration of CAMHS staff's capacity within an Irish mental health service to support transgender youth by considering their knowledge about and confidence in working with these youth. Method: A multi-method design was used to evaluate the knowledge and confidence levels of CAMHS clinicians in supporting transgender youth and to identify what factors would enable them to conduct this work. A questionnaire and a survey about supporting transgender youth were distributed to all clinicians in five Irish-based CAMHS services (N = 71), using an online platform. Additionally, semi-structured interviews were conducted with six clinicians. Quantitative, content, and thematic analyses were performed. Results: CAMHS staff reported limited knowledge and experience about supporting transgender youth. Findings indicated that both of these factors undermined their confidence in supporting these youths. Clinicians expressed a need for additional clinical education delivered through expert consultation, presentations, and learning from 'experts by experience'.Conclusion:CAMHS clinicians need and want further clinical education about supporting transgender youth and their families. Recommendations are made for enhancing the knowledge, confidence, and competence of CAMHS clinicians using methods identified as acceptable by clinicians, in order to best support these youths.
Keywords: adolescent; article; child; clinical education; consultation; controlled study; female; human; juvenile; learning; major clinical study; male; mental health service; quantitative analysis; questionnaire; semi structured interview; thematic analysis; transgender

Prevalence of somatic and psychiatric morbidity across occupations in Switzerland and its correlation with suicide mortality: Results from the Swiss national cohort (1990-2014) - Schmid, M.; Michaud, L.; Bovio, N.; Guseva Canu, I. (BMC Psychiatry, 2020)
Background: Suicide is a major and complex public health problem. In Switzerland, suicide accounts for about 1000 deaths yearly and is the fourth leading cause of mortality. The first nationwide Swiss study of suicides identified eight male and four female occupations with statistically significant excess of suicide compared to the general Swiss population. Working time, self-employer status, low socio-economic status and low skill level required for occupation were associated with increase in suicide risk. Presently, we aim to compare the distribution of suicide risk across occupations with the prevalence of somatic and psychiatric morbidity in Swiss working-aged adults. We hypothesized that some diseases would cluster in particular occupations, indicating potential work-relatedness of suicides found in these occupations. Methods: We used the Swiss National Cohort (SNC) and included 10575 males and 2756 females deceased by suicide between 1990 and 2014. We estimated the prevalence of 16 categories of concomitant diseases in each occupation, using national mortality records, and assessed the homogeneity of diseases distribution across occupations. For diseases, which prevalence varied significantly across occupations, we analyzed the correlation with the distribution of suicide risk, estimated as the standardized mortality ratio (SMR) of suicide. Results: Mental and behavioral disorders were the most commonly reported concomitant diseases in our population. In men, the prevalence of these disorders and more specifically, the prevalence of substance-related and addictive disorders, and of psychotic disorders varied significantly across occupations and was correlated with the SMR of suicide. The prevalence of malignant neoplasms and the prevalence of diseases of the musculoskeletal system and connective tissue also varied significantly across male occupations, while in women, such a variation was observed for neoplasms of uncertain or unknown behavior and diseases of the nervous system and sense organs, without being correlated with the SMR of suicide. Conclusion: Some of the identified morbidities can be occupation-related and could negatively affect the working capacity and the employability, which in turn could be related to the suicide. Disentangling concomitant diseases according to their work-relatedness and relationship with the suicide risk is important for identifying occupation-related suicides, understanding their characteristics, and developing appropriated interventions for their prevention.
Keywords: addiction; adult; aged; agricultural worker; anxiety disorder; article; bipolar disorder; chromosome aberration; conduct disorder; congenital malformation; connective tissue disease; controlled study; depression; disease association; driver; female; fishery; gastrointestinal disease; gender dysphoria; health care personnel; high risk patient; human; ICD-10; ICD-8; major clinical study; male; malignant neoplasm; military personnel; mining; mood disorder; mortality rate; musculoskeletal disease; neurologic disease; obsessive compulsive disorder; occupation; occupational hazard; operator; paraphilic disorder; personal experience; personality disorder; prevalence; psychosomatic disorder; respiratory tract disease; schizophrenia; sex difference; skin disease; suicide; Switzerland; teacher; urogenital tract disease

Effects of emotion regulation and perpetrator-victim roles in intimate partner violence on mental health problems among men who have sex with men in China - Wei, D.; Hou, F.; Cao, W.; Hao, C.; Gu, J.; Peng, L.; Li, J. (Epidemiology and Psychiatric Sciences, 2020)
AimsThis study assessed the relationships between different perpetrator-victim roles in intimate partner violence (IPV), emotion regulation (ER) and mental health problems among men who have sex with men (MSM) in China.MethodsFrom April to June 2019, 1233 participants were approached via gay-friendly non-governmental organisations in 15 cities across mainland China.ResultsOf the total, 578 eligible participants completed an anonymous online survey. All participants provided informed consent and information about their violent perpetrator-victim role and mental health status. The results revealed a high prevalence of IPV in this study sample, with 32.7% of participants reporting IPV victimisation and 32.5% of participants reporting IPV perpetration during their lifetime. A total of 81 (14.0%) participants were suicidal, 309 (53.5%) participants reported poor general mental health and 208 (36.0%) had significant depressive symptoms. Adjusted logistic regression models revealed that both physical victimisation (adjusted odds ratio [ORa] = 3.22, 95% confidence interval [CI] = 1.11-9.32) and sexual victimisation (ORa = 2.90, 95% CI = 1.39-6.05) had positive associations with suicidality, and unidirectional and bidirectional psychological perpetration were associated with poor general mental health and significant depressive symptoms. Although high cognitive reappraisal showed a negative association with poor general mental health (ORa = 0.89 1/4 95% CI = 0.86-0.92), the correlation with victims of IPV was weaker than it was with non-victims.ConclusionsThis study revealed that different perpetrator-victim roles in different IPV situations should be considered comprehensively in research, prevention and intervention. ER is not enough to buffer the effects of IPV on the mental health of MSM victims.
Keywords: adult; article; China; controlled study; depression; emotion regulation; human; major clinical study; male; men who have sex with men; men's health; mental disease; offender; partner violence; physical model; prevalence; suicidal behavior; victim; buffer

Mental Health Status of Cisgender and Gender-Diverse Secondary School Students in China - Wang, Y.; Yu, H.; Yang, Y.; Drescher, J.; Li, R.; Yin, W.; Yu, R.; Wang, S.; Deng, W.; Jia, Q.; Zucker, K.J.; Chen, R. (JAMA Network Open, 2020)
Importance: Transgender or gender nonconforming (TGNC) adolescents face a wide range of physical and mental health concerns. However, there has been no school-based study to explore the prevalence and mental health status of these adolescents in mainland China. Objectives: To assess the mental well-being of TGNC adolescents in China by comparing them with their cisgender peers. Design, Setting, and Participants: This was a cross-sectional survey study. Of the 12 354 adolescents who completed the questionnaire, 246 did not specify to which sex they identified and were therefore excluded from further analysis. Therefore, a total of 12108 adolescents were included from 18 secondary schools in Suzhou city, China, from June 2019 to July 2019. Participants provided consent and answered questions on sex assigned at birth and gender identity. Main Outcomes and Measures: All participants completed questionnaires, including the Patient Health Questionnaire for the measurement of depressive symptoms, a generalized anxiety disorder screening, the Pittsburgh Sleep Quality Index, and a self-harm and suicide risk checklist. The frequency of being bullied at school was also measured. Participants who reported their perceived gender as the opposite of their assigned sex at birth were classified as transgender, those who identified as neither male nor female were classified as nonbinary, and those who were not sure about their perceived gender were classified as questioning. All of these participants were categorized as TGNC adolescents. Results: A total of 12 108 adolescents (mean [SD] age, 15.8 [1.0] years; 6518 [53.8%] assigned male at birth [AMAB]) participated in the study. Of the 6518 participants AMAB in the sample, 5855 (89.8%) were classified as cisgender boys, 208 (3.2%) as transgender girls (transgender youth who perceive their current gender identity to be female), 138 (2.1%) as nonbinary youth AMAB, and 317 (4.9%) as questioning youth AMAB. Of the 5590 participants assigned female at birth (AFAB), 4142 (74.1%) were classified as cisgender girls, 861 (15.4%) as transgender boys (transgender youth who perceive their current gender identity to be male), 112 (2.0%) as nonbinary youth AFAB, and 475 (8.5%) as questioning youth AFAB. Compared with cisgender adolescents, TGNC adolescents reported significantly higher health concerns including lower overall health (t11 872 = -7.36; P <.001), poorer sleep (t11 683 = 10.49; P <.001), higher depression and anxiety symptoms (t11 830 = 12.43 and t11 847 = 11.47, respectively; P <.001), and higher rate of self-harm and suicide ideation (t11 860 = 12.22; P <.001). The TGNC youth who were AMAB were also more likely to be bullied at school than cisgender boys (transgender girls: odds ratio [OR], 2.34 [95% CI, 1.64-3.33]; nonbinary youth AMAB: OR, 1.97 [95% CI, 1.23-3.16]; and questioning youth AMAB: OR, 1.95 [95% CI, 1.43-2.67]). The TGNC groups also reported significantly greater amounts of thoughts of self-harm (transgender girls: OR, 3.06 [95% CI, 2.24-4.19]; transgender boys: OR, 4.06 [95% CI, 3.47-4.74]; nonbinary youth AMAB: OR, 2.86 [95% CI, 1.93-4.23]; nonbinary youth AFAB: OR, 3.71 [95% CI, 2.46-5.59]; questioning youth AMAB: OR, 2.61 [95% CI, 1.98-3.44]; and questioning youth AFAB: OR, 3.35 [95% CI, 2.70-4.16]), thoughts of suicide (transgender girls: OR, 3.93 [95% CI, 2.88-5.38]; transgender boys: OR, 3.71 [95% CI, 3.10-4.21]; nonbinary youth AMAB: OR, 3.13 [95% CI, 2.11-4.63]; nonbinary youth AFAB: OR, 3.78 [95% CI, 2.50-5.71]; questioning youth AMAB: OR, 2.53 [95% CI, 1.93-3.33]; and questioning youth AFAB: OR, 3.94 [95% CI, 3.17-4.88]), suicide plan formation (transgender girls: OR, 4.44 [95% CI, 2.88-6.83]; transgender boys: OR, 2.66 [95% CI, 2.03-3.50]; nonbinary youth AMAB: OR, 5.36 [95% CI, 3.22-8.93]; nonbinary youth AFAB: OR, 4.06 [95% CI, 2.25-7.30]; and questioning youth AFAB: OR, 2.36 [95% CI, 1.63-3.43]), deliberate self-harm during the last month (cisgender girls: OR, 1.49 [95% CI, 1.33-1.68]; transgender girls: OR, 2.74 [95% CI, 1.93-3.91]; transgender boys: OR, 3.06 [95% CI, 2.57-3.66]; nonbinary youth AMAB: OR, 2.56 [95% CI, 1.66-3.94]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.95-4.81]; questioning youth AMAB: OR, 2.14 [95% CI, 1.56-2.92]; and questioning youth AFAB: OR, 2.53 [95% CI, 2.00-3.01]), and attempts of suicide (transgender girls: OR, 4.35 [95% CI, 2.88-6.56]; transgender boys: OR, 2.92 [95% CI, 2.26-3.76]; nonbinary youth AMAB: OR, 3.94 [95% CI, 2.36-6.55]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.67-5.63]; questioning youth AMAB: OR, 2.61 [95% CI, 1.73-3.94]; and questioning youth AFAB: OR, 1.93 [95% CI, 1.33-2.81]) compared with cisgender boys. Conclusions and Relevance: Results of this cross-sectional survey study suggest poor mental health status among TGNC adolescents in China; in addition, findings suggest a compelling need for researchers, practitioners, and policy makers to address these mental health problems. Particular school-based interventions are recommended to support the mental health well-being of TGNC adolescents.
Keywords: adolescent; article; automutilation; checklist; child; China; controlled study; depression; female; gender identity; generalized anxiety disorder; high school; human; human tissue; major clinical study; male; mental disease; patient health questionnaire; physician; Pittsburgh Sleep Quality Index; sleep; suicidal ideation; transgender; wellbeing

Evaluation of Suicide Mortality among Sexual Minority US Veterans from 2000 to 2017 - Lynch, K.E.; Gatsby, E.; Viernes, B.; Schliep, K.C.; Whitcomb, B.W.; Alba, P.R.; Duvall, S.L.; Blosnich, J.R. (JAMA Network Open, 2020)
Importance: Identification of subgroups at greatest risk for suicide mortality is essential for prevention efforts and targeting interventions. Sexual minority individuals may have an increased risk for suicide compared with heterosexual individuals, but a lack of sufficiently powered studies with rigorous methods for determining sexual orientation has limited the knowledge on this potential health disparity. Objective: To investigate suicide mortality among sexual minority veterans using Veterans Health Administration (VHA) electronic health record data. Design, Setting, and Participants: This retrospective population-based cohort study used data on 8.1 million US veterans enrolled in the VHA after fiscal year 1999 that were obtained from VHA electronic health records from October 1, 1999 to September 30, 2017. Data analysis was carried out from March 1, 2020 to October 31, 2020. Exposure: Veterans with documentation of a minority sexual orientation. Documentation of sexual minority status was obtained through natural language processing of clinical notes and extraction of structured administrative data for sexual orientation in VHA electronic health records. Main Outcomes and Measures: Suicide mortality rate using data on the underlying cause of death obtained from the National Death Index. Crude and age-Adjusted mortality rates were calculated for all-cause death and death from suicide among sexual minority veterans compared with the general US population and the general population of veterans. Results: Among the 96893 veterans with at least 1 sexual minority documentation in the electronic health record, the mean (SD) age was 46 (16) years, 68% were male, and 70% were White. Of the 12591 total deaths, 3.5% were from suicide. Veterans had a significantly higher rate of mortality from suicide (standardized mortality ratio, 4.50; 95% CI, 4.13-4.99) compared with the general US population. Suicide was the fifth leading cause of death in 2017 among sexual minority veterans (3.8% of deaths) and the tenth leading cause of death in the general US population (1.7% of deaths). The crude suicide rate among sexual minority veterans (82.5 per 100000 person-years) was higher than the rate in the general veteran population (37.7 per 100000 person-years). Conclusions and Relevance: The results of this population-based cohort study suggest that sexual minority veterans have a greater risk for suicide than the general US population and the general veteran population. Further research is needed to determine whether and how suicide prevention efforts reach sexual minority veterans.
Keywords: adult; all cause mortality; cohort analysis; controlled study; data analysis; electronic health record; extraction; female; health disparity; heterosexuality; human; major clinical study; male; mortality rate; natural language processing; prevention; retrospective study; review; sexual and gender minority; standardized mortality ratio; suicide; veterans health

