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1.  Disproportionate Exposure to Early-Life Adversity and Sexual Orientation Disparities in Psychiatric Morbidity 
Child abuse & neglect  2012;36(9):645-655.
Objectives
Lesbian, gay, and bisexual (LGB) populations exhibit elevated rates of psychiatric disorders compared to heterosexuals, and these disparities emerge early in the life course. We examined the role of exposure to early-life victimization and adversity—including physical and sexual abuse, homelessness, and intimate partner violence—in explaining sexual orientation disparities in mental health among adolescents and young adults.
Methods
Data were drawn from the National Longitudinal Study of Adolescent Health, Wave 3 (2001–2002), a nationally representative survey of adolescents. Participants included gay/lesbian (n=227), bisexual (n=245), and heterosexual (n=13,490) youths, ages 18–27. We examined differences in the prevalence of exposure to child physical or sexual abuse, homelessness or expulsion from one’s home by caregivers, and physical and sexual intimate partner violence according to sexual orientation. Next we examined the associations of these exposures with symptoms of psychopathology including suicidal ideation and attempts, depression, binge drinking, illicit drug use, tobacco use, alcohol abuse, and drug abuse. Finally, we determined whether exposure to victimization and adversity explained the association between sexual orientation and psychopathology.
Results
Gay/lesbian and bisexual respondents had higher levels of psychopathology than heterosexuals across all outcomes. Gay/lesbian respondents had higher odds of exposure to child abuse and housing adversity, and bisexual respondents had higher odds of exposure to child abuse, housing adversity, and intimate partner violence, than heterosexuals. Greater exposure to these adversities explained between 10–20% of the relative excess of suicidality, depression, tobacco use, and symptoms of alcohol and drug abuse among LGB youths compared to heterosexuals. Exposure to victimization and adversity experiences in childhood and adolescence significantly mediated the association of both gay/lesbian and bisexual orientation with suicidality, depressive symptoms, tobacco use, and alcohol abuse.
Conclusions
Exposure to victimization in early-life family and romantic relationships explains, in part, sexual orientation disparities in a wide range of mental health and substance use outcomes, highlighting novel targets for preventive interventions aimed at reducing these disparities.
doi:10.1016/j.chiabu.2012.07.004
PMCID: PMC3445753  PMID: 22964371
2.  Associations of Racial/Ethnic Identities and Religious Affiliation with Suicidal Ideation among Lesbian, Gay, Bisexual, and Questioning Individuals 
Background
Our aim was to examine the associations of racial/ethnic identity and religious affiliation with suicidal ideation among lesbian, gay, bisexual, and questioning (LGBQ) and heterosexual college students. An additional aim was to determine the prevalence of passive suicidal ideation (i.e., death ideation) and active suicidal ideation among culturally diverse LGBQ individuals.
Methods
Data from the National Research Consortium probability-based sample of college students from 70 postsecondary institutions (n=24,626) were used to examine active and passive suicidal ideation in the past 12-months and lifetime active suicidal ideation among students by sexual orientation, racial/ethnic identity, and religious affiliation.
Results
Across most racial/ethnic groups and religious affiliations, LGBQ students were more likely to report active suicidal ideation than non-LGBQ individuals. Among LGBQ students, Latino individuals had lower odds of reporting both past 12-month passive and active suicidal ideation than their non-Hispanic white LGBQ counterparts. Compared to Christian LGBQ students, Agnostic/Atheist LGBQ individuals had greater odds of reporting past 12-month passive suicidal ideation, and Jewish LGBQ students were less likely to endorse past 12-month passive and active suicidal ideation.
Limitations
Cross-sectional design and self-reported data.
Conclusions
Results corroborate previous research showing elevated prevalence of suicidal ideation among LGBQ individuals in comparison to their heterosexual counterparts. These findings are among the first to document prevalence differences within the LGBQ population based on intersectional identities (race/ethnicity and religious affiliation). Providers should recognize that LGBQ individuals might need support in negotiating the complex relationship between multiple identities, especially due to their elevated prevalence of suicidal ideation.
doi:10.1016/j.jad.2014.07.039
PMCID: PMC4397160  PMID: 25795534
Suicidal Ideation; LGBT; Race/Ethnicity; Religious Affiliation
3.  Minority Stress and Mechanisms of Risk for Depression and Suicidal Ideation among Lesbian, Gay, and Bisexual Youth 
Developmental psychology  2015;51(5):688-696.
The experience of minority stress is often named as a cause for mental health disparities among lesbian, gay, and bisexual (LGB) youth, including higher levels of depression and suicidal ideation. The processes or mechanisms through which these disparities occur are understudied. The interpersonal-psychological theory of suicide posits two key mechanisms for suicidal ideation: perceived burdensomeness and thwarted belongingness (Joiner, 2009). The aim of the current study is to assess the mental health and adjustment among LGB youth emphasizing the minority stress model (Meyer, 2003) and the interpersonal-psychological theory of suicide (Joiner et al., 2009). With a survey of 876 LGB self-identified youth, levels of coming-out stress, sexual orientation victimization, perceived burdensomeness, thwarted belongingness, depression, and suicidal ideation were examined. The results of a multigroup mediation model show that for all gender and sexual identity groups, the association of sexual orientation victimization with depression and suicidal ideation was mediated by perceived burdensomeness. For gay, lesbian, and bisexual girls coming-out stress was also found to be related to depression and suicidal ideation, mediated by perceived burdensomeness. The results suggest that feeling like a burden to “people in their lives” is a critical mechanism in explaining higher levels of depression and suicidal ideation among LGB youth. These results have implications for community and social support groups, many of which base their interventions on decreasing social isolation rather than addressing youths' beliefs of burdensomeness. Implications for future research, clinical and community settings are discussed.
doi:10.1037/a0038994
PMCID: PMC4412799  PMID: 25751098
LGB youth; minority stress; interpersonal-psychological theory of suicide; depression; suicidal ideation; suicide; victimization; burdensomeness; belonging
4.  A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people 
BMC Psychiatry  2008;8:70.
Background
Lesbian, gay and bisexual (LGB) people may be at higher risk of mental disorders than heterosexual people.
Method
We conducted a systematic review and meta-analysis of the prevalence of mental disorder, substance misuse, suicide, suicidal ideation and deliberate self harm in LGB people. We searched Medline, Embase, PsycInfo, Cinahl, the Cochrane Library Database, the Web of Knowledge, the Applied Social Sciences Index and Abstracts, the International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases for articles published January 1966 to April 2005. We also used Google and Google Scholar and contacted authors where necessary. We searched all terms related to homosexual, lesbian and bisexual people and all terms related to mental disorders, suicide, and deliberate self harm. We included papers on population based studies which contained concurrent heterosexual comparison groups and valid definition of sexual orientation and mental health outcomes.
Results
Of 13706 papers identified, 476 were initially selected and 28 (25 studies) met inclusion criteria. Only one study met all our four quality criteria and seven met three of these criteria. Data was extracted on 214,344 heterosexual and 11,971 non heterosexual people. Meta-analyses revealed a two fold excess in suicide attempts in lesbian, gay and bisexual people [pooled risk ratio for lifetime risk 2.47 (CI 1.87, 3.28)]. The risk for depression and anxiety disorders (over a period of 12 months or a lifetime) on meta-analyses were at least 1.5 times higher in lesbian, gay and bisexual people (RR range 1.54–2.58) and alcohol and other substance dependence over 12 months was also 1.5 times higher (RR range 1.51–4.00). Results were similar in both sexes but meta analyses revealed that lesbian and bisexual women were particularly at risk of substance dependence (alcohol 12 months: RR 4.00, CI 2.85, 5.61; drug dependence: RR 3.50, CI 1.87, 6.53; any substance use disorder RR 3.42, CI 1.97–5.92), while lifetime prevalence of suicide attempt was especially high in gay and bisexual men (RR 4.28, CI 2.32, 7.88).
Conclusion
LGB people are at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self harm than heterosexual people.
doi:10.1186/1471-244X-8-70
PMCID: PMC2533652  PMID: 18706118
5.  Associations of Discrimination and Violence With Smoking Among Emerging Adults: Differences by Gender and Sexual Orientation 
Nicotine & Tobacco Research  2011;13(12):1284-1295.
Introduction:
Lesbian, gay, and bisexual (i.e., sexual minority) populations have higher smoking prevalence than their heterosexual peers, but there is a lack of empirical study into why such disparities exist. This secondary analysis of data sought to examine associations of discrimination and violence victimization with cigarette smoking within sexual orientation groups.
Methods:
Data from the Fall 2008 and Spring 2009 National College Health Assessments were truncated to respondents of 18–24 years of age (n = 92,470). Since heterosexuals comprised over 90% of respondents, a random 5% subsample of heterosexuals was drawn, creating a total analytic sample of 11,046. Smoking status (i.e., never-, ever-, and current smoker) was regressed on general (e.g., not sexual orientation–specific) measures of past-year victimization and discrimination. To examine within-group differences, two sets of multivariate ordered logistic regression analyses were conducted: one set of models stratified by sexual orientation and another set stratified by gender-by-sexual-orientation groups.
Results:
Sexual minorities indicated more experiences of violence victimization and discrimination when compared with their heterosexual counterparts and had nearly twice the current smoking prevalence of heterosexuals. After adjusting for age and race, lesbians/gays who were in physical fights or were physically assaulted had higher proportional odds of being current smokers when compared with their lesbian/gay counterparts who did not experience those stressors.
Conclusions:
When possible, lesbian/gay and bisexual groups should be analyzed separately, as analyses revealed that bisexuals had a higher risk profile than lesbians/gays. Further research is needed with more nuanced measures of smoking (e.g., intensity), as well as examining if victimization may interact with smoking cessation.
doi:10.1093/ntr/ntr183
PMCID: PMC3223581  PMID: 21994344
6.  Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001472.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
Please see later in the article for the Editors' Summary
Background
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
Methods and Findings
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).
Conclusions
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US, but it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
Why Was This Study Done?
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
What Did the Researchers Do and Find?
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
What Do These Findings Mean?
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001472.
This study is further discussed in a PLOS Medicine Perspective by Jerome Singh
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, including summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and men who have sex with men, on HIV prevention, and on AIDS in Africa (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about HIV/AIDS among men who have sex with men (in English and Spanish)
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
doi:10.1371/journal.pmed.1001472
PMCID: PMC3708702  PMID: 23853554
7.  Type of sexual intercourse experience and suicidal ideation, plans, and attempts among youths: a cross-sectional study in South Korea 
BMC Public Health  2016;16:1229.
Background
Despite abundant theoretical evidence of higher rates of suicide among lesbian, gay, and bisexual (LGB) youths, little is known about the relationship between suicide and types of sexual intercourse experience in youths. This study examines the association between the type of intercourse experience and suicide risk outcomes (SROs: suicidal ideation, plans for suicide, suicidal attempts) from the Korea Youth Risk Behavior Web-based Survey.
Methods
We analyzed cross-sectional data from 146,621 students aged 12–17 years for the years 2012 and 2013. We defined lesbian, gay, or bisexual youth as youths who engaged in a type of sexual intercourse (same-sex or both-sex intercourse). A chi-square test and logistic regression analysis were used to evaluate the association between intercourse experience and SROs.
Results
The results showed that the prevalence of suicidal ideation was higher among youths with same-sex intercourse experience (45.9% for females, 33.7% for males) than among youths with opposite-sex intercourse experience (42.2% for females, 23.8% for males) and those with no experience in intercourse (21.0% for females, 12.7% for males). After adjusting for revealed risk factors that were associated with suicide risks, among males, suicide risks based on intercourse experience seemed to increase in the following order: no experience in sexual intercourse, opposite-sex, same-sex, and then both-sexes sexual intercourse experience. Same- and both-sexes intercourse related SROs are strongly linked to violence (being physically assaulted, threatened, or bullied) and sexually transmitted diseases (STDs), including HIV infection. Those having no sexual intercourse experience showed the least probability of suicide risks among youths.
Conclusion
The SROs of youths with same-sex or both-sex intercourse experience had strong associations with gender (males), violence, and STDs. Therefore, school educators must continue to advocate for and to implement LGB inclusive policies and programs in order to promote safe and supportive learning environments where all students are protected from health risk behaviors.
doi:10.1186/s12889-016-3895-y
PMCID: PMC5142152  PMID: 27923371
Lesbian; Gay; Bisexual; Youths; Sexual intercourse; Suicide; Violence; Sexually transmitted diseases
8.  Sexual Minority-Related Victimization as a Mediator of Mental Health Disparities in Sexual Minority Youth: A Longitudinal Analysis 
Journal of youth and adolescence  2013;42(3):394-402.