Non-suicidal self-injury, suicide ideation, and past suicide attempts: Comparison between transgender and gender diverse veterans and non-veterans - Aboussouan, A.; Snow, A.; Cerel, J.; Tucker, R.P. (Journal of Affective Disorders, 2019)
Background: Transgender and gender diverse (TGD) individuals, especially veterans, experience elevated rates of non-suicidal self-injury (NSSI) and suicide related behaviors compared to gender majority individuals. Research has yet to compare TGD veterans to non-veterans or look at correlates of NSSI and related behaviors to suicide related outcomes. This study examines prevalence and suicide related correlates of NSSI among TGD veterans and TGD non-veterans. Method: Data analyzed in the were part of the Trans Lifeline Mental Health Survey. Both TGD veterans (N = 313) and non-veterans (N = 3,972) completed an online, cross-sectional survey that included self-report measures of NSSI, suicidal ideation (SI), and suicidal attempt (SA) along with lifetime hospitalization and avoidance of care due to NSSI. Results: Results of this paper indicate that prevalence of NSSI, SI, and SA are elevated in both the TGD veterans and non-veteran subpopulations. Further, veterans compared to non-veterans have a lower prevalence of NSSI but higher prevalence of hospitalization when self-harm is inflicted, reflecting more healthcare utilization or increased severity of NSSI episodes. Additionally, veterans were less likely to avoid care due to NSSI. Further, veteran status seemed to be a protective factor against demographic differences that increased rates of NSSI history in non-veteran TGD individuals. Limitations: The limitations of this study include its cross-sectional study design, one question assessing SA, and few TGD male veterans. Conclusion: NSSI is an important risk factor in future suicide related outcome such as SI and SA. Further, differences in healthcare utilization among TGD veterans and non-veterans are apparent.
Keywords: adult; article; automutilation; controlled study; cross-sectional study; disease severity; female; femininity; gender identity; health care utilization; hospitalization; human; intersex; major clinical study; male; masculinity; medical care; mental health service; middle aged; prevalence; priority journal; self report; suicidal ideation; suicide attempt; transgender; veterans health

Trans and gender diverse young people's attitudes towards game-based digital mental health interventions: A qualitative investigation - Strauss, P.; Morgan, H.; Wright Toussaint, D.; Lin, A.; Winter, S.; Perry, Y. (Internet Interventions, 2019)
Background: Trans and gender diverse (TGD) young people are at high risk for mental health difficulties. Previous research has shown that three in four TGD young people have been diagnosed with an anxiety disorder and/or depression and almost one in two have attempted suicide. TGD young people experience barriers to traditional mental health services, commonly faced with inexperienced providers and discrimination. Video and computer games, as well as online spaces, are sources of resilience for TGD young people. Digital mental health interventions are a feasible, but understudied, approach to consider for this population. Methods: N = 14 TGD young people aged 11–18 years were recruited to take part in focus groups as part of a multistage project. The focus groups were transcribed verbatim and analysed using a general inductive thematic analysis approach. This paper reports on their attitudes towards digital games and game-based digital mental health interventions. Discussion: Aspects of game-based digital mental health interventions should be inclusive of diverse genders and sexuality, moderated appropriately and include content such as storylines and characters who are of diverse sexualities and/or gender. Participants were of the opinion that games should be preventative rather than treatment-focused; however, considering the high rate of mental health difficulties in this population, interventions should ideally address symptoms along the continuum from sub-clinical to clinical.
Keywords: adolescent; adult; article; attitude to health; child; clinical article; cohort analysis; coping behavior; female; human; male; mental health; mental health service; personal experience; priority journal; psychological resilience; qualitative analysis; school child; social media; suicide attempt; transgender; video game

Family, School, and Peer Support Are Associated With Rates of Violence Victimization and Self-Harm Among Gender Minority and Cisgender Youth - Ross-Reed, D.E.; Reno, J.; Peñaloza, L.; Green, D.; FitzGerald, C. (Journal of Adolescent Health, 2019)
Purpose: Gender minority (GM) youth experience high rates of violence, and research on protective factors to reduce violence victimization and self-harm is lacking. The purpose of this study was to determine how family, school, peer, and community support influenced rates of violence victimization and self-harm among GM and cisgender adolescents. Methods: This research uses data from the 2017 New Mexico Youth Risk and Resiliency Survey (N = 18,451). The main independent variable was gender, dichotomized into GM and cisgender, and the secondary independent variables were family, school, community, and peer support. Dependent variables were sexual and dating violence, suicide attempts, and nonsuicidal self-injury. Logistic regression models were built for the four dependent variables, including demographics, support scores, and interaction terms between gender and support. Results: Six percent of high school students in New Mexico identified as GM are unsure of their gender. GM students experienced higher rates of violence and self-harm and lower levels of support than cisgender students. Among all students, family support was associated with lower odds of sexual violence and self-harm, while school support was associated with lower odds of dating violence and nonsuicidal self-injury. There were significant interactions between gender, violence, and support. The protective effects of support were less pronounced for GM students than for cisgender students. Conclusions: Family and school support are associated with lower rates of some forms of violence and self-harm among adolescents. Additional support may be necessary to reduce harm among GM adolescents, who are at higher risk for violence and its sequelae.
Keywords: adolescent; article; automutilation; crime victim; cross-sectional study; dating violence; family; female; gender identity; high risk behavior; high school; high school student; human; major clinical study; male; New Mexico; peer group; priority journal; school; sexual and gender minority; sexual violence; social support; suicide attempt; transgender

Drug-related and psychopathological symptoms in HIV-positive men who have sex with men who inject drugs during sex (slamsex): Data from the U-SEX GESIda 9416 study - Dolengevich-Segal, H.; Gonzalez-Baeza, A.; Valencia, J.; Valencia-Ortega, E.; Cabello, A.; Tellez-Molina, M.J.; Perez-Elias, M.J.; Serrano, R.; Perez-Latorre, L.; Martin-Carbonero, L.; Arponen, S.; Sanz-Moreno, J.; et al. (PLoS ONE, 2019)
Objectives Sexualized intravenous drug use, also known as slamsex, seems to be increasing among HIV-positive men who have sex with men (MSM). Physical and psychopathological symptoms have previously been reported in this population, although research on the subject of slamsex is scarce. The objectives of our study were to describe the psychopathological background of a sample of HIV-positive MSM who engaged in slamsex during the previous year and to compare physical, psychopathological, and drug-related symptoms between these participants and those who engaged in non-injecting sexualized drug use. Design and methods Participants (HIV-positive MSM) were recruited from the U-Sex study in 22 HIV clinics in Madrid during 2016–17. All participants completed an anonymous cross-sectional online survey on sexual behavior and recreational drug use. When participants met the inclusion criteria, physicians offered them the opportunity to participate and gave them a card with a unique code and a link to access the online survey. The present analysis is based on HIV-positive MSM who had engaged in slamsex and non-injecting sexualized drug use. Results The survey sample comprised 742 participants. Of all the participants who completed the survey, 216 (29.1%) had engaged in chemsex, and of these, 34 (15.7%) had engaged in slamsex. Participants who engaged in slamsex were more likely to have current psychopathology (depression, anxiety, and drug-related disorders) than participants who engaged in non-injecting sexualized drug use. In addition, participants who engaged in slamsex more frequently reported high-risk sexual behaviors and polydrug use and were more often diagnosed with sexually transmitted infections (STIs) and hepatitis C than those who did not inject drugs. Compared with participants who did not inject drugs, participants who engaged in slamsex experienced more severe drug-related symptoms (withdrawal and dependence), symptoms of severe intoxication (loss of consciousness), and severe psychopathological symptoms during or after slamsex (eg, paranoid thoughts and suicidal behaviors). Conclusion Slamsex is closely associated with current psychiatric disorders and severe drug-related and psychiatric symptoms.
Keywords: 4' methylmethcathinone; cathinone; cocaine; ketamine; methamphetamine; adult; anxiety; article; controlled study; cross-sectional study; depression; disease severity; drug dependence; drug induced disease; drug use; health survey; hepatitis C; human; Human immunodeficiency virus infection; injection drug user; major clinical study; male; men who have sex with men; mental disease; online system; paranoia; personal experience; physician; population research; recreation; sexual behavior; sexual intercourse; sexually transmitted disease; Spain; suicidal behavior; unconsciousness; withdrawal syndrome

Awareness, willingness to use, and history of HIV PrEP use among gay, bisexual, and other men who have sex with men in Nigeria - Ogunbajo, A.; Iwuagwu, S.; Williams, R.; Biello, K.; Mimiaga, M.J. (PLoS ONE, 2019)
Background Nigerian gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV, with an estimated prevalence of between 11-35%. Pre-exposure prophylaxis (PrEP) has the potential to significantly decrease incident HIV infections among Nigerian GBMSM. Understanding the relationship between socio-demographic, sexual risk behavior, and psychosocial factors with PrEP awareness, willingness to use, and history of use among this group is pivotal to maximizing PrEP uptake. Methods Between March and June 2019, 419 participants completed an interviewer-administered survey assessing PrEP awareness, willingness to use, and history of use; socio-demographics; sexual risk behavior; and psychosocial factors. Bivariate and multivariable logistic regression were used to examine factors associated with PrEP awareness, willingness to use, and history of use. Results 53.6% were aware of PrEP; 80.1% were willing to use PrEP; and 29.7% had previously used PrEP. In multivariable analysis, factors associated with an increased odds of PrEP awareness include residing in Abuja [adjusted odds ratio (aOR) 5.02; 95% confidence interval (CI): 2.13 to 11.83] and Lagos (aOR 12.30; 95% CI: 4.92 to 30.67) vs. residing in Plateau, living with HIV (aOR 2.56; 95% CI: 1.54 to 4.72), using location-based apps for seeking sexual partners (aOR 4.06; 95% CI: 2.28 to 7.24), having health insurance (aOR 2.31; 95% CI: 1.08 to 4.40), history of suicidal thoughts (aOR 2.05; 95% CI: 1.02 to 4.10), and history of PrEP use (aOR 45.5; 95% CI: 5.60 to 370.04). Decreasing clinically significant depressive symptoms was associated with lower willingness to use PrEP (aOR 0.96; 95% CI: 0.92 to 0.99). Lastly, factors associated with increased odds of having a history of PrEP use were those reporting 6 or more insertive anal sex acts in the last 30 days compared to those with none (aOR 5.76; 95% CI: 1.58 to 20.98) and being aware of PrEP (aOR 29.6; 95% CI: 3.78 to 231.84). Discussion Nearly half of the Nigerian GBMSM in this study had no prior awareness of PrEP, but after being informed about its potential benefits, the majority were willing to use it. However, PrEP uptake among Nigerian GBMSM remains low. Findings suggest that educational messages are necessary to ensure appropriate PrEP scale-up, especially tailored towards Nigerian GBMSM.
Keywords: adult; anal intercourse; article; bivariate analysis; controlled study; demography; health insurance; human; Human immunodeficiency virus infected patient; LGBT people; male; men who have sex with men; multivariate logistic regression analysis; Nigeria; Nigerian; pre-exposure prophylaxis; sexual behavior; social psychology

"I Never Saw a Future": Childhood Trauma and Suicidality Among Sexual Minority Women - Creighton, G.M.; Oliffe, J.L.; Broom, A.; Rossnagel, E.; Ferlatte, O.; Darroch, F. (Qualitative health research, 2019)
While a significant health concern for sexual minority women, there is little qualitative research investigating their experiences of childhood trauma and suicidality. In this study, we used photovoice methods and an intersectionality framework. Drawing on qualitative interviews, we inductively derived three themes (a) Traumatized and discredited, (b) Cascading marginality, estrangement, and suicidality, (c) Reconstruction and reclaiming resilience. In Traumatized and discredited, we describe the sense of abandonment flowing from childhood trauma heightened by a lack of protection and neglect on the part of parents/guardians. The lack of support to deal with childhood trauma and the layering effects of marginality characterizes the theme Cascading marginality, estrangement, and suicidality. In the third theme, we discuss strategies for reconstruction and reclaiming resilience as participants worked to overcome these challenging experiences. Our study findings offer guidance to suicide prevention counseling programs for sexual minority women and affirm actions to address health inequities.
Keywords: adolescent; adult; Canada; child; child abuse survivor; child sexual abuse; female; human; psychology; sexual and gender minority; suicidal ideation; suicide attempt; young adult

Mental health, social support, and HIV-related sexual risk behaviors among HIV-negative adolescent sexual minority males: three U.S. cities, 2015 - Agnew-Brune, C.B.; Balaji, A.B.; Mustanski, B.; Newcomb, M.E.; Prachand, N.; Braunstein, S.L.; Brady, K.A.; Hoots, B.E.; Smith, J.S.; Paz-Bailey, G.; Broz, D. (AIDS and behavior, 2019)
We examined the association between mental health issues, social support, and HIV among adolescent sexual minority males (SMM), who are disproportionally affected by HIV. National HIV Behavioral Surveillance among Young Men Who Have Sex with Men (NHBS-YMSM) data among SMM aged 13-18 years were collected in three cities (Chicago, New York City, and Philadelphia). Separate log-linked Poisson regression models were used to estimate associations between mental health issues and social support (general and family), and 3 HIV-related sexual risk behavior outcomes: past-year condomless anal intercourse (CAI) with a male partner, past-year sex with ≥ 4 partners, and first vaginal or anal sex before age 13. Of 547 adolescent SMM, 22% reported ever attempting suicide and 10% reported past-month suicidal ideation. The majority (52%) reported depression and anxiety. Thirty-nine percent reported CAI, 29% reported ≥ 4 sex partners and 22% reported first sex before age 13. Ever attempting suicide, suicidal ideation, and depression and anxiety were associated with CAI. Separately, ever attempting suicide and lack of family support were associated with  ≥ 4 sex partners. None of the mental health or support measures were associated with having sex before age 13. General social support was not associated with any sexual risk behaviors. Mental health issues are common among adolescent SMM and associated with sexual risk behaviors. Including mental health support in comprehensive HIV prevention for adolescent SMM could potentially reduce HIV risk in this population.
Keywords: adolescent; anxiety; depression; high risk behavior; human; Human immunodeficiency virus infection; Illinois; male; male homosexuality; mental health; New York; Pennsylvania; sexual and gender minority; sexual behavior; sexuality; social support; suicidal ideation; suicide attempt

Sexual Orientation and the Integrated Motivational-Volitional Model of Suicidal Behavior: Results from a Cross-Sectional Study of Young Adults in the United Kingdom - Rasmussen, S.; Cramer, R.J.; McFadden, C.; Haile, C.R.; Sime, V.L.; Wilsey, C.N. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2019)
Sexual orientation minority (i.e., lesbian, gay, bisexual, queer, and other; LGBQ+) persons represent a vulnerable population with respect to suicide-related behavior. An emerging theory of suicide, the Integrated Motivational-Volitional Model of Suicide (IMV), is utilized in the present study to examine sexual orientation, as well as a number of other IMV-defined pre-motivational factors (i.e., demographics, psychological distress and personality), as they impact the IMV motivational factors of defeat, entrapment, and suicidal ideation/intent. The present investigation featured a cross-sectional online survey of young adults (ages 18-34 years; n = 418; 27% identified as LGBTQ+) across the United Kingdom. The key findings included: (1) high rates of 12-month suicidal ideation prevalence (54.5%) and willingness to enact a future suicide attempt (60.8%); (2) bisexual and other (e.g., pansexual)-identifying sexual minority persons reported higher levels of IMV-related outcomes (e.g., internal entrapment, defeat); (3) sexual orientation accounted for significant variance in predicting motivational constructs controlling for a number of other pre-motivational factors; (4) other sexual minority status, compared to heterosexual identity, predic all motivational outcomes, and; (5) extraversion, agreeableness, and emotional stability emerged as pre-motivational protective factors for varying motivational outcomes. Findings are discussed with respect to the suicide and sexual minority theories, as well as tailored suicide prevention efforts and future research.
Keywords: adult; article; bisexuality; controlled study; cross-sectional study; emotional stability; extraversion; female; heterosexuality; human; major clinical study; male; mental stress; prevalence; prevention; sexual and gender minority; suicidal ideation; suicide attempt; theoretical study; United Kingdom; young adult