Sexual minority youth (youth who are attracted to the same sex or endorse a gay/lesbian/bisexual identity) report significantly higher rates of depression and suicidality than heterosexual youth. The minority stress hypothesis contends that the stigma and discrimination experienced by sexual minority youth create a hostile social environment that can lead to chronic stress and mental health problems. The present study used longitudinal mediation models to directly test sexual minority-specific victimization as a potential explanatory mechanism of the mental health disparities of sexual minority youth. One hundred ninety seven adolescents (14–19 years old; 70% female; 29% sexual minority) completed measures of sexual minority-specific victimization, depressive symptoms, and suicidality at two time points six months apart. Compared to heterosexual youth, sexual minority youth reported higher levels of sexual minority-specific victimization, depressive symptoms, and suicidality. Sexual minority-specific victimization significantly mediated the effect of sexual minority status on depressive symptoms and suicidality. The results support the minority stress hypothesis that targeted harassment and victimization are partly responsible for the higher levels of depressive symptoms and suicidality found in sexual minority youth. This research lends support to public policy initiatives that reduce bullying and hate crimes because reducing victimization can have a significant impact on the health and well-being of sexual minority youth.
doi:10.1007/s10964-012-9901-5
PMCID: PMC3570607  PMID: 23292751
sexual minority youth; victimization; depression; suicidality; minority stress
9.  Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(3):e1001609.
Ana Maria Buller and colleagues review 19 studies and estimate the associations between the experience and perpetration of intimate partner violence and various health conditions and sexual risk behaviors among men who have sex with men.
Please see later in the article for the Editors' Summary
Background
Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant problem. Little is known about the association between IPV and health for MSM. We aimed to estimate the association between experience and perpetration of IPV, and various health conditions and sexual risk behaviours among MSM.
Methods and Findings
We searched 13 electronic databases up to 23 October 2013 to identify research studies reporting the odds of health conditions or sexual risk behaviours for MSM experiencing or perpetrating IPV. Nineteen studies with 13,797 participants were included in the review. Random effects meta-analyses were performed to estimate pooled odds ratios (ORs). Exposure to IPV as a victim was associated with increased odds of substance use (OR = 1.88, 95% CIOR 1.59–2.22, I2 = 46.9%, 95% CII2 0%–78%), being HIV positive (OR = 1.46, 95% CIOR 1.26–1.69, I2 = 0.0%, 95% CII2 0%–62%), reporting depressive symptoms (OR = 1.52, 95% CIOR 1.24–1.86, I2 = 9.9%, 95% CII2 0%–91%), and engagement in unprotected anal sex (OR = 1.72, 95% CIOR 1.44–2.05, I2 = 0.0%, 95% CII2 0%–68%). Perpetration of IPV was associated with increased odds of substance use (OR = 1.99, 95% CIOR 1.33–2.99, I2 = 73.1%). These results should be interpreted with caution because of methodological weaknesses such as the lack of validated tools to measure IPV in this population and the diversity of recall periods and key outcomes in the identified studies.
Conclusions
MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in unprotected anal sex. MSM who perpetrate IPV are more likely to engage in substance use. Our results highlight the need for research into effective interventions to prevent IPV in MSM, as well as the importance of providing health care professionals with training in how to address issues of IPV among MSM and the need to raise awareness of local and national support services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Intimate partner violence (IPV, also called domestic violence) is a common and widespread problem. Globally, nearly a third of women are affected by IPV at some time in their life, but the prevalence of IPV (the proportion of the population affected by IPV) varies widely between countries. In central sub-Saharan Africa, for example, nearly two-thirds of women experience IPV during their lifetime, whereas in East Asia only one-sixth of women are affected. IPV is defined as physical, sexual, or emotional harm that is perpetrated on an individual by a current or former partner or spouse. Physical violence includes hitting, kicking, and other types of physical force; sexual violence means forcing a partner to take part in a sex act when the partner does not consent; and emotional abuse includes threatening a partner by, for example, stalking them or preventing them from seeing their family. The adverse effects of IPV for women include physical injury, depression and suicidal behaviour, and sexual and reproductive health problems such as HIV infection and unwanted pregnancies.
Why Was This Study Done?
IPV affects men as well as women. Men can be subjected to IPV either by a female partner or by a male partner in the case of men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). Recent reviews suggest that the prevalence of IPV in same-sex couples is as high as the prevalence of IPV for women in opposite-sex relationships: reported lifetime prevalences of IPV in homosexual male relationships range between 15.4% and 51%. Little is known, however, about the adverse health effects of IPV on MSM. It is important to understand how IPV affects the health of MSM so that appropriate services and interventions can be provided to support MSM who experience IPV. In this systematic review (a study that identifies all the research on a given topic using predefined criteria) and meta-analysis (a study that combines the results of several studies using statistical methods), the researchers investigate the associations between the experience and perpetration of IPV and various health conditions and sexual risk behaviours among MSM.
What Did the Researchers Do and Find?
The researchers identified 19 studies that investigated associations between IPV and various health conditions or sexual risk behaviours (for example, unprotected anal sex, a risk factor for HIV infection) among MSM. The associations were expressed as odds ratios (ORs); an OR represents the odds (chances) that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The researchers estimated pooled ORs from the data in the individual studies using meta-analysis. The pooled lifetime prevalence of experiencing any IPV (which was measured in six studies) was 48%. Exposure to IPV as a victim was associated with an increased risk of substance (alcohol or drug) use (OR = 1.88, data from nine studies), reporting depressive symptoms (OR = 1.52, data from three studies), being HIV positive (OR = 1.46, data from ten studies), and engagement in unprotected sex (OR = 1.72, data from eight studies). Perpetration of IPV was associated with an increased risk of substance abuse (OR = 1.99, data from six studies).
What Do These Findings Mean?
These findings suggest that MSM frequently experience IPV and that exposure to IPV is associated with several adverse health conditions and sexual risk behaviours. There were insufficient data to estimate the lifetime prevalence of IPV perpetration among MSM, but these findings also reveal an association between IPV perpetration and substance use. The accuracy of these findings is limited by heterogeneity (variability) between the studies included in the meta-analyses, by the design of these studies, and by the small number of studies. Despite these and other limitations, these findings highlight the need to undertake research to identify interventions to prevent IPV among MSM and to learn more about the health effects of IPV among MSM. They highlight the importance of health care professionals being aware that IPV is a problem for MSM and of training these professionals to assess MSM for IPV. Finally, these results highlight the need to improve the availability and effectiveness of support services to which health care professionals can refer MSM experiencing or perpetrating IPV.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001609.
The World Health Organization provides detailed information on intimate partner violence
The US Centers for Disease Control and Prevention provides information about IPV and a fact sheet on understanding IPV that includes links to further resources
The UK National Health Service Choices website has a webpage about domestic violence, which includes descriptions of personal experiences
The US National Domestic Violence Hotline provides confidential help and support to people experiencing IPV, including MSM; its website includes personal stories of IPV
The US Gay Men's Domestic Violence Project/GLBTQ Domestic Violence Project provides support and services to MSM experiencing IPV; its website includes some personal stories
The UK not-for-profit organization Respect runs two advice lines: the Men's Advice Line provides advice and support for men experiencing domestic violence and abuse and the Respect Phoneline provides advice for domestic violence perpetrators and for professionals who would like further information about services for those using violence/abuse in their intimate partner relationships
The UK not-for-profit organization ManKind Initiative also provides support for male victims of IPV
The UK not-for-profit organization Broken Rainbow UK provides help and support for lesbians and MSM experiencing IPV
MedlinePlus provides links to other resources about domestic violence (in English and Spanish)
The UK charity Galop gives advice and support to people who have experienced biphobia, homophobia, transphobia, sexual violence, or domestic abuse
doi:10.1371/journal.pmed.1001609
PMCID: PMC3942318  PMID: 24594975
10.  Effects of Victimization and Violence on Suicidal Ideation and Behaviors Among Sexual Minority and Heterosexual Adolescents 
LGBT Health  2016;3(2):153-161.
Abstract
Purpose: Sexual minority youth (SMY) are at higher risk for victimization and suicide than are heterosexual youth (HY). Relatively little research has examined which types of victimization are most closely linked to suicide, which is necessary to develop targeted prevention interventions. The present study was conducted to address this deficit.
Methods: The data come from the 2011 Chicago Youth Risk Behavior Survey (n = 1,907). Structural equation modeling (SEM) in Mplus evaluated the direct, indirect, and total effects of sexual orientation on a latent indicator of suicidal ideation and behaviors via seven types of victimization. Four indicators of victimization were school-specific (e.g., harassment due to sexual orientation or gender identity (SO/GID), bullying, threatened or injured with a weapon, and skipping school due to safety concerns), and three indicators assessed other types of victimization (e.g., electronic bullying, intimate partner violence, and sexual abuse).
Results: Thirteen percent of youth were classified as SMY. Significantly more SMY than HY reported suicidal ideation (27.95% vs. 13.64%), a suicide plan (22.78% vs. 12.36%), and at least one suicide attempt (29.92% vs. 12.43%) in the past year (all P < .001). A greater percentage of SMY reported SO/GID-related harassment, skipping school, electronic bullying, and sexual abuse. Sexual orientation was not directly related to suicidal ideation and behaviors in SEM. Rather, SMY's elevated risk of suicidality functioned indirectly through two forms of school-based victimization: being threatened or injured with a weapon (B = .19, SE = .09, P ≤ .05) and experiencing SO/GID-specific harassment (B = .40, SE = .15, P ≤ .01). There also was a trend for SMY to skip school as a strategy to reduce suicide risk.
Conclusion: Although SMY experience higher rates of victimization than do HY, school-based victimization that involves weapons or is due to one's SO/GID appear to be the most deleterious. That SMY may skip school to reduce their risk of suicidal ideation and behaviors is problematic, and schools should be encouraged to enact and enforce policies that explicitly protect SMY from victimization.
doi:10.1089/lgbt.2015.0037
PMCID: PMC4841901  PMID: 26789401
child and adolescent development; LGBT youth; sexual orientation; suicide
11.  The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth 
Pediatrics  2011;127(5):896-903.
OBJECTIVE:
To determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors.
METHODS:
A total of 31 852 11th grade students (1413 [4.4%] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006–2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and antibullying) that specifically protected lesbian, gay, and bisexual students.
RESULTS:
Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96–0.99]).
CONCLUSIONS:
This study documents an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation–related disparities in suicide attempts.
doi:10.1542/peds.2010-3020
PMCID: PMC3081186  PMID: 21502225
suicide attempts; sexual orientation; disparities; social determinants of health
12.  Out Yonder: Sexual-Minority Adolescents in Rural Communities in British Columbia 
American journal of public health  2008;99(1):118-124.
Objectives
We compared sexual-minority adolescents living in rural communities with their peers in urban areas in British Columbia, exploring differences in emotional health, victimization experiences, sexual behaviors, and substance use.
Methods
We analyzed a population-based sample of self-identified lesbian, gay, or bisexual respondents from the British Columbia Adolescent Health Survey of 2003 (weighted n=6905). We tested rural–urban differences separately by gender with the χ2 test and logistic regressions.
Results
We found many similarities and several differences. Rural sexual-minority adolescent boys were more likely than were their urban peers to report suicidal behaviors and pregnancy involvement. Rural sexual-minority adolescents, especially girls, were more likely to report various types of substance use. Rural status was associated with a lower risk of dating violence and higher risk of early sexual debut for sexual-minority girls and a higher risk of dating violence and lower risk of early sexual debut for sexual-minority boys.
Conclusions
Location should be a demographic consideration in monitoring the health of sexual-minority adolescents. Lesbian, gay, and bisexual adolescents in rural communities may need additional support and services as they navigate adolescence.
doi:10.2105/AJPH.2007.122945
PMCID: PMC2636614  PMID: 19008511
13.  Sexual orientation disparities in physical health: age and gender effects in a population-based study 
Background
Recent studies have identified substantial health disparities between lesbian, gay, and bisexual (LGB) individuals compared to heterosexuals. However, possible variation in sexual orientation health disparities by age and according to gender remains largely unexplored.
Purpose
To examine physical health disparities between LGB and heterosexual individuals in a general population sample in Sweden, to explore potential age and gender differences in these disparities, and to test potential mechanisms underlying any observed disparities.