Sexual orientation and complete mental health - Gilmour, H. (Health reports, 2019)
BACKGROUND: Previous research indicates that lesbian, gay and bisexual individuals have poorer mental health than their heterosexual counterparts. The concept of complete mental health, which combines the presence of positive mental health and the absence of mental disorder, has not been thoroughly examined in this population. DATA AND METHODS: Data from the 2015 Canadian Community Health Survey (CCHS) were used to estimate the number and percentage of men and women aged 15 and older who self-identify as lesbian, gay, bisexual, or heterosexual. Complete mental health was defined as the presence of flourishing mental health together with the absence of any self-reported mood disorder, anxiety disorder or suicide ideation in the previous 12 months. Multivariate logistic regression models stratified by sex were used to identify differences in complete mental health among gay, lesbian, bisexual, and heterosexual individuals. RESULTS: In 2015, an estimated 252,000 (1.9%) Canadian men identified as gay and 145,000 (1.1%) as bisexual, while 153,000 Canadian women (1.1%) identified as lesbian and 299,000 (2.2%) as bisexual. Gay men had significantly lower unadjusted odds of complete mental health, but this association was no longer significant when controlling for sociodemographic and health factors. The likelihood of complete mental health was not significantly different for lesbians than for heterosexual women. Both bisexual men and bisexual women had significantly lower odds of complete mental health in the fully adjusted models. DISCUSSION: Awareness of poorer mental health outcomes, particularly for bisexual individuals, can help guide specific interventions aimed at improving the mental health and well-being of sexual minority populations.
Keywords: adolescent; adult; aged; anxiety disorder; bisexuality; Canada; female; health survey; human; lesbianism; male; male homosexuality; mental disease; mental health; middle aged; mood disorder; psychology; sexual and gender minority; statistical model; suicidal ideation; very elderly; young adult

Sounding the Alarm: Perinatally HIV-Infected Youth More Likely to Attempt Suicide Than Their Uninfected Cohort Peers - Kreniske, P.; Mellins, C.A.; Dolezal, C.; Korich, R.; Leu, C.-S.; Wiznia, A.; Abrams, E.J. (Journal of Adolescent Health, 2019)
Purpose: Suicide is the second leading cause of death among youth in the U.S., yet there are few studies on suicide among youth with perinatally acquired HIV infection (YPHIV). Our aim was to determine if suicide attempts differed for YPHIV compared with perinatally HIV-exposed but uninfected peers (YPHEU). Methods: Data come from a longitudinal behavioral health cohort (N = 340) of YPHIV (n = 206) and YPHEU (n = 134) recruited between ages 9 and 16 years and interviewed with psychosocial batteries every 12–18 months. Logistic regression analyses were conducted to assess the association between reported suicide attempt and participants' HIV status. We assessed whether baseline demographic characteristics and sexual orientation were potential confounding factors. Fisher's exact tests were used to evaluate the association between first attempted suicide and HIV status within age groups. Results: YPHIV were more likely to make a suicide attempt than YPHEU (odds ratio = 2.35, 95% confidence interval = 1.28–4.34). Youth most often reported their first attempt between the ages of 14–18 years. Demographic characteristics and sexual orientation were not associated with attempted suicide. Conclusions: YPHIV compared with YPHEU were more likely to report a suicide attempt, and this difference emerged during late adolescence and persisted through young adulthood.
Keywords: adolescent; adolescent health; adult; article; cause of death; child; cohort analysis; controlled study; female; human; Human immunodeficiency virus infected patient; Human immunodeficiency virus infection; longitudinal study; major clinical study; male; perinatal infection; priority journal; sexual orientation; suicide; suicide attempt; transition to adult care

A new theory of gender dysphoria incorporating the distress, social behavioral, and body-ownership networks - Gliske, S.V. (eNeuro, 2019)
When postmortem studies related to transgender individuals were first published, little was known about the function of the various identified nuclei. Now, over 2 decades later, significant progress has been made associating function with specific brain regions, as well as in identifying networks associated with groups of behaviors. However, much of this progress has not been integrated into the general conceptualization of gender dysphoria in humans. I hypothesize that in individuals with gender dysphoria, the aspects of chronic distress, gender atypical behavior, and incongruence between perception of gender identity and external primary sex characteristics are all directly related to functional differences in associated brain networks. I evaluated previously published neuroscience data related to these aspects and the associated functional networks, along with other relevant information. I find that the brain networks that give individuals their ownership of body parts, that influence gender typical behavior, and that are involved in chronic distress are different in individuals with and without gender dysphoria, leading to a new theory—that gender dysphoria is a sensory perception condition, an alteration in the sense of gender influenced by the reflexive behavioral responses associated with each of these networks. This theory builds upon previous work that supports the relevance of the body-ownership network and that questions the relevance of cerebral sexual dimorphism in regard to gender dysphoria. However, my theory uses a hierarchical executive function model to incorporate multiple reflexive factors (body ownership, gender typical/atypical behavior, and chronic distress) with the cognitive, reflective process of gender identity.
Keywords: estrogen; testosterone; anterior insula; anxiety; article; bed nucleus of the stria terminalis; body ownership; circadian rhythm; depression; distress syndrome; gender dysphoria; gender identity; homosexuality; human; hypothalamus; intraparietal sulcus; mate choice; nerve cell network; nonhuman; orbital cortex; priority journal; puberty; self concept; sensation; sex difference; sex role; social behavior; stria terminalis; suicidal ideation; superior parietal lobule

Suicidality disparities between transgender and cisgender adolescents - Thoma, B.C.; Salk, R.H.; Choukas-Bradley, S.; Goldstein, T.R.; Levine, M.D.; Marshal, M.P. (Pediatrics, 2019)
BACKGROUND AND OBJECTIVES: Emerging evidence indicates transgender adolescents (TGAs) exhibit elevated rates of suicidal ideation and attempt compared with cisgender adolescents (CGAs). Less is known about risk among subgroups of TGAs because of limited measures of gender identity in previous studies. We examined disparities in suicidality across the full spectrum of suicidality between TGAs and CGAs and examined risk for suicidality within TGA subgroups. METHODS: Adolescents aged 14 to 18 completed a cross-sectional online survey (N = 2020, including 1148 TGAs). Participants reported gender assigned at birth and current gender identity (categorized as cisgender males, cisgender females, transgender males, transgender females, nonbinary adolescents assigned female at birth, nonbinary adolescents assigned male at birth, and questioning gender identity). Lifetime suicidality (passive death wish, suicidal ideation, suicide plan, suicide attempt, and attempt requiring medical care) and nonsuicidal self-injury were assessed. RESULTS: Aggregated into 1 group, TGAs had higher odds of all outcomes as compared with CGAs. Within TGA subgroups, transgender males and transgender females had higher odds of suicidal ideation and attempt than CGA groups. CONCLUSIONS: In this study, we used comprehensive measures of gender assigned at birth and current gender identity within a large nationwide survey of adolescents in the United States to examine suicidality among TGAs and CGAs. TGAs had higher odds of all suicidality outcomes, and transgender males and transgender females had high risk for suicidal ideation and attempt. Authors of future adolescent suicidality research must assess both gender assigned at birth and current gender identity to accurately identify and categorize TGAs.
Keywords: adolescent; adult; article; automutilation; cisgender; cross-sectional study; data analysis; demography; documentation; female; gender; gender identity; health survey; human; male; medical care; online analysis; priority journal; risk factor; secondary analysis; sex difference; suicidal behavior; suicidal ideation; suicide attempt; transgender

Perceived Barriers to Mental Health Services Among Canadian Sexual and Gender Minorities with Depression and at Risk of Suicide - Ferlatte, O.; Salway, T.; Rice, S.; Oliffe, J.L.; Rich, A.J.; Knight, R.; Morgan, J.; Ogrodniczuk, J.S. (Community mental health journal, 2019)
This study examines barriers to mental health services among sexual and gender minorities (SGM) who screened positive for depression and risk of suicide. Data from an online survey of SGM (N = 2778) are analyzed. 37.5% met criteria for depression and 73.6% screened for being at risk of suicide. The most frequently cited barriers to mental health services access were inability to pay (62.3%), insufficient insurance (52.2%), a preference for 'waiting' for the problems to go away (51.5%), discomfort discussing emotions (45.7%), and feeling embarrassed and ashamed about mental health challenges (42.5%). Policy and practices implications of these findings are discussed.
Keywords: adolescent; adult; Canada; depression; female; health care delivery; human; male; middle aged; psychology; questionnaire; risk factor; sexual and gender minority; suicide; young adult

Mediators of increased self-harm and suicidal ideation in sexual minority youth: a longitudinal study - Oginni, O.A.; Robinson, E.J.; Jones, A.; Rahman, Q.; Rimes, K.A. (Psychological medicine, 2019)
BACKGROUND: Sexual minority youth have elevated suicidal ideation and self-harm compared with heterosexual young people; however, evidence for mediating mechanisms is predominantly cross-sectional. Using a longitudinal design, we investigated self-esteem and depressive symptoms as mediators of increased rates of suicidal ideation or self-harm (SISH) among sexual minority youth, and the roles of childhood gender nonconformity (CGN) and sex as moderators of these relationships. METHOD: In total, 4274 youth from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort reported sexual orientation at age 15 years, and past-year SISH at age 20 years. Self-esteem and depressive symptoms were assessed at ages 17 and 18 years, respectively. CGN was measured at 30-57 months. Covariates included sociodemographic variables and earlier measures of mediator and outcome variables. Mediation pathways were assessed using structural equation modelling. RESULTS: Sexual minority youth (almost 12% of the sample) were three times more likely than heterosexual youth to report past-year SISH (95% confidence interval 2.43-3.64) at 20 years. Two mediation pathways were identified: a single mediator pathway involving self-esteem and a multiple-mediated pathway involving self-esteem and depressive symptoms. Although CGN was associated with past-year SISH, it did not moderate any mediation pathways and there was no evidence for moderation by sex. CONCLUSIONS: Lower self-esteem and increased depressive symptoms partly explain the increased risk for later suicidal ideation and self-harm in sexual minority youth. Preventive strategies could include self-esteem-enhancing or protecting interventions, especially in female sexual minority youth, and treatment of depression.
Keywords: adolescent; automutilation; depression; female; heterosexuality; human; longitudinal study; male; psychology; risk factor; self concept; sexual and gender minority; statistical model; suicidal ideation; United Kingdom; young adult

Stigma in the bereavement experiences of gay men who have lost a partner to suicide - Ferlatte, O.; Oliffe, J.L.; Salway, T.; Knight, R. (Culture, health & sexuality, 2019)
Despite the high prevalence of suicide in gay communities, the impact of suicide on surviving male partners is poorly understood. This article presents a qualitative case study of two gay men who lost a partner to suicide and explores how stigma may shape gay men's bereavement experiences. Data were collected using photovoice methods and analysed using a thematic approach. Five themes were inductively derived: (1) trying to prevent the inevitable; (2) guilty of keeping secrets; (3) dreams shattered by suicide; (4) abandoned and alone in grief; and (5) a lonesome road to recovery. Within each theme, the article indentifies how stigma-related challenges associated with suicide, mental illness and minority sexual identity shaped gay men's bereavement experiences. Practice and policy implications are discussed, including how the provision of tailored clinical and peer supports can assist gay men in the bereavement of a same-sex partner to suicide. The findings detailed in this study highlight the need for interventions to de-stigmatise mental illness and suicide within and outside the gay community.
Keywords: adult; bereavement; human; male; male homosexuality; patient attitude; photography; psychology; qualitative research; sexuality; social stigma; suicide

Examining risk factors for self-harm and suicide in LGBTQ+ young people: A systematic review protocol - Williams, A.J.; Arcelus, J.; Townsend, E.; Michail, M. (BMJ Open, 2019)
Introduction Young people who identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ+) are at increased risk for self-harm, suicide ideation and behaviours. However, there has yet to be a comprehensive understanding of what risk factors influence these behaviours within LGBTQ+ young people as a whole. The purpose of this systematic review is to examine risk factors associated with self-harm, suicidal ideation and behaviour in LGBTQ+) young people. Methods and analysis A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (MEDLINE, Scopus, EMBASE, PsycINFO and Web of Science) will be systematically searched for cross-sectional, prospective, longitudinal, cohort and case-control designs which examine risk factors for self-harm and/or suicidal ideation and behaviour in LGBTQ+ young people (aged 12-25 years). Only studies published in English will be included. No date restrictions will be applied. Study quality assessment will be conducted using the original and modified Newcastle-Ottawa Scales. Meta-analysis or narrative synthesis will be used, dependent on findings. Ethics and dissemination This is a systematic review of published literature and thereby ethical approval was not sought. The review will be submitted to a peer-reviewed journal, be publicly disseminated at conferences focusing on mental health, self-harm and suicide prevention. The findings will also be shared through public engagement and involvement, particularly those related to young LGBTQ+ individuals.
Keywords: article; automutilation; case control study; cohort analysis; cross-sectional study; Embase; human; LGBT people; longitudinal study; Medline; Newcastle-Ottawa scale; practice guideline; prospective study; PsycINFO; risk factor; Scopus; suicide; systematic review; Web of Science

Internalized Homophobia, Depressive Symptoms, and Suicidal Ideation Among Lesbian, Gay, and Bisexual Adults in South Korea: An Age-Stratified Analysis - Lee, H.; Operario, D.; Yi, H.; Choo, S.; Kim, S.-S. (LGBT health, 2019)
Purpose: Little research on internalized homophobia (IHP) and mental health among lesbian, gay, and bisexual (LGB) individuals has been done in South Korea, a context in which LGB populations widely experience societal stigma. This study examined the association between IHP and depressive symptoms and suicidal ideation among Korean LGB adults and investigated whether the association differed by participants' age. Methods: Cross-sectional data from the "Rainbow Connection Project I - Korean Lesbian, Gay, & Bisexual Adults' Health Study" were used for this study (N = 2178). Descriptive analyses were conducted to explore the distribution of IHP, depressive symptoms, and suicidal ideation across all covariates. Multivariate analyses were also used to investigate the overall and age-stratified associations between IHP and depressive symptoms and suicidal ideation. Results: The prevalence of high IHP was greater among older LGB adults, whereas the prevalence of depressive symptoms and suicidal ideation was higher among younger LGB adults. LGB individuals with high IHP levels had significantly greater risk of depressive symptoms than those with low IHP levels. In the age-stratified analyses, the associations between IHP and depressive symptoms were statistically significant only among older LGB adults with high IHP levels. Regarding suicidal ideation, the overall association was statistically significant in the full sample, but not in the age-stratified analyses. Conclusion: These findings suggest that mental health interventions are needed for LGB adults who have high IHP levels, especially among older generations. Furthermore, greater efforts are needed to enact protective legislation for sexual minority individuals in South Korea.
Keywords: adult; age; aged; cross-sectional study; depression; female; homophobia; human; male; mental health; middle aged; psychology; risk factor; sexual and gender minority; social stigma; socioeconomics; South Korea; suicidal ideation; young adult