Method
Between 2008 and 2013, 60,922 individuals (16–84 years of age) responded to nationwide population-based health surveys. In the sample, 430 (0.7 %) individuals self-identified as gay/lesbian and 757 (1.3 %) self-identified as bisexual. Logistic and negative binomial regression analyses were used to explore health disparities based on sexual orientation.
Results
Overall, LGB individuals were more likely to report worse self-rated health as well as more physical health symptoms (e.g., pain, insomnia, dermatitis, tinnitus, intestinal problems) and conditions (e.g., diabetes, asthma, high blood pressure) compared to heterosexuals. However, these physical health disparities differed by age. Disparities were largest among adolescents and young adults and generally smallest in older age groups. Health behaviors and elevated reports of exposure to perceived discrimination, victimization, and threats of violence among sexual minorities partially explained the sexual orientation disparities in physical health.
Conclusions
Age emerged as an important effect modifier of physical health disparities based on sexual orientation. Gender-specific findings suggest that sexual orientation disparities persist into adulthood for women but are gradually attenuated for older age groups; in contrast, for men, these disparities disappear starting with young adults. These results support a developmental model of minority stress and physical health among LGB individuals.
doi:10.1007/s00127-015-1116-0
PMCID: PMC4747986  PMID: 26298574
Self-rated health; Minority stress; Health behaviors; Gay/bisexual; Sexual orientation; Life span
14.  A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP) 
PLoS Medicine  2016;13(3):e1001968.
Background
Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.
Methods and Findings
Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.
The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.
During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.
Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.
Conclusions
ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.
Trial registration
ClinicalTrials.gov NCT02505373
In a randomized controlled trial, Konrad Michel and colleagues test the efficacy of a manual-based therapy intended to prevent repeat suicide attempts.
Editors' Summary
Background
Suicide is a serious public health problem. Over 800,000 people worldwide die by suicide every year. In the US, one suicide death occurs approximately every 12 minutes. While the causes of suicide are complex, the goals of suicide prevention are simple—reduce factors that increase risk, and increase factors that promote resilience or coping. Factors that increase suicide risk include family history of suicide, family history of child abuse, previous suicide attempts, history of mental disorders (particularly depression), history of alcohol and substance abuse, and access to lethal means. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. A previous suicide attempt is the main risk factor for repeat attempts and for completed suicide. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide.
Why Was This Study Done?
A number of suicide prevention treatments have been developed. Most of them involve therapy sessions and personal follow-up. While some of them have been shown to work in clinical trials—often with participants who have made a previous suicide attempt—few interventions have proven to be effective consistently in different settings. For this study, the researchers developed a treatment called Attempted Suicide Short Intervention Program (ASSIP) composed of three therapy sessions shortly after the suicide attempt and follow-up over two years with personalized mailed letters. They wanted the therapy part to be short, in order to provide a treatment that would allow a psychiatric service to cope with the large number of patients seen in the emergency department after a suicide attempt. The therapeutic elements of the treatment emphasized building an early therapeutic alliance, which would then serve as a basis (“anchoring”) for long-term outreach contact through regular letters. The therapy sessions and letters follow a detailed script, which the researchers developed into a manual that includes a step-by-step description of the highly structured treatment, checklists, handouts, and standardized letters for use by health professionals in various clinical settings. This study was done to test whether ASSIP can reduce suicidal behavior in addition to routine treatment.
What Did the Researchers Do and Find?
The researchers carried out a randomized clinical trial testing ASSIP in people who had attempted suicide (the majority by intentional overdosing) and been admitted to the emergency department of the Bern University General Hospital in Switzerland. Participants were randomly assigned to two groups. The treatment group received ASSIP in addition to treatment as usual (inpatient, day patient, and outpatient care as deemed appropriate by the hospital clinicians); the control group received a single structured assessment interview plus treatment as usual. The study objective was to evaluate—with follow-up questionnaires and health-care data—whether ASSIP can reduce the rate of repeated suicide attempt in the 24 months after a suicide attempt. The researchers also compared suicidal ideation (i.e., whether and how often participants had suicidal thoughts), levels of depression, and how often people were hospitalized between the two groups.
A total of 120 patients who had recently attempted suicide were randomly allocated to treatment as usual or treatment as usual plus ASSIP. The 60 ASSIP participants received three therapy sessions followed by regular contact over 24 months. During the first therapy session, the patient was prompted to tell the story of how he or she had reached the point of attempting suicide. Narrative interviewing is a key element of ASSIP’s patient-centered collaborative approach. The first session was videotaped, and parts were watched and discussed by patient and therapist during the second session, to recreate the experience of psychological pain and analyze how stress developed into suicidal action. During the final session, therapist and patient developed a list of long-term goals, warning signs, and safety strategies. These were printed and given to the patient in a credit-card-sized folded leaflet along with a list of telephone help numbers. Patients were told to carry both items at all times and to use them in the event of an emotional crisis. Over the subsequent two years, patients received six letters from their therapist reminding them of the risk of future suicidal crises and the importance of the collaboratively developed safety strategies.
During the 24 months of follow-up, one death by suicide occurred in each group, five repeat suicide attempts were recorded in the ASSIP group, and 41 repeat suicide attempts were recorded in the control group. ASSIP was associated with an approximately 80% reduced risk of repeat suicide attempt. In addition, ASSIP participants spent 72% fewer days in the hospital during follow-up. There was no difference in patient-reported suicidal ideation or in levels of depression.
What Do these Findings Mean?
The results show that ASSIP, administered in addition to the usual clinical treatment, was able to reduce suicidal behavior over 24 months in patients who had recently attempted suicide. The addition of ASSIP to usual treatment directly or its effect on repeat attempts might also reduce health care costs. The absence of effects on suicidal thoughts and depression is consistent with ASSIP’s objective to help people cope with crises as opposed to eliminating them. The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising. They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001968.