Sexual assault, sense of belonging, depression and suicidality among LGBQ and heterosexual college students - Backhaus, I.; Lipson, S.K.; Fisher, L.B.; Kawachi, I.; Pedrelli, P. (Journal of American college health : J of ACH, 2019)
Objective: To compare the effect of sexual orientation, history of sexual assault and sense of belonging on depression and suicidality among lesbian, gay, bisexual, queer and questioning (LGBQ) and heterosexual students. Participants: A total of 60,194 students from 60 US campuses who participated in the 2017-2018 Healthy Minds Study. Methods: Three-way interaction effects were analyzed using PROCESS macro models in SPSS. Results: Significant three-way interaction effects were found for sexual orientation, sexual assault and sense of belonging predicting depressive symptoms (b = -0.06, p= 0.042, CI: -0.12 to -0.00), and suicidality (b = -0.10, p= 0.004, CI: -0.01 to -0.003). The effect of sexual assault on mental health differed depending on sexual orientation and sense of belonging. Particularly among LGBQ students, high sense of belonging was protective in the presence of sexual assault, and its absence had a deleterious effect on mental health. Conclusion: Enhancing sense of belonging may represent a strategy to mitigate depression and promote suicide prevention, particularly among LGBQ students.
Keywords: adult; article; college student; controlled study; depression; female; heterosexuality; human; major clinical study; male; mental health; prevention; sexual assault; suicide

Suicidality among Gender Minority Youth: Analysis of 2017 Youth Risk Behavior Survey Data - Jackman, K.B.; Caceres, B.A.; Kreuze, E.J.; Bockting, W.O. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2019)
We examined differences in suicidality based on gender identity while adjusting for known suicide risk factors in a sample of United States adolescents. Using data from the 2017 Youth Risk Behavior Survey we used logistic regression models to examine three suicide-related outcomes. Youth were categorized as transgender (1.3%), gender-questioning (1.4%), or cisgender (97.3%). In fully adjusted models, compared to cisgender youth, transgender youth had 2.71 (95% CI 1.50-4.92) higher odds of past-year suicide attempts and 2.54 (95% CI 1.05-6.15) higher odds of past-year suicide attempts requiring treatment. Gender-questioning youth had 2.31 (95% CI 1.48-3.60) higher odds of past-year suicidal ideation compared to cisgender youth. Policies and interventions are needed to reduce suicidality among gender minority youth, improve access to mental healthcare, and reduce peer victimization and substance use.
Keywords: adolescent; article; controlled study; female; gender identity; human; juvenile; male; mental health; risk factor; substance use; suicidal ideation; suicide attempt; transgender; United States

Application of an intersectional framework to understanding the association of disability and sexual orientation with suicidal ideation among Oregon Teens - Higgins Tejera, C.; Horner-Johnson, W.; Andresen, E.M. (Disability and Health Journal, 2019)
Background: Suicide is the second leading cause of death among U.S. youth. Prior research has found that disability and sexual orientation are each independently associated with suicide risk. However, most analyses regarding sexual orientation or disability in relation to teenagers’ health have isolated the effects of these identities via multiple regression models. That approach assumes there is no multiplicative or synergistic effect between the two identities. Objective: To examine the association between suicidal ideation and the intersection of disability and sexual orientation. Methods: Cross-sectional data from the 2015 Oregon Healthy Teens Survey were analyzed using Poisson regression analysis with robust variance to estimate the relationship between the intersection of disability and sexual orientation and youth reports of suicidal ideation. We calculated three measures of interaction: 1) the excess risk due to interaction (RERI); 2) the proportion attributable to interaction (AP); and 3) the synergy index (SI). Results: Sexual minority teenagers with disabilities had higher risk of suicidal ideation (adjusted relative risk [ARR] = 2.82, 95% CI: 2.47–3.21) with respect to heterosexual teenagers without disabilities. The risk was also elevated, to a lesser degree, for heterosexual youth with disabilities (ARR = 1.97, 95% CI: 1.78–2.19) and LGB youth without disabilities (ARR = 2.17, 95% CI: 1.95–2.42) with respect to the reference group. Our measures of interaction were indicative of a synergistic effect between disability and sexual orientation. Conclusions: Our findings suggest the combination of disability and minority sexual orientation may be associated with compounded negative experiences that could exacerbate the risk of suicide.
Keywords: adolescent; article; bisexuality; child psychiatry; controlled study; cross-sectional study; disability; disabled person; disease association; female; gender identity; heterosexuality; high risk population; homosexual female; homosexual male; human; major clinical study; male; minority group; Oregon; personal experience; prevalence; priority journal; risk factor; sexual and gender minority; sexual orientation; suicidal ideation

“TRANS”-questionnaire (TRANS-Q): a novel, validated pre- and postoperative satisfaction tool in 145 patients undergoing gender confirming mastectomies - Wanta, J.; Gatherwright, J.; Knackstedt, R.; Long, T.; Medalie, D.A. (European Journal of Plastic Surgery, 2019)
Keywords: anxiety; article; breast reduction; chronic pain; depression; female; follow up; human; Likert scale; major clinical study; mastectomy; mental health; patient satisfaction; postoperative period; priority journal; questionnaire; reliability; sexual behavior; sexual satisfaction; sexuality; suicide attempt; transgender; transgender specific preoperative survey; validation process

Sexual minority status and child maltreatment: How do health outcomes among sexual minority young adults differ due to child maltreatment exposure? - Paul, J.C.; Monahan, E.K. (Child Abuse and Neglect, 2019)
Background: Although prior studies indicate heightened health and well-being concerns for sexual minority (SM) youth, as well as for youth exposed to child maltreatment in the general population, it is unclear whether there are differences in these outcomes among SM youth that have and have not experienced maltreatment. Objective: Our aim was to investigate the unique associations between child maltreatment and emerging health outcomes beyond the impact of SM status. Data was drawn from a nationally representative sample of 648 SM youth in the U.S. in grades 7–12 during the 1994–1995 school year. Methods: Using data from the National Longitudinal Study of Adolescent to Adult Health, descriptive statistics and ordinary least squares regression models were used to investigate differences in SM young adult outcomes by experiences of child maltreatment. Results: Maltreatment among SM individuals showed strong associations with poor adult mental health outcomes (e.g. depression, anxiety, isolation, and suicidal ideation) and fairly strong negative associations with general health outcomes (e.g., heart and lung problems) when compared to their non-maltreated peers. Associations with maltreatment and behavioral health and socioeconomic outcomes were not as strong for this population, which suggests the effects of maltreatment for SM youth are most salient in regards to mental and physical health. Conclusions: Findings provide insight into what areas of health and well-being should be focused on when working with SM youth that have been maltreated, and offer evidence to encourage further exploration of the outcomes of SM maltreated individuals in young adulthood.
Keywords: adolescent; adult; adulthood; article; behavioral research; child; child abuse; controlled study; criminal behavior; descriptive research; disease association; educational status; employment status; evidence based practice; exposure to violence; female; health behavior; health disparity; health status; human; longitudinal study; male; mental health; peer pressure; physical capacity; political participation; population research; psychological well-being; risk assessment; sexual and gender minority; sexual behavior; sexual orientation; socioeconomics; substance use; United States; young adult

HIV self-testing among men who have sex with men in China: A qualitative implementation research study - Liu, F.; Qin, Y.; Meng, S.; Zhang, W.; Tang, W.; Han, L.; Liu, C.; Zhang, Y.; Huang, S.; Zheng, H.; Yang, B.; Tucker, J.D. (Journal of Virus Eradication, 2019)
Background: HIV self-testing (HIVST) may expand HIV testing, but there have been few pilot programmes among men who have sex with men (MSM). This purpose of this study was to evaluate HIVST implementation among MSM in China using qualitative methods. Methods: We undertook semistructured interviews among MSM and those organising HIVST programmes for MSM. Purposive sampling method was used to ensure men with different HIV serostatuses, ages and HIVST frequencies were included. Men were recruited from MSM community-based organisations and a local HIV clinic. An implementation science framework was used to interpret the findings. Two individuals used a standard code-based methodology to identify themes. Results: Forty-two MSM and six stakeholders were interviewed. Our data showed many MSM and stakeholders preferred HIVST to facility-based testing. Most men reported that HIVST empowered MSM and informed sexual decision making. Many men noted that decreasing the HIVST price may increase demand. Some men noted that HIVST could be scaled up through social media and by modifying bulky packaging. Minimal adverse events were reported. Conclusions: HIVST may expand HIV testing and promote empowerment of MSM. Minimal adverse outcomes were noted, but further implementation research is needed.
Keywords: HIV test; adult; adverse outcome; article; bisexuality; China; clinical article; decision making; distress syndrome; homosexual male; human; Human immunodeficiency virus infection; implementation science; male; men who have sex with men; methodology; packaging; partner violence; persuasive communication; pilot study; qualitative research; scale up; self evaluation; semi structured interview; social media; suicide; young adult

Mental health disparities and high-risk alcohol use among non-heterosexual high school students - Goodin, A.; Elswick, A.; Fallin-Bennett, A. (Perspectives in psychiatric care, 2019)
PURPOSE: To examine disparities in mental health and high-risk alcohol use among high school students by sexual orientation, and the impact of having access to an adult with whom to talk. DESIGN AND METHODS: Cross-sectional survey, from the 2015 Kentucky Youth Risk Behavior Survey. Logistic regression estimated the relationship between being "non-heterosexual" on mental health (e.g, suicidal ideation/attempt) and alcohol behaviors (e.g, binge drinking), controlling for demographics and "having an adult to talk to." FINDINGS: Non-heterosexual students were more likely to report all adverse outcomes and risk was lower among students who report "having an adult to talk to." PRACTICE IMPLICATIONS: Psychiatric nurses need to assess sexual minority youth for access to positive adult relationships.
Keywords: adolescent; adolescent behavior; alcoholism; cross-sectional study; female; health disparity; high risk behavior; human; human relation; Kentucky; male; mental health; risk; sexual and gender minority; student; suicidal ideation; suicide attempt; underage drinking

Higher Educational Attainment is Associated with Lower Risk of a Future Suicide Attempt Among Non-Hispanic Whites but not Non-Hispanic Blacks - Assari, S.; Schatten, H.T.; Arias, S.A.; Miller, I.W.; Camargo, C.A.; Boudreaux, E.D. (Journal of racial and ethnic health disparities, 2019)
PURPOSE: In a sample of patients presenting to the emergency department (ED), the current study was conducted with two aims: (1) to investigate the protective effects of educational attainment (i.e., completing college) on subsequent risk of suicide attempt/death among patients presenting to the ED and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients. METHODS: The current study analyzed data from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study, a quasi-experimental, eight-center study of universal suicide screening and follow-up of ED patients presenting for suicidal ideation and behavior. Our sample included 937 non-Hispanic White and 211 non-Hispanic Blacks. The dependent variable was suicide attempt/death during the 52-week follow-up. The independent variable was completing college. Age, gender, lesbian/gay/bisexual status, psychiatric history, and previous suicide attempts at baseline were covariates. Race/ethnicity was the focal effect modifier. Logistic regression models were used to test the protective effects of educational attainment on suicide risk in the overall sample and by race/ethnicity. RESULTS: In the overall sample, educational attainment was not associated with suicide risk over the follow-up period. A significant interaction was found between race/ethnicity and educational attainment on suicide risk, suggesting a larger protective effect for non-Hispanic Whites compared with non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks. CONCLUSIONS: Consistent with the Minorities' Diminished Return theory, educational attainment better protected non-Hispanic White than non-Hispanic Blacks against future suicide attempt/death. While Whites who have not completed college may be at an increased risk of suicide, risk of suicide seems to be independent of educational attainment for non-Hispanic Blacks.
Keywords: adult; African American; Caucasian; educational status; ethnology; female; follow up; forecasting; hospital emergency service; human; male; middle aged; risk assessment; suicide attempt

Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment - Sevlever, M.; Meyer-Bahlburg, H.F.L. (Archives of sexual behavior, 2019)
The rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
Keywords: adolescent; affect; anxiety; case report; female; gender dysphoria; human; male; physiology; procedures; psychology; psychotherapy; transgender

Early roots of sexual-orientation health disparities: associations between sexual attraction, health and well-being in a national sample of Australian adolescents - Perales, F.; Campbell, A. (Journal of epidemiology and community health, 2019)
BACKGROUND: Research documents substantial adolescent health disparities by sexual orientation, but studies are confined to a small number of countries-chiefly the USA. We provide first-time evidence of associations between sexual orientation and adolescent health/well-being in a new country-Australia. We also add to knowledge by examining health/well-being outcomes not previously analysed in national samples, considering adolescents reporting no sexual attractions, and rank-ordering sexual-orientation health disparities by magnitude. METHODS: Data from an Australian national probability sample of 14/15 years old (Longitudinal Study of Australian Children, n=3318) and regression models adjusted for confounding and for multiple comparisons were used to examine the associations between sexual attraction and 30 outcomes spanning multiple domains of health/well-being-including socio-emotional functioning, health-related quality of life, depressive symptoms, health-related behaviours, social support, self-harm, suicidality, victimisation, self-concept, school belonging and global health/well-being assessments. RESULTS: Lesbian, gay, bisexual and questioning adolescents displayed significantly worse health/well-being than their heterosexual peers in all outcomes (p<0.05). The magnitude of the disparities ranged between 0.13 and 0.75 SD, and was largest in the domains of self-harm, suicidality, peer problems and emotional problems. There were fewer differences between the heterosexual and no-attraction groups. Worse outcomes were observed among both-sex-attracted adolescents compared with same-sex-attracted adolescents, and sexual-minority girls compared with sexual-minority boys. CONCLUSIONS: Consistent with the minority stress model and recent international scholarship, sexual-minority status is an important risk factor for poor adolescent health/well-being across domains in Australia. Interventions aimed at addressing sexual-orientation health disparities within Australian adolescent populations are urgently required.
Keywords: adolescent; adolescent health; Australia; automutilation; female; health disparity; human; longitudinal study; male; sexual and gender minority; sexual behavior

Intersectionality and Health Behaviors Among US High School Students: Examining Race/Ethnicity, Sexual Identity, and Sex - Gattamorta, K.A.; Salerno, J.P.; Castro, A.J. (The Journal of school health, 2019)
BACKGROUND: Little research exists examining the impact of multiple minority identities, particularly sexual orientation, race/ethnicity, and sex on health-risk behaviors like mental health, substance use, violence, and sexual risk among high school students in the United States. In this study, we use a nationally representative dataset to examine differences between non-Hispanic white heterosexuals (HSs) and non-Hispanic white sexual minority, black HS, black sexual minority, Hispanic HS, and Hispanic sexual minority students. METHODS: Data from the 2015 wave of the Youth Risk Behavioral Surveillance System were used in this study. Chi-square and hierarchical logistic regression models examined differences between the groups on outcomes including: (1) mental health and suicide, (2) alcohol, tobacco, and illicit substances, (3) sexual risk and protective factors, and (4) school and physical and/or sexual violence. RESULTS: Whereas sexual minority youth (SMY) generally demonstrate poorer health outcomes compared to HSs, SMY who are also racial/ethnic minorities often have even poorer health outcomes, particularly relating to substance use, sexual risk behaviors, physical/sexual violence, and suicide. CONCLUSIONS: The need for culturally tailored education and school-based interventions that consider intersections between race/ethnicity, sexual identity, and biological sex are warranted to address health disparities related to mental health and suicide, substance use, sexual risk, and violence.
Keywords: adolescent; African American; behavioral risk factor surveillance system; Caucasian; comparative study; drug dependence; epidemiology; ethnic group; ethnology; female; gender identity; health behavior; high risk behavior; Hispanic; human; male; minority group; psychology; sexual behavior; sexuality; suicidal ideation; United States; violence

School Climate & Sexual and Gender Minority Adolescent Mental Health - Colvin, S.; Egan, J.E.; Coulter, R.W.S. (Journal of youth and adolescence, 2019)
Sexual/gender minority (Sexual/gender minority people are also referred to as Lesbian, Gay, Bisexual, Transgender, Queer) youth are more likely than cisgender heterosexual youth to exhibit depressive symptoms and be victimized. School climate research indicates that the presence of a Gay-Straight Alliance (a Gay-Straight Alliance or Gender-Sexuality Alliance is also referred to as a GSA and is a youth group to support sexual/gender minority youth), a supportive school climate, and seeking help from teachers are associated with more positive mental health outcomes; however, they are not typically measured together. This study uses a survey that measures all four measures of school environment with a national sample of 240 sexual/gender minority high school students ages 14-18 (mean age 15.77) where 53% of participants had a Gay-Straight Alliance in their school. The sample is 53% cisgender, 100% sexual minority and 62% white. Adjusting for demographics and presence of a Gay-Straight Alliance, fewer depressive symptoms were associated with lower help-seeking intentions for suicidal thoughts. The presence of Gay-Straight Alliance was not statistically associated with past-month help-seeking intentions or behaviors. Additionally, a more supportive school climate was associated with lower anxiety and depressive symptoms. However, the presence of a Gay-Straight Alliance was not statistically associated with anxiety or depressive symptoms. These findings suggest that a supportive school climate and supportive school personnel may be important for supporting the mental health of sexual/gender minority students.
Keywords: adolescent; adolescent health; bisexuality; bullying; crime victim; female; heterosexuality; human; male; mental health; prejudice; psychology; school; sexual and gender minority; sexual behavior; sexuality; student

Relationship Status and Suicidal Behavior in Gay Men: The Role of Thwarted Belongingness and Hope - Riley, K.; McLaren, S. (Suicide & life-threatening behavior, 2019)
OBJECTIVE: Levels of suicidal behavior among gay men are a significant concern. The Interpersonal Theory of Suicide proposes that being unpartnered is a risk factor for suicidal behavior due to thwarted belongingness; however, this has yet to be tested empirically. Recent studies also indicate that the two components of hope, agency and pathways, may be protective against suicidal behavior. The first aim of the current study was to investigate whether thwarted belongingness mediates the relationship between relationship status and suicidal behavior in gay men. The study also examined whether agency and pathways weaken the association between relationship status and thwarted belongingness, and whether agency weakens the relation between thwarted belongingness and suicidal behavior. METHOD: A sample of 370 self-identified gay men aged from 18 to 66 years old (M = 26.13, SD = 8.02) completed the Suicidal Behaviors Questionnaire-Revised, the Interpersonal Needs Questionnaire-Revised, and the Adult Dispositional Hope Scale. RESULTS: Results showed that thwarted belongingness mediated the relationship between relationship status and suicidal behavior. The hypothesized moderated-mediation models were not supported. CONCLUSIONS: These findings have implications for the development of interventions that aim to reduce suicidal behaviors in gay men.
Keywords: adult; female; human; human relation; male; psychology; questionnaire; risk factor; sexual and gender minority; social behavior; suicidal ideation; suicide

The Relationship Between Suicide-Related Exposure and Personal History of Suicidal Behavior in Transgender and Gender-Diverse Veterans - Tucker, R.P.; Pardue-Bourgeois, S.; Snow, A.; Bradstreet, M.; Cerel, J. (LGBT health, 2019)
Purpose: Transgender and gender-diverse (TGD) veterans experience a high prevalence of suicidal thoughts and behaviors (STBs). Within the general U.S. population, suicide-related exposure is an identified risk factor for STBs. This study explores the impact of suicide-related exposure in TGD veterans. Methods: Self-identified TGD veterans (n = 195) completed an online cross-sectional survey that included self-report measures of suicide-related exposures, experience of past-year suicidal ideation (SI), and history of suicide attempt (SA)(s). Results: A considerable number of respondents indicated that they were close to someone who attempted suicide (40.5%) or died by suicide (32.8%). When asked about the gender identity of decedents, 6.7% indicated that at least one individual was TGD and 18.5% indicated knowing at least one close TGD individual who attempted suicide. Exposure to SA and to suicide were both independently related to a history of at least one SA. Neither type of suicide exposure was related to past year SI. Participants exposed to the SA of a close TGD individual were more likely to report past-year SI than those not exposed. Conclusion: TGD veterans may be more vulnerable to suicidal behaviors if suicide-related exposures are experienced. Public health suicide prevention initiatives, both inside and outside of the TGD community, may help to reduce suicide in these veterans.
Keywords: adult; cross-sectional study; female; gender identity; human; male; prevalence; risk factor; self report; sexual and gender minority; social environment; suicidal ideation; suicide attempt; transgender; transsexualism; United States; veteran

Relationship Of Suicide Attempt With Depression And Other Socio-Demographic Factors Among The Transgenders - Zubair, U.B.; Khan, M.A.; Jalil, A.; Kamal, A.; Nizami, A.; Minhas, F.; Tasleem, S. (Journal of Ayub Medical College, Abbottabad : JAMC, 2019)
BACKGROUND: This study was conducted assess the frequency of suicide attempt among the transgender population and analyse the relationship of depression and other socio-demographic factors with the suicide attempt Cross-sectional study. METHODS: The sample population comprised of one hundred and forty-eight transgender people of Rawalpindi and Islamabad. Suicidal attempt was assessed by the simple question that "Have you ever performed an action with the intent to take your own life in your life time?" Answer of yes or no was recorded. Hamilton rating scale for Depression (HAM-D) was used to look for the presence of depression among the target population. Relationship of the age, smoking, family income, illicit substance use and depression was studied with the presence of suicidal attempt among these transgender population of twin cities of Pakistan. RESULTS: A total of 148 transgender people were included in the final analysis. Mean age of the study participants was 38.24±3.18. Out of these, 70.9% had no suicidal attempt in their whole life while 29.1% had one or more suicidal attempts during the course of their life. Twelve had more than one suicidal attempt while 19 had attempt in last one year. Fifty-five did not showed depression while 93 had depression on HAM-D. With binary logistic regression we found that presence of depression and low income had significant association with the presence of suicidal attempt among the target population. CONCLUSIONS: This study showed a high prevalence of suicidal attempts among the transgender population of twin cities of Pakistan. Routine screening for mental health problems should be performed on this high-risk group and adequate employment resources should be generated in order to enable them to earn their livelihood and prevent them from making attempts to take their own life.
Keywords: adult; cross-sectional study; depression; female; human; income; male; middle aged; Pakistan; prevalence; psychological rating scale; psychology; risk factor; suicide attempt; transgender

Self-reported Rates of Abuse, Neglect, and Bullying Experienced by Transgender and Gender-Nonbinary Adolescents in China - Peng, K.; Zhu, X.; Gillespie, A.; Wang, Y.; Gao, Y.; Xin, Y.; Qi, J.; Ou, J.; Zhong, S.; Zhao, L.; Liu, J.; Wang, C.; et al. (JAMA Network Open, 2019)
Importance: This is the first comprehensive national study reporting the rates of abuse, neglect, and bullying from family and classmates or teachers among Chinese transgender and gender-nonbinary adolescents and identifying risk factors associated with poor mental health in this population. Objective: To assess the rates of abuse, neglect, and bullying and their association with poor mental health among Chinese transgender and gender nonbinary adolescents. Design, Setting, and Participants: This national survey study used an online self-selecting survey conducted between January 1, 2017, and September 29, 2017, in China. Eligibility criteria included reporting being aged 12 to 18 years and being transgender or gender nonbinary. Data analysis was performed from March 25 to 28, 2019. Main Outcomes and Measures: The main outcome was self-reported poor mental health, including depressive symptoms, anxiety symptoms, and suicidal ideation. Depressive symptoms were measured using the Center for Epidemiological Studies Depression 9-item scale. Anxiety symptoms were measured using the 7-item General Anxiety Disorder scale. Suicidal ideation was measured using standardized questions adapted from previous Chinese studies. Abuse, neglect, and bullying were measured using specifically designed questions. Results: Of 564 responses collected, 385 respondents (mean [SD] age, 16.7 [1.2] years) met inclusion criteria, including 109 (28.3%) transgender adolescent boys, 167 (43.4%) transgender adolescent girls, and 109 (28.3%) gender-nonbinary adolescents. Among 319 respondents who reported that their parents were aware of their gender identity, 296 (92.8%) reported having experienced parental abuse or neglect. Among the full cohort, 295 respondents (76.6%) reported having experienced abuse or bullying owing to being transgender or gender nonbinary in school from classmates or teachers. There were 173 respondents (44.9%) with Center for Epidemiological Studies Depression 9-item scale scores indicating they were at risk of major depressive disorder, and 148 respondents (38.4%) had 7-item General Anxiety Disorder scale scores indicating they were at risk of an anxiety disorder. In univariate analysis, reporting experiences of bullying from a classmate or teacher was significantly associated with suicidal ideation (odds ratio, 1.68 [95% CI, 1.04-2.70]; P =.03), but the association was no longer statistically significant after controlling for level of educational attainment, aversion to assigned sex, and depressed mood at the onset of puberty (odds ratio, 1.63 [95% CI, 0.97-2.73]; P =.06). Conclusions and Relevance: In this survey study, transgender and gender-nonbinary adolescents in China reported high rates of abuse, neglect, and bullying at home and in school and high rates of symptoms associated with poor mental health. This study highlights the importance of reducing home- and school-based abuse, neglect, and bullying of transgender and gender-nonbinary adolescents in China to improve mental health outcomes; however, broader change in the social environment may be required to address the prejudice and stigma aimed at gender minorities..
Keywords: abuse; adolescent; adult; anxiety assessment; anxiety disorder; article; bullying; Center for Epidemiological Studies Depression Scale; China; cohort analysis; female; gender identity; general anxiety disorder scale; human; major clinical study; major depression; male; mental capacity; neglect; outcome assessment; priority journal; self report; suicidal ideation; suicide attempt; transgender; young adult

Substance use, violence experiences, and mental health issues: are these health risks associated with HIV testing among sexually experienced U.S. high school students? - Pampati, S.; Lowry, R.; Steiner, R.J. (AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV, 2019)
HIV testing is a critical strategy for prevention of HIV yet testing among sexually experienced adolescents is sub-optimal. The purpose of this study is to examine associations between risk behaviors and experiences related to substance use, violence, and mental health and suicide and receipt of testing. We analyzed cross-sectional data from the 2017 national Youth Risk Behavior Survey, a nationally representative sample of U.S. high school students in grades 9–12. Analyses were limited to sexually experienced participants (n = 5192). Measures included nine indicators related to substance use, violence, and mental health and suicide. Unadjusted and adjusted prevalence ratios were calculated for each indicator to examine associations with testing. Adjusted models controlled for same-sex sexual behavior, sexual risk, and demographic characteristics. Prevalence of HIV testing was 17.2%. In adjusted models, forced sexual intercourse, injection drug use, other illicit drug use, and persistent feelings of sadness or hopelessness were associated with a higher likelihood of testing. Prevalence of HIV testing in this sexually experienced sample was low. Some behaviors and experiences that may be indicative of HIV risk, including sexual dating violence and prescription opioid misuse, were not associated with testing.
Keywords: HIV test; illicit drug; narcotic analgesic agent; article; cross-sectional study; dating violence; demography; female; health hazard; high school student; human; injection drug user; major clinical study; male; mental disease; prescription; priority journal; sexual behavior; sexual intercourse; substance use; suicidal ideation; suicide; suicide attempt; United States; violence

Gender Minority Mental Health in the U.S.: Results of a National Survey on College Campuses - Lipson, S.K.; Raifman, J.; Abelson, S.; Reisner, S.L. (American Journal of Preventive Medicine, 2019)
Introduction: The purpose of this study was to examine mental health status by gender identity among undergraduate and graduate students. Methods: Data came from the 2015–2017 Healthy Minds Study, a mobile survey of randomly selected students (N=65,213 at 71 U.S. campuses, including 1,237 gender minority [GM] students); data were analyzed in 2018. Outcomes were symptoms of depression, anxiety, eating disorders, self-injury, and suicidality based on widely used, clinically validated screening instruments. Bivariable and multivariable analyses explored differences between GM and cisgender (non-GM) students as well as by assigned sex at birth. Results: Across mental health measures, a significantly higher prevalence of symptoms was observed in GM students than cisgender students. Compared with 45% of cisgender students, 78% of GM students met the criteria for 1 or more of the aforementioned mental health outcomes. GM status was associated with 4.3 times higher odds of having at least 1 mental health problem (95% CI=3.61, 5.12). Conclusions: Findings from this largest campus-based study of its kind using representative data with both gender identity and mental health measures underscore the importance of recognizing and addressing GM mental health burdens, such as by screening for mental health and providing gender-affirming services. There is broad urgency to identify protective factors and reduce mental health inequities for this vulnerable population.
Keywords: adult; anxiety disorder; article; automutilation; bivariate analysis; college; controlled study; cross-sectional study; depression; eating disorder; female; gender identity; graduate student; health status; human; male; mental health; multivariate analysis; prevalence; sexual and gender minority; suicide attempt; undergraduate student; United States

Research on relationships between sexual identity, adverse childhood experiences and non-suicidal self-injury among rural high school students in less developed areas of China - Li, X.; Zheng, H.; Tucker, W.; Xu, W.; Wen, X.; Lin, Y.; Jia, Z.; Yuan, Z.; Yang, W. (International Journal of Environmental Research and Public Health, 2019)
Purpose: The objective of this study was to examine the influence of sexual identity and adverse childhood experiences (ACEs) on non-suicidal self-injury (NSSI) among rural high school students in less developed areas of China. Methods: Behavior risk factors data collected from 1810 students from a high school in Jiangxi province, China. Five measures of childhood abuse and household dysfunction were summarized, and ACE was divided into 0, 1, 2, 3–5 ACEs. Logistic regression analysis was used to explore the influence of sexual identity, adverse childhood experiences, and their interaction with non-suicidal self-injury. Results: Compared with heterosexual students, high school students who identify as lesbian, gay, or bisexual (LGB) have a higher tendency of non-suicidal self-injury (AOR = 3.250, 95% CI = 1.69–6.28, p < 0.01). There was also a graded relationship between cumulative ACEs exposure and non-suicidal self-injury behaviors (AOR = 1.627, 95% CI = 1.02–2.60, p < 0.05). Odds for NSSI are higher among students with both experienced ACEs and identified as LGB (AOR = 2.821, 95% CI = 1.51–5.29, p < 0.05). Conclusions: Non-suicidal self-injury is associated with ACEs exposure and with those who identify as LGB, and the NSSI odds are greater when students identify as LGB and have experienced ACEs. More interventions to reduce non-suicidal self-injury should focus on LGB and ACEs and more attention needs to be paid to those who identify as LGB and have been exposed to ACEs.
Keywords: adolescent; adult; article; automutilation; bisexuality; child; child abuse; childhood adversity; China; clinical research; controlled study; dysfunctional family; economic aspect; female; gender identity; heterosexuality; high school student; homosexual female; human; information processing; LGBT people; logistic regression analysis; major clinical study; male; risk factor; rural area