National Action Alliance for Suicide Prevention has information on research prioritization for suicide prevention
There is also a supplemental issue of the American Journal of Preventive Medicine focused on research about suicide prevention
More information about suicide is available from ZEROSuicide http://zerosuicide.sprc.org/ and the Suicide Prevention Resource Center http://www.sprc.org/
The US Centers for Disease Control and Prevention has information on suicide
The UK Mental Health Foundation also has information on suicide
The page “About Suicide” from the American Foundation for Suicide Prevention has information on warning signs, risk factors, and statistics
The US National Suicide Prevention Lifeline offers help and information
The Bern University Hospital of Psychiatry has a page describing ASSIP for patients (in German)
The Finnish Association for Mental Health has a page describing ASSIP (in English)
doi:10.1371/journal.pmed.1001968
PMCID: PMC4773217  PMID: 26930055
15.  Suicide related ideation and behavior among Canadian gay and bisexual men: a syndemic analysis 
BMC Public Health  2015;15:597.
Background
While several studies have demonstrated that gay and bisexual men are at increased risk of suicide less attention has been given to the processes that generate the inherent inequity with the mainstream population. This study tested whether syndemic theory can explain the excess suicide burden in a sample of Canadian gay and bisexual men. Syndemic theory accounts for co-occurring and mutually reinforcing epidemics suffered by vulnerable groups due to the effects of social marginalization.
Methods
This study used data from Sex Now 2011, a cross-sectional survey of Canadian gay and bisexual men (n = 8382). The analysis measured the extent to which anti-gay marginalization and several psychosocial health problems are associated with suicide related ideation and attempts. Since psychosocial health problems were hypothesized to have an additive effect on suicide related ideation and attempts, the analysis calculated the effect of accumulated psychosocial health problems on suicide behavior.
Results
Suicide ideation and attempts were positively associated with each individual marginalization indicator (verbal violence, physical violence, bullying, sexual violence and work discrimination) and psychosocial health problems (smoking, party drugs, depression, anxiety, STIs, HIV risk and HIV). Furthermore, prevalence of suicide ideation and attempts increased with each added psychosocial health problem. Those who reported 3 or more had 6.90 (5.47–8.70) times the odds of experiencing suicide ideation and 16.29 (9.82–27.02) times the odds of a suicide attempt compared to those with no psychosocial health problems.
Conclusions
This investigation suggests that syndemics is a useful theory for studying suicide behavior among gay and bisexual men. Moreover, the findings highlight a need to address gay and bisexual men’s health problems holistically and the urgent need to reduce this population’s experience with marginalization and violence.
doi:10.1186/s12889-015-1961-5
PMCID: PMC4489209  PMID: 26136235
Gay men; Bisexual men; Suicide; Syndemic; Homophobia; Violence; Canada
16.  Stress mediates the relationship between sexual orientation and behavioral risk disparities 
BMC Public Health  2014;14:401.
Background
Growing evidence documents elevated behavioral risk among sexual-minorities, including gay, lesbian, and bisexual individuals; however, tests of biological or psychological indicators of stress as explanations for these disparities have not been conducted.
Methods
Data were from the 2005-2010 National Health and Nutrition Examination Survey, and included 9662 participants; 9254 heterosexuals, 153 gays/lesbians and 255 bisexuals. Associations between sexual orientation and tobacco, alcohol, substance, and marijuana use, and body mass index, were tested using the chi-square test. Stress, operationalized as depressive symptoms and elevated C-reactive protein, was tested as mediating the association between sexual orientation and behavioral health risks. Multiple logistic regression was used to test for mediation effects, and the Sobel test was used to evaluate the statistical significance of the meditating effect.
Results
Gays/lesbians and bisexuals were more likely to report current smoking (p < .001), a lifetime history of substance use (p < .001), a lifetime history of marijuana use (p < .001), and a lifetime period of risky drinking (p = .0061). The largest disparities were observed among bisexuals. Depressive symptoms partially mediated the association between sexual orientation and current smoking (aOR 2.04, 95% CI 1.59, 2.63), lifetime history of substance use (aOR 3.30 95% CI 2.20, 4.96), and lifetime history of marijuana use (aOR 2.90, 95% CI 2.02, 4.16), among bisexuals only. C-reactive protein did not mediate the sexual orientation/behavior relationship.
Conclusion
Higher prevalence of current smoking and lifetime history of substance use was observed among sexual minorities compared to heterosexuals. Among bisexuals, depressive symptoms accounted for only 0.9-3% of the reduction in the association between sexual orientation and marijuana use and tobacco use, respectively. More comprehensive assessments of stress are needed to inform explanations of the disparities in behavioral risk observed among sexual minorities.
doi:10.1186/1471-2458-14-401
PMCID: PMC4038400  PMID: 24767172
Sexual minorities; Health-related disparities; Substance use; Depressive symptoms; CRP
17.  Discrimination, Mental Health, and Substance Use Disorders Among Sexual Minority Populations 
LGBT Health  2016;3(4):258-265.
Abstract
Purpose: Sexual minority (lesbian, gay, bisexual) populations have a higher prevalence of mental health and substance use disorders compared to their heterosexual counterparts. Such disparities have been attributed, in part, to minority stressors, including distal stressors such as discrimination. However, few studies have examined associations between discrimination, mental health, and substance use disorders by gender among sexual minority populations.
Methods: We analyzed data from 577 adult men and women who self-identified as lesbian, gay, or bisexual and participated in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Six questions assessed discrimination due to sexual orientation. Weighted multivariable logistic regression examined associations between experiences of sexual orientation discrimination and both mental health and substance use disorders. Analyses were conducted separately for sexual minority men and women, adjusting for sociodemographic covariates.
Results: Sexual minority men who ever experienced discrimination (57.4%) reported higher odds of any lifetime drug use disorder and cannabis use disorder compared to sexual minority men who never experienced discrimination. Sexual minority women who ever experienced discrimination (42.9%) reported higher odds of any lifetime mood disorder and any lifetime anxiety disorder compared to sexual minority women who never experienced discrimination.
Conclusion: The findings suggest that discrimination is differentially associated with internalizing (mental health) and externalizing (substance use) disorders for sexual minority men and women. These findings indicate a need to consider how homophobia and heteronormative discrimination may contribute to distinct health outcomes for lesbian and bisexual women compared with gay and bisexual men.
doi:10.1089/lgbt.2015.0135
PMCID: PMC4976222  PMID: 27383512
discrimination; gender; mental health; sexual minorities; substance use
18.  Disparities in Adverse Childhood Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-State Probability-Based Sample 
PLoS ONE  2013;8(1):e54691.