Effect of same-sex marriage referendums on the suicidal ideation rate among nonheterosexual people in Taiwan - Lin, I.-H.; Ko, N.-Y.; Huang, Y.-T.; Chen, M.-H.; Lu, W.-H.; Yen, C.-F. (International Journal of Environmental Research and Public Health, 2019)
Taiwan held voter-initiated referendums to determine same-sex marriage legalization on 24 November 2018. This study aims to compare suicidal ideation rates in heterosexual and nonheterosexual participants of a first-wave survey (Wave 1, 23 months before the same-sex marriage referendums) and a second-wave survey (Wave 2, one week after the same-sex marriage referendums) in Taiwan and to examine the influence of gender, age, and sexual orientation on the change in suicidal ideation rates in nonheterosexual participants. In total, 3286 participants in Wave 1 and 1370 participants in Wave 2 were recruited through a Facebook advertisement. Each participant completed an online questionnaire assessing suicidal ideation. The proportions of heterosexual and nonheterosexual participants with suicidal ideation were compared between the Wave 1 and Wave 2 surveys. Suicidal ideation rates between participants in the Wave 1 and Wave 2 surveys were further compared by stratifying nonheterosexual participants according to gender, age, and sexual orientation. Nonheterosexual participants in the Wave 2 survey had a higher suicidal ideation rate than those in the Wave 1 survey, whereas no difference was observed in suicidal ideation rates between heterosexual participants in Wave 2 and Wave 1. Nonheterosexual participants who were female, younger, gay, lesbian, and bisexual in Wave 2 had a higher suicidal ideation rate than those in Wave 1. The suicidal ideation rate significantly increased in nonheterosexual participants experiencing the same-sex marriage referendums in Taiwan. Whether civil rights of sexual minority individuals can be determined through referendums should be evaluated.
Keywords: adult; age; article; bisexuality; controlled study; female; gender; groups by age; health survey; heterosexuality; homosexual female; homosexual male; human; major clinical study; male; mental disease assessment; online system; questionnaire; same-sex marriage; sexual orientation; suicidal ideation; Taiwan

Overview of care for transgender children and youth - Weiselberg, E.C.; Shadianloo, S. (Current Problems in Pediatric and Adolescent Health Care, 2019)
Over the past decade, more and more children and adolescents are identifying as transgender and gender diverse (TGD). Often, they and their parents first turn to their primary care pediatrician for guidance and support. Therefore, in 2018, the American Academy of Pediatrics (AAP) released a policy statement focusing on the health care of TGD youth.4 The AAP acknowledges that many pediatricians have a lack of training in this area and therefore need to increase their knowledge base and expertise in order to provide culturally competent care. While most sexual and gender minority individuals are healthy and well adjusted, some TGD youth are at an increased risk of mental health concerns, including anxiety, depression, substance abuse, eating disorders and suicidality. This is theorized to be due to the experienced or internalized marginalization, stigmatization, victimization, harassment or rejection and not inherent in having gender dysphoria or being transgender. The pediatrician therefore needs to be knowledgeable of, and skilled to screen for, the health disparities that may exist, as well as to be able to support the individual who may disclose their gender identity status during treatment. Parents and guardians may also turn to the pediatrician for guidance when faced with their child who presents with gender non-conforming behaviors or gender dysphoria. Therefore the pediatrician needs to be able to guide the parents as well, as their acceptance and support of their child's journey to gender identity is probably the most important protective factor against health disparities encountered. To deliver optimum care for TGD children and youth, the pediatrician needs to establish an office setting that is inclusive, gender-neutral and TGD friendly. By becoming familiar with the diversity of gender expression and identities, use of gender-appropriate terminology, health disparities often encountered and the importance of providing a safe and welcoming environment, issues that are all covered in this article, the primary care pediatrician will be in position to provide comprehensive health care to this often marginalized population.
Keywords: penis prosthesis; hormone; adolescent; adulthood; anxiety; article; asexual; autism; bisexuality; breast reconstruction; child; child care; clinical feature; confidentiality; demisexual; depression; eating disorder; female; gender affirming surgery; gender affirming treatment; gender dysphoria; gender identity; general practitioner; health care; health care disparity; health care policy; health disparity; heterosexuality; homelessness; homosexuality; human; Human immunodeficiency virus infection; juvenile; knowledge base; male; medical history; mental health care; pansexual; pediatrician; physical examination; polyamoruous; preschool child; primary health care; protection; puberty; school child; sex reassignment; sex transformation; sexual and gender minority; sexual development; sexually transmitted disease; social interaction; social transitioning; substance use; suicide; toddler; transgender

Gender affirming medical care of transgender youth - Salas-Humara, C.; Sequeira, G.M.; Rossi, W.; Dhar, C.P. (Current Problems in Pediatric and Adolescent Health Care, 2019)
The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.
Keywords: drug implant; penis prosthesis; cyproterone acetate; doxycycline; estradiol; ethinylestradiol; follitropin; gestagen; gonadorelin agonist; histrelin; isotretinoin; leuprorelin; luteinizing hormone; minocycline; progesterone; prolactin; spironolactone; testosterone; testosterone cipionate; testosterone enantate; triptorelin; abdominal hysterectomy; acne; adjuvant therapy; adolescent; adulthood; article; blood pressure; body composition; body height; body mass; bone density; bottom surgery; breast cancer; breast development; cancer risk; cardiovascular risk; care behavior; clinical practice; cognition; delayed puberty; drug contraindication; drug cost; drug formulation; drug safety; dual energy X ray absorptiometry; estradiol blood level; female; female to male transgender; feminization; gender affirming surgery; gender dysphoria; gender identity; gender reassignment surgery; health care organization; hormonal therapy; human; hyperkalemia; hyperprolactinemia; hypothalamus hypophysis gonad system; informed consent; juvenile; laboratory test; larynx surgery; lipid blood level; liver function; liver injury; male; male to female transgender; medical assessment; medical care; medical decision making; mental health; metabolic parameters; neovagina; orchiectomy; ovariectomy; ovary insufficiency; patient counseling; patient monitoring; patient referral; pediatrician; phalloplasty; polycythemia; practice guideline; prepuberty; puberty; risk benefit analysis; secondary sexual characteristics; sex reassignment; skin graft; suicide; surgery; testosterone blood level; transfeminine surgery; transgender; transmasculine sruegry; treatment indication; vagina reconstruction; venous thromboembolism

Coping, stress, and negative childhood experiences: The link to psychopathology, self-harm, and suicidal behavior - McLafferty, M.; Armour, C.; Bunting, B.; Ennis, E.; Lapsley, C.; Murray, E.; O'Neill, S. (PsyCh journal, 2019)
Early life experiences, such as childhood adversities or poor parenting practices, can impact on the ability to cope with stressors across the lifespan. Furthermore, poor coping skills can lead to the development of mental illnesses, self-harm, and suicidal behavior. This study aimed to examine demographic differences in stress levels and to determine if those who had endured negative childhood experiences would be more likely to develop psychological problems and display suicidal behavior when current stress levels were accounted for. The study also explored the link between coping and mental health problems. Finally, it aimed to predict risk and protective factors related to good coping skills. The study utilized data obtained from the Ulster University Student Wellbeing Study, conducted across four university campuses in Northern Ireland in 2015 (n = 716) as part of the World Health Organization World Mental Health (WMH) International College Student Initiative. Mental health problems and early childhood experiences were examined using questions adapted from the WMH Composite International Diagnostic Interview, with self-harm and suicidal behavior measured using the Self-Injurious Thoughts and Behaviors Interview (SITBI). Females, non-heterosexuals, and older students experienced more current stress. When current stress levels were high, childhood adversities and parental overcontrol and overindulgence were related to higher rates of mental health problems, self-harm, and suicidal behavior. Poor coping skills were associated with negative mental health outcomes. Social support and good emotion-regulation strategies were related to effective coping, while parental overcontrol and overindulgence, female gender, and younger age were related to poorer coping. The study highlights the importance of developing good coping skills to deal with life stressors, thereby minimizing the risk of psychological problems and suicidal behavior. The findings provide support for initiatives to help parents improve their parenting skills and other programs to help young people cope with stress, and to develop social networks and adaptive emotion-regulation strategies.
Keywords: article; automutilation; child; child parent relation; childhood adversity; college student; controlled study; coping behavior; emotionality; female; gender; human; infant; interview; major clinical study; male; mental health; Northern Ireland; outcome assessment; skill; social network; social support; physiological stress; suicidal behavior; university student; wellbeing; World Health Organization

Sexual orientation disparities in mental health and substance use among Black American young people in the USA: effects of cyber and bias-based victimisation - Mereish, E.H.; Sheskier, M.; Hawthorne, D.J.; Goldbach, J.T. (Culture, health & sexuality, 2019)
Few studies have explored sexual orientation disparities in mental health and substance use outcomes among racial minorities. This study examined sexual orientation disparities in depression, suicidality and substance use among Black American young people in the USA, and the mediating role of cyber and bias-based victimisation in accounting for these disparities. Secondary analyses were performed on data from a probability sample of young people (N = 1,129) collected in a school district in the south-eastern USA. Participants reported socio-demographics, depressive symptoms, suicidality, substance use and experiences of bias-based and cyber victimisation. With some exceptions, Black participants who were lesbian, gay, bisexual or mostly heterosexual reported higher rates of depression, suicidal ideation, suicide planning and substance use than Black heterosexual participants. Black lesbian, gay, bisexual and mostly heterosexual participants reported more cyber and bias-based victimisation than Black heterosexual participants. Sexual orientation disparities in mental health and, to some extent, substance use were partially explained by both forms of victimisation. Further research is needed to address the role of bias-based and cyber victimisation in disparities in mental health and substance use among Black sexual minority young people. The present study carries implications for prevention and treatment efforts for racially diverse sexual minorities.
Keywords: adolescent; African American; child; crime victim; cross-sectional study; drug dependence; ethnology; female; health disparity; heterosexuality; human; male; mental health; psychology; questionnaire; sexual and gender minority; sexual behavior; suicidal ideation; United States

Progress Regarding Transgender Issues? - Thomas, S.P. (Issues in mental health nursing, 2019)
Keywords: cross-sectional study; ethnic group; ethnology; female; human; male; mental disease; nursing; psychology; social distance; suicide; transgender; United States; violence

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion - Argento, E.; Strathdee, S.A.; Shoveller, J.A.; Braschel, M.; Shannon, K. (Journal of interpersonal violence, 2019)
Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.
Keywords: aged; anxiety disorder; article; Canada; child sexual abuse; cohort analysis; controlled study; depression; female; homelessness; human; major clinical study; male to female transgender; mental health; partner violence; posttraumatic stress disorder; prospective study; questionnaire; sex worker; suicide

An asexual flower of Silene latifolia and Microbotryum lychnidis-dioicae promotes sex-organ development - Kawamoto, H.; Yamanaka, K.; Koizumi, A.; Ishii, K.; Kazama, Y.; Abe, T.; Kawano, S. (PLoS ONE, 2019)
Silene latifolia is a dioecious flowering plant with sex chromosomes in the family Caryophyllaceae. Development of a gynoecium and stamens are suppressed in the male and female flowers of S. latifolia, respectively. Microbotryum lychnidis-dioicae promotes stamen development when it infects the female flower. If suppression of the stamen and gynoecium development is regulated by the same mechanism, suppression of gynoecium and stamen development is released simultaneously with the infection by M. lychnidis-dioicae. To assess this hypothesis, an asexual mutant without a gynoecium or stamen was infected with M. lychnidis-dioicae. A filament of the stamen in the infected asexual mutant was elongated at stages 11 and 12 of flower bud development as well as in the male, but the gynoecium did not form. Instead of the gynoecium, a filamentous structure was suppressed as in the male flower. Developmental suppression of the stamen was released by M. lychnidis-dioicae, but that of gynoecium development was not released. M. lychnidis-dioicae would have a function similar to stamen-promoting factor (SPF), since the elongation of the stamen that is not observed in the healthy asexual mutant was observed after stage 8 of flower bud development. An infection experiment also revealed that a deletion on the Y chromosome of the asexual mutant eliminated genes for maturation of tapetal cells because the tapetal cells did not mature in the asexual mutant infected with M. lychnidis-dioicae.
Keywords: article; asexual reproduction; chromosome deletion; controlled study; flower development; infection; Microbotryum; Microbotryum lychnidis dioicae; mutant; nonhuman; pistil; plant cell; Silene; Silene latifolia; stamen; Y chromosome

Waivers of parental consent for sexual minority youth - Smith, A.U.; Schwartz, S.J. (Accountability in research, 2019)
The Society for Adolescent Health and Medicine emphasizes the need for research to focus on the health outcomes of sexual minority youth (i.e., lesbian, gay, bisexual, transgender, queer). However, sexual minority youth (SMY) are often less willing to participate in research studies where parental consent is required due to potential victimization and discrimination. This is a major concern given that more research is needed to understand the health needs of this population, especially in terms of suicide, substance use, and HIV prevention. The National Suicide Prevention Strategy classifies SMY as a high-risk group, emphasizing the need to explore suicide risks (along with other health outcomes) among this group. However, this high-risk classification also increases the safeguards necessary to conduct research with this population. Many researchers have argued for waivers of parental consent, but such waivers present with several ethical implications. This article discusses ethical principles, risks, benefits, safeguards, and potential alternative approaches to waivers of parental consent for SMY. We conclude by emphasizing the need for policy changes to allow parental consent waivers for research targeting SMY.
Keywords: adolescent; child; ethics; female; human; male; organization and management; parental consent; professional standard; psychology; research; risk assessment; sexual and gender minority; suicide

Transgender Expressions and Psychosis: Towards an Ethics of Sexual Difference - Gherovici, P. (British Journal of Psychotherapy, 2019)
Psychoanalysis has a regrettable history of pathologizing non-normative expressions of gender and sexuality; this tendency is even more prevalent with analysands who identify as trans. However, this has not been Jacques Lacan's position. In order to flesh out Lacan's complex intervention in the domain of transsexualism and to show his nuanced position that has often been misinterpreted, I will discuss three of his clinical interventions with patients presenting ‘transgender expressions’. Examining Lacan's work, I propose moving towards a differential clinic, a clinic where the diagnosis preserves the subjectivity of the patient and is a tool in the direction of the treatment and not a label. This type of structural diagnosis is not standardized but decided case by case, based on the particulars of each treatment.
Keywords: article; castration; delusion; embarrassment; ethical decision making; ethics; femininity; freedom; gender identity; gesture; human; impotence; pessimism; psychoanalysis; psychology; psychosis; psychotherapy; sex difference; sex reassignment; sexuality; social behavior; suicide attempt; symbolism; transgender; transgender expression; visual hallucination