Background
Adverse childhood experiences (e.g., physical, sexual and emotional abuse, neglect, exposure to domestic violence, parental discord, familial mental illness, incarceration and substance abuse) constitute a major public health problem in the United States. The Adverse Childhood Experiences (ACE) scale is a standardized measure that captures multiple developmental risk factors beyond sexual, physical and emotional abuse. Lesbian, gay, and bisexual (i.e., sexual minority) individuals may experience disproportionately higher prevalence of adverse childhood experiences.
Purpose
To examine, using the ACE scale, prevalence of childhood physical, emotional, and sexual abuse and childhood household dysfunction among sexual minority and heterosexual adults.
Methods
Analyses were conducted using a probability-based sample of data pooled from three U.S. states’ Behavioral Risk Factor Surveillance System (BRFSS) surveys (Maine, Washington, Wisconsin) that administered the ACE scale and collected information on sexual identity (n = 22,071).
Results
Compared with heterosexual respondents, gay/lesbian and bisexual individuals experienced increased odds of six of eight and seven of eight adverse childhood experiences, respectively. Sexual minority persons had higher rates of adverse childhood experiences (IRR = 1.66 gay/lesbian; 1.58 bisexual) compared to their heterosexual peers.
Conclusions
Sexual minority individuals have increased exposure to multiple developmental risk factors beyond physical, sexual and emotional abuse. We recommend the use of the Adverse Childhood Experiences scale in future research examining health disparities among this minority population.
doi:10.1371/journal.pone.0054691
PMCID: PMC3553068  PMID: 23372755
19.  Sexual Orientation and Risk Factors for Suicidal Ideation and Suicide Attempts: a Multi-centre Cross-Sectional Study in Three Asian Cities 
Journal of Epidemiology  2015;25(2):155-161.
Purpose
Despite robust empirical and theoretical evidence for higher rates of suicide among lesbian, gay, and bisexual (LGB) youths, little is known about the relationship between suicide and sexual orientation among Asian youths. This study examined differences in prevalence of suicidal ideation and suicide attempts between LGB and heterosexual youths in the cities of Hanoi, Shanghai, and Taipei, China.
Methods
The data are from a community-based multi-centre cross-sectional study conducted from 2006 to 2007, with a sample of 17 016 youths aged 15–24 years from Hanoi, Shanghai, and Taipei. Chi-square test and logistic regression were used to evaluate correlates of suicidal ideation and suicide attempts.
Results
The overall prevalence of suicidal ideation and suicide attempts in the preceding 12 months in LGB youths were both higher than in heterosexual youth (12.8% vs. 8.1% and 4.0% vs. 2.4%, respectively). Stratified by city, the prevalence of suicidal ideation was lowest in Hanoi (2.2%), followed by Shanghai (8.0%) and Taipei (17.0%). Similar trends were observed in the prevalence of suicide attempts, which was lowest in Hanoi (0.3%), followed by Shanghai (1.2%) and Taipei (2.5%). Of note, however, multivariate logistic regression results revealed that LGB youth were at a higher risk for suicidal ideation than heterosexual youth only in Taipei (odds ratio 1.65).
Conclusions
Suicidality is common among Asian youth, with higher prevalence observed in urbanized cities. LGB youths are at greater risk of suicidal ideation than their heterosexual counterparts in Taipei than in the other two examined cities.
doi:10.2188/jea.JE20140084
PMCID: PMC4310877  PMID: 25446798
suicide; China; Vietnam; Taiwan; sexual orientation; youth
20.  Sexual orientation and diurnal cortisol patterns in a cohort of U.S. young adults 
Psychoneuroendocrinology  2016;69:197-208.
Sexual minorities in the United States are at elevated risk of bullying, discrimination, and violence victimization, all stressors that have been linked to psychological and behavioral stress responses including depressive and anxious symptoms and substance use. Acute and chronic stressors may also elicit physiologic stress responses, including changes in the regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis. Few studies, however, have examined the relationship between minority sexual orientation and diurnal cortisol patterns. The present study included 1670 young adults ages 18–32 years (69% female, 31% male) from the Growing Up Today Study, a prospective cohort of U.S. youth. Participants provided five saliva samples over one day to estimate diurnal cortisol patterns. Sexual orientation groups included: completely heterosexual with no same-sex partners (referent), completely heterosexual with same-sex partners/mostly heterosexual, and gay/lesbian/bisexual. Covariates included perceived stress and stressful life events in the past month. Sex-stratified multilevel models of log-transformed cortisol values were used to model diurnal cortisol patterns, and generalized estimating equations were used to model area under the curve (AUC), both with respect to ground (AUCg) and increase (AUCi). Among females, sexual minorities reported significantly more stressful life events in the past month than their heterosexual counterparts. In adjusted multilevel models, sexual orientation was not significantly associated with diurnal cortisol patterns or with AUCg or AUCi in either females or males. There were no significant interactions between sexual orientation and stressful life events. Time-varying negative mood was significantly associated with higher cortisol levels across the day for both female and male participants, after adjusting for all covariates. This study from a large cohort of U.S. young adults did not detect a relationship between sexual orientation and diurnal cortisol patterns. Despite consistent evidence indicating that, compared to heterosexuals, sexual minorities experience elevated exposure to multiple forms of stressors and adversity across the life course, we did not find differences in diurnal cortisol rhythms by sexual orientation. One possible explanation is that sexual minority participants in the study exhibited physiologic resilience.
doi:10.1016/j.psyneuen.2016.04.012
PMCID: PMC4880491  PMID: 27131052
Sexual orientation; Cortisol; Diurnal rhythm; HPA axis; Stressful life events; Young adults
21.  Suicidality and sexual orientation: Characteristics of symptom severity, disclosure, and timing across the life course 
This investigation explored suicide-related characteristics and help-seeking behavior by sexual orientation. Population-based data are from the California Quality of Life Surveys, which included 1,478 sexual minority (lesbian, gay, bisexual, and homosexually experienced individuals) and 3,465 heterosexual individuals. Bisexual women had nearly 6-fold increased risk of lifetime suicide attempts than heterosexual women (RR=5.88, 95%CI: 3.89–8.90), and homosexually experienced men had almost 7 times higher risk of lifetime suicide attempts than heterosexual men (RR=6.93, 95%CI: 3.65–13.15). Sexual minority men and women were more likely than heterosexual men and women to have disclosed suicide attempts to a medical professional (RR=1.48 and RR=1.44, respectively). Among persons who ever attempted suicide, sexual minority women had a younger age of index attempt than heterosexual women (15.9 versus 19.6 years of age, respectively). Health care professionals should be aware of suicidal risk heterogeneity among sexual minority individuals, including vulnerable points of risk and evidenced-based treatments.