Comparison of male and female victims of intimate partner homicide and bidirectionality-an analysis of the national violent death reporting system - Velopulos, C.G.; Carmichael, H.; Zakrison, T.L.; Crandall, M. (The journal of trauma and acute care surgery, 2019)
BACKGROUND: Intimate partner violence (IPV) is a public health crisis, affecting at least 1:4 women and 1:9 men. A recent multicenter trial on universal screening in trauma patients showed similar rates of positive screens between men and women. Few studies have explored the bidirectional violence in opposite-sex or same-sex relationships. Our goal was to estimate prevalence and risk factors for the most severe manifestation of IPV: intimate partner homicide. METHODS: This is a 2003-2015 retrospective review of the National Violent Death Reporting System, a Centers for Disease Control and Prevention database of surveillance data. Deaths were coded IPV if the primary relationship between the suspect and victim fell into the categories of current partner or ex-partner. Bivariable and multivariable analysis examined differences between groups for factors and circumstances. RESULTS: A total of 6,131 persons in opposite-sex relationships and 181 in same-sex relationships were murdered as a result of IPV. Women and Black men were disproportionately affected, and alcohol and preceding arguments were a factor in a higher proportion of male victims. Abuse preceded homicide in many women with almost half of male suspects attempting or committing suicide at the time of intimate partner homicide. Women were more likely than men to use a stabbing instrument, although firearms were still the most common means for each group. In 46.5% of homicides of women, the male suspect attempted suicide (p < 0.001). Bidirectionality was highest in male victims of female perpetrators and in same-sex pairings regardless of sex of the victim. CONCLUSION: Homicide caused by IPV is a significant public health crisis for both men and women, with women and Black men at particular risk. Firearms are the most commonly used weapon for homicide in both sexes, and mental illness is not a common risk factor. A staggering proportion of these homicides involve suicide of the suspect, suggesting that each potential incident has two victims to target for prevention and intervention. Interventional programs to prevent such bidirectional mortality are urgently needed. LEVEL OF EVIDENCE: Retrospective secondary data analysis, level III.
Keywords: adult; aged; comparative study; epidemiology; factual database; female; homicide; human; male; middle aged; partner violence; retrospective study; risk factor; sex factor; United States; young adult

Transgender population's experiences with regard to accessing reproductive health care in Kwazulu-Natal, South Africa: A qualitative study - Luvuno, Z.P.B.; Ncama, B.; Mchunu, G. (African journal of primary health care & family medicine, 2019)
BACKGROUND: The transgender population has unique health risks, including increased risk of mental illness, substance abuse, suicide and a high prevalence of human immunodeficiency virus (HIV). Worldwide studies indicate that this population is marginalised and faces barriers in accessing health care. In South Africa, there is limited information and research on the transgender population's interaction with health services. AIM: The purpose of this study was to examine the experiences of the transgender population in accessing health care facilities for sexual and reproductive needs. SETTING: The study took place in KwaZulu-Natal province of South Africa. METHODS: A qualitative study combining phenomenological and critical ethnographic approaches was conducted to explore the experiences of the transgender population in the health care setting. Critical ethnography was chosen because it is an emancipatory method that highlights the plight of disenfranchised groups, and phenomenology was used to illuminate experiences of the transgender population. Purposive snowball sampling was applied to select nine transgender participants who had experiences of contact with a health care setting. Data collection was performed through semi-structured interviews and a focus group discussion. RESULTS: Participants provided details about the paucity of facilities, resources and targeted programmes to cater for the transgender populations' sexual and reproductive health needs. The participants engage in high-risk behaviour, comprising unprotected sex and use of cross-gender hormones without medical supervision. Furthermore, the participants reported experiences of hostile and discriminatory behaviour by healthcare workers. CONCLUSION: It emerged that there is a paucity of resources and knowledge to provide appropriate health care services to the transgender population, resulting in adverse experiences. Policies on transgender care and training of health workers will contribute towards improvement of health care access for the transgender population.
Keywords: adult; female; health care delivery; health personnel attitude; health service; human; information processing; interview; male; qualitative research; South Africa; transgender

History of Physical Teen Dating Violence and Its Association With Suicidal Behaviors Among Adolescent High School Students: Results From the 2015 Youth Risk Behavior Survey - Baiden, P.; Mengo, C.; Small, E. (Journal of interpersonal violence, 2019)
Although studies have investigated and found physical teen dating violence (TDV) has a significant negative impact on mental health outcomes, few studies are yet to investigate the effect of physical TDV on suicidal behaviors among adolescents. The objectives of this study are to examine the prevalence of physical TDV, suicidal ideation, suicide plan, and suicide attempt among adolescents aged 14 to 18 years and the association between physical TDV and these suicidal behaviors. Data for this study were obtained from the 2015 Youth Risk Behavior Survey. A sample of 9,693 adolescents aged 14 to 18 years (50.4% males) was analyzed using logistic regression with suicidal ideation, suicide plan, and suicide attempt as outcome variables and physical TDV as the main explanatory variable. About 17% of the adolescent students experienced suicidal ideation, 13.7% made a suicide plan, and 7.6% attempted suicide during the past 12 months. Among those who were dating, 9.9% experienced physical TDV. In the multivariate logistic regression, adolescent students who experienced physical TDV were 1.92 times more likely to have experienced suicidal ideation, 1.67 times more likely to have made a suicide plan, and 2.42 times more likely to have attempted suicide during the past 12 months when compared with their counterparts who were dating but experienced no physical TDV. Other significant predictors of suicidal behaviors include being a sexual minority, experiencing forced sex, bullying, feeling sad or hopeless, and binge drinking. Having sufficient sleep lowered the odds of suicidal ideation and suicide plan. The topic of physical TDV and its association with suicidal behaviors among adolescents is such an important issue for researchers, policymakers, and practitioners in the United States and around the world. Prevention and intervention efforts should be culturally tailored to reflect the unique experiences with physical TDV and suicide among minority populations such as sexual minority adolescents.
Keywords: adolescent; adult; article; binge drinking; bullying; controlled study; dating violence; explanatory variable; female; high school student; human; juvenile; major clinical study; male; outcome variable; physician; prevalence; scientist; sexual and gender minority; sleep; suicidal ideation; suicide attempt; United States

We need to talk about Fabian: Klein’s ‘lost’ theory of projective identification and the social construction of gender/queer objects - Clarke, J. (Psychoanalytic Psychotherapy, 2019)
Melanie Klein’s seminal concept of projective identification provides an important theoretical mechanism for working through the Oedipus complex. Klein saw it as the key to achieving emotional maturity. As well as the choice of object, which decides our sexual identity, Klein sees a second choice to be made as subject, which shapes our gender. The question is not only ‘what does a woman (or man) want?’, as Freud and Jones argued, but ‘who (and how) does a woman (or man) become?’, as Simone de Beauvoir memorably asked. How is our gender acquired for us and by us? Queer theory asks us to refuse gender normativity. That is one response. But unless we arrive at our own answer to gender, says Klein, the capacities both to love and to be loved will remain elusive. Klein invites us to leave Oedipus behind in Ancient Thebes and move the stage to Paris in 1920, the setting for a novel by Julien Green, If I Were You. Our Modern hero is a young man, Fabian Especel. This article rediscovers Fabian and adds to Klein’s theory of internal objects the role of queer objects as Weberian ‘abject types’, to update the Oedipus complex today.
Keywords: article; bisexuality; depression; ego development; evolution; experiential learning; femininity; feminism; France; gender; gender identity; heterosexuality; homophobia; homosexual female; homosexuality; human; introspection; loneliness; love; melancholia; Oedipus complex; personality; priority journal; psychoanalysis; psychological theory; schizophrenia; sensibility; sexual development; social psychology; social stigma; suicidal ideation; transgender

Health disparities between genderqueer, transgender, and cisgender individuals: An extension of minority stress theory - Lefevor, G.T.; Boyd-Rogers, C.C.; Sprague, B.M.; Janis, R.A. (Journal of counseling psychology, 2019)
Interpersonal, social, and structural stressors have been identified as key elements that explain health disparities between transgender and cisgender individuals. However, most of this research has focused on binary transgender individuals or has not differentiated between binary and nonbinary individuals; little research has examined the experiences of minority stress or health of those identifying outside the gender binary. Guided by intersectionality and drawing on a sample of 3,568 college students from the Center for Collegiate Mental Health's 2012-2016 database-of whom 892 identified outside the gender binary-we conducted analyses of demographic and outcome measures administered in participants' 1st counseling appointment, examining differences between cisgender, transgender, and genderqueer individuals. We found that genderqueer individuals were harassed, sexually abused, and subjected to traumatic events at higher rates than were either cisgender or binary transgender individuals, with approximately 50% of genderqueer individuals reporting one of these experiences. We found that genderqueer individuals experienced more anxiety, depression, psychological distress, and eating concerns than did binary transgender and cisgender individuals and more social anxiety than did cisgender individuals. Genderqueer individuals more frequently reported self-harm and suicidality than did any other group, with approximately 2/3 of participants' having contemplated and nearly 50% making a suicide attempt. We extend current theorizing about minority stress (Hendricks & Testa, 2012; Meyer, 2003) to include genderqueer individuals and delineate several structural aspects of genderqueer experiences that may be responsible for these trends, including others' lack of knowledge about genderqueer experiences and pronouns, poor access to legal and medical resources, and systemic discrimination. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Keywords: adult; anxiety; depression; female; gender identity; health status; human; male; mental stress; minority group; psychology; sexual crime; sexual harassment; transgender; transsexualism

Suicide Prevention From the Perspectives of Gay, Bisexual, and Two-Spirit Men - Ferlatte, O.; Oliffe, J.L.; Louie, D.R.; Ridge, D.; Broom, A.; Salway, T. (Qualitative health research, 2019)
Although gay, bisexual, and two-spirit men (GBTSM) experience high rates of suicidality, there have been few empirical studies of prevention initiatives and policies that could address or reverse this major social problem. This article reports on a photovoice study of 29 GBTSM who had a history of suicidality or lost a fellow GBTSM to suicide. We focused our analysis on participants' perspectives on suicide prevention. Participants described four key considerations for GBTSM suicide prevention: (a) recognizing and addressing enduring homophobia, biphobia, and mental illness stigma; (b) provision of low-barrier, long-term, and GBTSM-affirming counseling; (c) de-isolation through peer support and community connection; and (d) fostering creativity and cultural resilience. By engaging GBTSM affected by suicide through photographs that depict their experiences and points of view, in this study, we offer concrete recommendations to reduce suicidality among GBTSM.
Keywords: Canada; homophobia; human; male; psychology; qualitative research; sexual and gender minority; social stigma; suicidal ideation; suicide

Using Photovoice to Understand Suicidality Among Gay, Bisexual, and Two-Spirit Men - Ferlatte, O.; Oliffe, J.L.; Salway, T.; Broom, A.; Bungay, V.; Rice, S. (Archives of sexual behavior, 2019)
This study explored the drivers of suicidality from the perspectives of gay, bisexual, and two-spirit men (GB2SM) with a history of suicidality. Twenty-one GB2SM participated in this photovoice study taking photographs to depict and discuss their previous suicidality. Data were collected from in-depth individual interviews in which participants discussed their photographs and in turn offered verbal/narrative accounts of suicidality. Drawing on intersectionality, analyses of the photographs and interview data revealed three interconnected themes. First, adverse childhood events and negative adolescent experiences were described as the root causes of mental health struggles and suicidality. Second, violence and homophobia had disrupted these men's education and employment opportunities and some participants detailed how their lack of capital and challenges for maintaining employment shaped their suicidality. Third, a sociality of stigma and sense of isolation compounded experiences of suicidality. The three themes overlapped and were shaped by multiple intersectional axes including sexuality, class, ethnicity, and mental health status. The findings have implications for services and health professionals working with GB2SM who need to thoughtfully consider life-course trajectories and multiple social axes when assessing and treating GB2SM experiencing suicidality. More so, because these factors relate to social inequities, structural and policy changes warrant targeted attention.
Keywords: adult; aged; bisexuality; devices; human; male; middle aged; photography; psychology; sexual and gender minority; sexual behavior; suicide; verbal communication; young adult

A Systematic Review of Characteristics of Nonprobability Community Venue Samples of Sexual Minority Individuals and Associated Methods for Assessing Selection Bias - Salway, T.J.; Morgan, J.; Ferlatte, O.; Hawkins, B.; Lachowsky, N.J.; Gilbert, M. (LGBT health, 2019)
The majority of research on sexual minority individuals relies on nonprobability community venue samples. These samples are prone to selection bias; however, empirical syntheses of evidence of these biases are not available. We conducted, therefore, a systematic review of published sexual minority health research to summarize methods used to identify characteristics and health outcomes found to differ in nonprobability samples. We searched five health and social science databases to identify observational studies that included a nonprobability sexual minority community sample and applied an empirical method to infer selection bias. We extracted data regarding sociodemographic characteristics, behaviors, and health outcomes and examined whether the nonprobability sample was found to differ disproportionately (over- or underrepresenting the characteristic) based on appropriate statistical tests (p < 0.05 was considered statistically significant). A total of 21 studies were included. Nineteen studies used a cross-sample comparison, one used time/location sampling weights, and one used frequency of venue attendance adjustment to assess differences. The evidence was mostly consistent, that is, associations were in the same direction in >50% of studies examined, for nine variables. Nonprobability community venue samples tended to overrepresent sexual minority individuals with the following characteristics: higher income, current employment, lesbian/gay-identified, greater number of sex partners, past-year sexually transmitted infection diagnosis, suicidal ideation, alcohol use, and substance use; nonprobability community venue samples tended to underrepresent married/partnered sexual minority individuals. This review provides a nuanced empirical picture of aggregate differences in sample characteristics presumed to threaten the validity of nonprobability sexual minority community venue studies, and highlights feasible methods that can be applied to future studies to add specificity to researchers' description of selection biases.
Keywords: human; observational study; procedures; selection bias; sexual and gender minority; sexuality; statistical analysis

Protective Factors of Suicide and Suicidal Behavior Relevant to Emergency Healthcare Settings: A Systematic Review and Narrative Synthesis of Post-2007 Reviews - McClatchey, K.; Murray, J.; Chouliara, Z.; Rowat, A. (Archives of suicide research : official journal of the International Academy for Suicide Research, 2019)
Suicide is a major public health concern and, with recent societal changes, such as economic and technological changes, there may be emerging protective factors that mitigate suicide risk that are unrecognized in emergency healthcare. This systematic review aims to identify protective factors for suicide that can feasibly be assessed in time-limited emergency healthcare settings. A systematic review of reviews was conducted via PsycINFO, CINAHL and Medline (2007-2015). Reviews were assessed for methodological quality using AMSTAR. A total of 24 reviews met the inclusion criteria and 8 were assessed as high quality and included in a narrative synthesis. Known protective factors were identified (e.g., social support), along with emerging protective factors (e.g., internet support). The review synthesizes recent research evidence on protective factors and discusses their relevance to emergency healthcare.
Keywords: family relation; female; health status; human; Internet; literature; male; marriage; pregnancy; protection; sexual and gender minority; social distance; social support; suicide

Mass media representation of suicide in a high suicide state in India: An epidemiological comparison with suicide deaths in the population - Armstrong, G.; Vijayakumar, L.; Pirkis, J.; Jayaseelan, M.; Cherian, A.; Soerensen, J.B.; Arya, V.; Niederkrotenthaler, T. (BMJ Open, 2019)
Objectives Suicide rates in India are among the highest in the world, equating to over 200 000 suicides annually. Reports of suicides are a routine feature in major newspapers in India, and reporters may selectively present â € newsworthy' suicide stories. The aim of this paper was to systematically investigate whether mass media reports of suicides reflect the epidemiological data on suicide in a high suicide state in India. Design We undertook a content analysis study to extract sociodemographic data on suicides reported among nine of the most highly read daily newspapers in the high suicide southern state of Tamil Nadu between June and December 2016. A total of 1258 newspaper articles were retrieved containing reports on 1631 suicides. Two-tailed binomial tests on aggregate frequencies assessed whether the sociodemographic characteristics of suicides in the newspaper articles were different to the population suicide statistics for Tamil Nadu. Results We identified some statistically significant discrepancies between suicide characteristics in the population and the media. Suicides involving females (p<0.001), those aged under 30 years (p<0.001), separated or widowed males (p<0.001), unmarried females (p<0.001), those using methods with a higher case fatality rate (ie, hanging (p<0.001), jumping off high structures (p<0.001) and coming under vehicles (p<0.001) and those who were students (p<0.001) or working in the agricultural sector (p<0.001) were significantly over-reported relative to their occurrence in the broader population. Suicides involving men (p<0.001), those aged over 30 years and above (p<0.001), those who were married and suicides by poisoning (p<0.001) were significantly under-reported relative to their occurrence in the broader population. Conclusions The suicide characteristics in the print media were not entirely representative of suicides in the broader Tamil Nadu population, which may lead the general public to develop misunderstandings about suicide in their state. The discrepancies we identified will inform tailored suicide prevention education for media professionals.
Keywords: adult; article; automutilation; case fatality rate; content analysis; death; drowning; female; hanging; human; intoxication; major clinical study; male; marriage; mass medium; middle aged; publication; suicide; Tamil Nadu; transgender

Differences in Characteristics and Exposure to Stressors Between Persons With and Without Diagnosed Mental Illness Who Died by Suicide in Victoria, Australia - Clapperton, A.; Newstead, S.; Bugeja, L.; Pirkis, J. (Crisis, 2019)
Background: Mental illness is an established risk factor for suicide. To develop effective prevention interventions and strategies, the demographic characteristics and stressors (other than, or in addition to, mental illness) that can influence a person's decision to die by suicide need to be identified. Aim: To examine cases of suicide by the presence or absence of a diagnosed mental illness (mental illness status) to identify differences in factors associated with suicide in the groups. Method: Logistic regression analyses were used to investigate mental illness status and exposure to stressors among 2,839 persons who died by suicide in Victoria, Australia (2009-2013), using the Victorian Suicide Register. Results: Females, metropolitan residents, persons treated for physical illness/injury, those exposed to stressors related to isolation, family, work, education, and substance use and those who had made a previous suicide attempt had increased odds of having a diagnosed mental illness. Employed persons had decreased odds of having a diagnosed mental illness. Limitations: The retrospectivity of data collection as well as the validity and reliability of some of the data may be questionable owing to the potential for recall bias. Conclusion: The point of intervention for suicide prevention cannot always be a mental health professional; some people who die by suicide either do not have a mental illness or have not sought help.
Keywords: adolescent; adult; aged; bereavement; child; demography; divorce; employment; family conflict; female; human; male; marriage; mental disease; mental stress; middle aged; retrospective study; sexual and gender minority; very elderly; Victoria; young adult

Suicidal Ideation and Behavior Among Youth Victims of Sex Trafficking in Kentuckiana - Frey, L.M.; Middleton, J.; Gattis, M.N.; Fulginiti, A. (Crisis, 2019)
Background: Youth experiencing homelessness are at risk for sex trafficking and mental health concerns. Aims: More information is needed to elucidate the prevalence and characteristics of suicidal ideation and behavior among youth experiencing sex trafficking. Method: The present study examined suicidal ideation and behavior in a convenience sample of 128 youths experiencing homelessness aged 12-25 years in metropolitan Louisville, Kentucky, and southern Indiana. Participants were asked seven questions regarding suicidal ideation and attempts as part of an enhanced version of the 60-item Youth Experiences Survey (YES). Results: Approximately 53% of the sample reported experiencing suicidal ideation at some point in their lifetime and the odds of a youth experiencing homelessness who had experienced sex trafficking reporting suicidal ideation was 3.87 times higher than the odds of a youth experiencing homelessness who had not experienced sex trafficking. Additionally, of those who reported experiencing suicidal ideation, the majority (84.4%) reported they had attempted suicide in their lifetime. Limitations: This study relied on a convenience sample of youth receiving services in the Kentuckiana region and brief, self-report measures yielding categorical data. Conclusion: Programs servicing youth experiencing homelessness should require additional training and resources regarding the identification, screening, and assessment of youth who are at risk of or who have experienced sex trafficking in order to more quickly connect youth with much-needed, trauma-informed services.
Keywords: adolescent; child; crime victim; epidemiology; ethnic group; female; homeless person; human; human trafficking; Indiana; interpersonal communication; Kentucky; male; minority group; psychology; sexual and gender minority; suicidal ideation; suicide attempt; young adult

Why and how to support depsychiatrisation of adult transidentity in ICD-11: A French study - Askevis-Leherpeux, F.; de la Chenelière, M.; Baleige, A.; Chouchane, S.; Martin, M.-J.; Robles-García, R.; Fresán, A.; Quach, A.; Stona, A.-C.; Reed, G.; Roelandt, J.-L. (European Psychiatry, 2019)
Background: For the 11th version of the International Classification of Diseases, the WHO recommended to rename transgender transidentity as “gender incongruence”, to remove it from the chapter of mental and behavioral disorders, and to put it in a new category titled “Conditions related to sexual health”. This should contribute to reduce stigmatisation while maintaining access to medical care. One argument in favor of depsychiatrisation is to demonstrate that essential features of gender identity disorders, namely psychological distress and functional impairment, are not necessarily reported by every transgender person, and may result from social rejection and violence rather than dysphoria itself. Initially confirmed in Mexico, these hypotheses were tested in a specific French medical context, where access to care does not require any prior mental health evaluation or diagnosis. Method: In 2017, 72 transgender persons completed retrospective interviews which focused on the period when they became aware that they might be transgender and perhaps would need to do something about it. Results: Results showed that psychological distress and functional impairment were not reported by every participant, that they may result from rejection and violence, and especially from rejection and violence coming from coworkers and schoolmates. Additional data showed that the use of health services for body transformation did not depend on distress and dysfunction. Finally, participants preferred ICD 11 to employ “transgender” or “transidentity” rather than “gender incongruence”. Conclusion: Results support depsychiatrisation. They are discussed in terms of medical, ethical, legal, and social, added values and implications of depsychiatrisation.
Keywords: adult; anxiety; article; coworker; depression; distress syndrome; female; female to male transgender; France; functional disease; gender dysphoria; gender identity; human; ICD-11; major clinical study; male; male to female transgender; mental health service; priority journal; retrospective study; social disability; social rejection; suicidal ideation; transgender; violence

Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the World Health Organization's World Mental Health International College Student Initiative - Ebert, D.D.; Franke, M.; Kählke, F.; Küchler, A.-M.; Bruffaerts, R.; Mortier, P.; Karyotaki, E.; Alonso, J.; Cuijpers, P.; Berking, M.; Auerbach, R.P.; Kessler, R.C.; et al. (International journal of methods in psychiatric research, 2019)
BACKGROUND: The majority of university students with mental health problems are untreated. Only a small empirical literature exists on strategies to increase mental health service use. AIMS: To investigate the effects and moderators of a brief acceptance-facilitating intervention on intention to use mental health services among university students. METHOD: Within the German site of the World Health Organization's World Mental Health International College Student (WMH-ICS) initiative, 1,374 university students were randomized to an intervention condition (IC; n = 664) or a control condition (CC; n = 710) that was implemented in the survey itself. Both conditions received the questions assessing mental disorders and suicidality that were included in other WMH-ICS surveys. The IC group then additionally received: Internet-based personalized feedback based on subject symptom severity in the domains of depression, anxiety, substance use, suicidal thoughts and behaviors, and nonsuicidal self-injury; psychoeducation tailored to the personal symptom profile; and information about available university and community mental health services. The primary outcome was reported intention to use psychological interventions in the next semester, which was the last question in the survey. A broad range of potential moderating factors was explored. RESULTS: There was a significant main effect of the intervention with students randomized to IC, reporting significantly higher intentions to seek help in the next semester than students in the CC condition (d = 0.12, 95% CI: 0.02 to 0.23). Moderator analyses indicated that the intervention was more effective among students that fulfilled the criteria for lifetime (d = 0.34; 95% CI: -0.08 to 0.7) and 12-month panic-disorder (d = 0.32; 95% CI: -0.10 to 0.74) compared with those without lifetime (d = 0.11; 95% CI: 0.00 to 0.22) or 12-month panic disorder (d = 0.11; 95% CI: 0.00 to 0.22), students with lower (d = 0.37; 95% CI: -0.77 to 1.51) than higher (d = -0.01; 95% CI: -0.36 to 0.34) self-reported physical health, and students with nonheterosexual (d = 0.38; 95% CI: 0.08 to 0.67) compared with heterosexual (d = 0.06; 95% CI: -0.06 to 0.17) sexual orientation. The intervention had no effects among students who reported that they recognized that they had an emotional problem and "are already working actively to change it" (Stage 4 "stages of change"). CONCLUSIONS: A simple acceptance-facilitating intervention can increase intention to use mental health services, although effects, are on average, small. Future studies should investigate more personalized approaches with interventions tailored to barriers and clinical characteristics of students. In order to optimize intervention effects, the development and evaluation should be realized in designs that are powered to allow incremental value of different intervention components and tailoring strategies to be evaluated, such as in multiphase optimization designs.
Keywords: anxiety; article; automutilation; clinical feature; college student; controlled study; depression; female; health behavior; heterosexuality; human; Internet; major clinical study; male; mental health service; outcome assessment; panic; psychoeducation; randomized controlled trial; risk factor; substance use; suicidal ideation; university student; World Health Organization

Caring for the Transgender Adolescent: It Takes a Village - Agana, M.; Apple, R.; Alavi, Z.; Gibb, T.; Soares, N.; Augustyn, M. (Journal of developmental and behavioral pediatrics : JDBP, 2019)
CASE: Christa is a 15-year-old male-to-female (MTF) transgender patient who comes to your Developmental-Behavioral Pediatrics office for consultation on attention deficit/hyperactivity disorder (ADHD) management and concerns about worsening anxiety. Review of medical history included mild persistent asthma managed with steroid inhaler and leukotriene antagonist. She was diagnosed with ADHD at 12 years and has been placed on methylphenidate and clonidine over the years with little improvement. She struggles in school, with barely passing grades, and feels that she cannot focus on her assignments.She was diagnosed with MTF transition gender dysphoria, social anxiety disorder, and depressive disorder at 13 years by a psychiatrist and was treated with sertraline with some mood improvement. More recently, she reports having thoughts of wanting to hurt people and "wanting to watch them wither away." She expressed being terrified by these thoughts, which lasted for a couple of days but have since resolved. She denied any suicidal thoughts recently and gives credit to her "best girlfriend" for her overall improved mood, improved sleep pattern, and increased energy level. She expressed having deepening feelings for this girlfriend but admitted to not having acted on these feelings as she is afraid of the consequences. She currently uses the pronouns she/her/hers.Family history is pertinent for paternal bipolar disorder. There is considerable psychosocial stress as Christa is estranged from her father, who is not supportive of her transition, although mother is. Unfortunately, she is dependent on her father for medical insurance coverage, and he is refusing to give authorization to proceed with the evaluations and diagnostic workup for the transformation. Christa has been repeatedly encouraged to seek counseling but has declined because of previous poor experiences with counselors. Her primary care clinician in Family Medicine has been administering hormonal replacement therapy because she cannot access the regional center of excellence because of above-mentioned insurance issues. She presents to you now with her mother for management suggestions and diagnostic clarification. What is your next step?
Keywords: adolescent; attention deficit disorder; case report; clinical observation; clinical study; diagnosis; female; gender dysphoria; hormone substitution; human; sex reassignment; transgender

Instances of online suicide, the law and potential solutions - Phillips, J.G.; Diesfeld, K.; Mann, L. (Psychiatry, Psychology and Law, 2019)
To understand the social and legal issues posed by suicide-related communications over the Internet (messages of threatened suicide and advocated suicide), this article examines a selection of cases involving different types of online baiting and harassment that illustrate different legal and technological issues. The anonymity afforded by computer-mediated communication allows bullies to harass vulnerable individuals and leak (disclose) their personal information. Computer mediation of communication potentially diffuses responsibility; imposes a temporal asynchrony between signified intent and audience response; and reduces the empathy that might motivate observers or witnesses to intervene and render assistance, factors that make online baiting a serious social, legal and technological problem. Potential actions (both legal and technological) for addressing this problem are outlined.
Keywords: electronic device; mobile phone; application service provider; article; child pornography; confidentiality; cyberbullying; emotionality; empathy; fraud; harassment; human; information center; Internet; law; mobile application; online harassment; online monitoring; online support group; search engine; sexual orientation; social media; social network; suicidal ideation; suicide; suicide attempt

Associations of Lesbian, Gay, Bisexual, Transgender, and Questioning–Inclusive Sex Education With Mental Health Outcomes and School-Based Victimization in U.S. High School Students - Proulx, C.N.; Coulter, R.W.S.; Egan, J.E.; Matthews, D.D.; Mair, C. (Journal of Adolescent Health, 2019)
Purpose: Homophobic school climates are related to increased victimization for sexual minority youth (SMY), leading to increased risk of adverse mental health outcomes. Interventions that promote positive school climate may reduce the risk of victimization and adverse mental health outcomes in SMY. This study explored whether lesbian, gay, bisexual, transgender, and questioning (LGBTQ)–inclusive sex education is associated with adverse mental health and school-based victimization in U.S. youth. Methods: Data analysis of representative data from the 2015 Youth Risk Behavior Survey and the 2014 School Health Profiles was conducted using multilevel logistic models testing whether youth in states with higher proportions of schools teaching LGBTQ-inclusive sex education had lower odds of reporting being bullied in school and experiencing adverse mental health outcomes, including depressive symptoms and suicidality. Results: After controlling for covariates, protective effects for all youth were found for suicidal thoughts (adjusted odds ratio [AOR]:.91, 95% confidence interval [CI]:.89–.93) and making a suicide plan (AOR:.79; 95% CI:.77–.80). Lesbian and gay youth had lower odds of experiencing bullying in school as the proportion of schools within a state teaching LGBTQ-inclusive sex education increased (AOR:.83; CI:.71–.97). Bisexual youth had significantly lower odds of reporting depressive symptoms (AOR:.92; 95% CI:.87–.98). Conclusions: Students in states with a greater proportion of LGBTQ-inclusive sex education have lower odds of experiencing school-based victimization and adverse mental health. These findings can be used to guide intervention development at the school and state levels.
Keywords: adolescent depression; adolescent health; adolescent sexual behavior; article; bisexuality; bullying; female; health survey; heterosexuality; high school student; homophobia; homosexual female; homosexual male; human; male; mental health; outcome assessment; priority journal; risk factor; sexual and gender minority; sexual education; suicide; transgender; United States