doi:10.1037/ort0000112
PMCID: PMC4720972  PMID: 26752446
mental disorders; gay; lesbian; bisexual; sexual minority; suicide
22.  Age of Minority Sexual Orientation Development and Risk of Childhood Maltreatment and Suicide Attempts in Women 
Women with minority sexual orientations (e.g., lesbian, bisexual) are more likely than heterosexual women to report histories of childhood maltreatment and attempted suicide; however, the importance of the timing of minority sexual orientation development in contributing to this increased risk is uncertain. This study investigated relationships between self-reported ages of achieving minority sexual orientation development milestones (first awareness of same-gender attractions, disclosure of a minority sexual orientation to another person, and same-gender sexual contact), and childhood maltreatment and suicide attempt experiences in a sample of 2,001 women recruited from multiple-community sources. Younger age of minority sexual orientation development milestones was positively linked to self-reported recall of childhood maltreatment experiences, and to a childhood suicide attempt. After adjusting for differences in maltreatment, the odds of suicide attempt attributable to younger age of sexual orientation development milestones was reduced by 50 to 65%, suggesting that maltreatment may account for about half of the elevated risk for childhood suicide attempts among women with early minority sexual orientation development. Implications for services, interventions, and further research to address maltreatment disparities for sexual minorities are discussed.
doi:10.1037/a0017163
PMCID: PMC3375131  PMID: 20099942
sexual orientation; suicide attempt; childhood maltreatment; victimization; racial/ethnic minority
23.  Sexual orientation disparities in longitudinal alcohol use patterns among adolescents: Findings from the Growing Up Today Study 
Objectives
To compare sexual orientation group differences in the longitudinal development of alcohol use behaviors during adolescence.
Design
Community-based prospective cohort study.
Setting
Self-reported questionnaires.
Participants
A total of 13450 Growing Up Today Study participants (79.7% of the original cohort) aged 9 to 14 years at baseline in 1996 were followed for over seven years.
Main Exposure
Self-reported sexual orientation classified as heterosexual, mostly heterosexual, bisexual, or lesbian/gay.
Main Outcome Measures
Age of alcohol use initiation, any past-month drinking, number of alcohol drinks usually consumed, and number of binge drinking episodes in the past year.
Results
Compared to heterosexuals, youth reporting any minority sexual orientation reported initiating alcohol use at younger ages. Greater risk of alcohol use was consistently observed for mostly heterosexual males and females and for bisexual females, whereas gay and bisexual males and lesbians reported elevated levels of alcohol use on only some indicators. Gender was an important modifier of alcohol use risk; mostly heterosexual and bisexual females exhibited the highest relative risk. Younger age of alcohol use initiation among minority sexual orientation participants significantly contributed to their elevated risk for binge drinking.
Conclusions
Our findings suggest that disparities in alcohol use among youth with a minority sexual orientation emerge in early adolescence and persist into young adulthood. Healthcare providers should be aware that adolescents with a minority sexual orientation are at greater risk for alcohol use.
doi:10.1001/archpedi.162.11.1071
PMCID: PMC3725748  PMID: 18981356
24.  Self-Reported Mental Disorders and Distress by Sexual Orientation 
Introduction
Sexual minority college students (i.e., those not identifying as heterosexual, or those reporting same-sex sexual activity) may be at increased risk of poor mental health, given factors such as minority stress, stigma, and discrimination. Such disparities could have important implications for students’ academic achievement, future health, and social functioning. This study compares reports of mental disorder diagnoses, stressful life events, and frequent mental distress across five gender-stratified sexual orientation categories.
Methods
Data were from the 2007–2011 College Student Health Survey, which surveyed a random sample of college students (N=34,324) at 40 Minnesota institutions. Data analysis was conducted in 2013–2014. The prevalence of mental disorder diagnoses, frequent mental distress, and stressful life events were calculated for heterosexual, discordant heterosexual, gay or lesbian, bisexual, and unsure students. Logistic regression models were fit to estimate the association between sexual orientation and mental health outcomes.
Results
Lesbian, gay, and bisexual students were more likely to report any mental health disorder diagnosis than heterosexual students (p<0.05). Lesbian, gay, bisexual, and unsure students were significantly more likely to report frequent mental distress compared to heterosexual students (OR range, 1.6–2.7). All sexual minority groups, with the exception of unsure men, had significantly greater odds of experiencing two or more stressful life events (OR range, 1.3–2.8).
Conclusions
Sexual minority college students experience worse mental health than their heterosexual peers. These students may benefit from interventions that target the structural and social causes of these disparities, and individual-level interventions that consider their unique life experiences.
doi:10.1016/j.amepre.2015.01.024
PMCID: PMC4476922  PMID: 25997903
25.  Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults 
Growing evidence suggests that lesbian, gay, and bisexual adults may be at elevated risk for mental health and substance use disorders, possibly due to anti-gay stigma. Little of this work has examined putative excess morbidity among ethnic/racial minorities resulting from the experience of multiple sources of discrimination. We report findings from the National Latino and Asian American Survey (NLAAS), a national household probability psychiatric survey of 4,488 Latino and Asian American adults. Approximately 4.8% of persons interviewed identified as lesbian, gay, bisexual, and/or reported recent same-gender sexual experiences. Although few sexual orientation-related differences were observed, among men, gay/bisexual men were more likely than heterosexual men to report a recent suicide attempt. Among women, lesbian/bisexual women were more likely than heterosexual women to evidence positive 1-year and lifetime histories of depressive disorders. These findings suggest a small elevation in psychiatric morbidity risk among Latino and Asian American individuals with a minority sexual orientation. However, the level of morbidity among sexual orientation minorities in the NLAAS appears similar to or lower than that observed in population-based studies of lesbian, gay, and bisexual adults.
doi:10.1037/0022-006X.75.5.785
PMCID: PMC2676845  PMID: 17907860
gay; lesbian; bisexual; Latino; Asian-American; psychiatric epidemiology

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