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The Centers for Disease Control and Prevention (CDC) developed a workforce training on sexual and gender minorities (SGMs).This article describes the evaluation of the training.Participants completed pre- and posttest surveys. After the pilot evaluation, some improvements were made to the curriculum and to the pre- and posttest questionnaires. Participants in subsequent (implementation) training were similarly asked to complete pre- and posttest questionnaires.CDC.CDC staff.Participants' knowledge, ally identity, and perceptions of SGMs.Pilot and implementation training data showed increases in participant knowledge of 44% and 49%, respectively, increases in ally identity of 11% and 14%, respectively, and increases in positive perceptions of SGM of 25% and 31%, respectively.These results suggest that the CDC Ally Training may be a useful tool for improving staff knowledge and perceptions of SGM people.

The purpose of this research is to explore the relationship between substance use and sexual risk behaviors among transgender youth.Data from the transgender subsample of the Survey of Today's Adolescent Relationships and Transitions (Among participants, lifetime marijuana use (AOR=0.45), cocaine use (AOR=0.46), prescription drug misuse (AOR=0.52), and injecting substances with a needle (AOR=0.45) were all associated with lower odds of reporting condom use during the last act of receptive anal sex. Similarly, marijuana use in the last 30 days (AOR=0.46), lifetime marijuana use (AOR=0.25), heroin use (AOR=0.29), methamphetamine use (AOR=0.32), misuse of prescription drugs (AOR=0.40), and injecting substances with a needle (AOR=0.17) were all associated with lower odds of reporting condom use during the last act of insertive anal sex. No associations between substance use and condom use during last act of receptive frontal (vaginal) sex were found.We found that transgender youth who reported any lifetime substance use were more likely to report condomless sex during receptive and insertive anal sex than those who did not report substance use. Significant differences exist among demographic groups, type of substance use, and sexual risk behaviors for respondents based on gender identity.

Perceived racism in school (i.e., a student's report of being treated badly or unfairly because of their race or ethnicity) is an important yet understudied determinant of adolescent health and well-being. Knowing how perceived racism influences adolescent health can help reduce health inequities. CDC's 2021 Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705), was conducted during January-June 2021 to assess student behaviors during the COVID-19 pandemic. CDC analyzed data from ABES to measure perceived racism and the extent to which perceptions of racism are associated with demographic, mental health, and behavioral characteristics. Mental health and behavioral characteristics analyzed included mental health status; virtual connection with others outside of school; serious difficulty concentrating, remembering, or making decisions; and feeling close to persons at school. Demographic characteristics analyzed included sex, race and ethnicity, and grade. Prevalence of perceived racism and associations between perceived racism and demographic, mental health, and behavioral characteristics are reported overall and stratified by race and ethnicity. Approximately one third (35.6%) of U.S. high school students reported perceived racism. Perceived racism was highest among Asian (63.9%), Black (55.2%), and multiracial students (54.5%). Students who reported perceived racism had higher prevalences of poor mental health (38.1%); difficulty concentrating, remembering, or making decisions (44.1%); and not feeling close to persons at school (40.7%). Perceived racism was higher among those students who reported poor mental health than those who did not report poor mental health during the pandemic among Asian (67.9% versus 40.5%), Black (62.1% versus 38.5%), Hispanic (45.7% and 22.9%), and White students (24.5% versus 12.7%). A better understanding of how negative health outcomes are associated with student experiences of racism can guide training for staff and students to promote cultural awareness and antiracist and inclusivity interventions, which are critical for promoting safe school environments for all students.

When children and youth feel connected to their school, family, and others in their community, they are less likely to engage in risky behaviors and experience negative health. Disruptions to school operations during the COVID-19 pandemic have led many teachers and school administrators to prioritize finding ways to strengthen and re-establish a sense of connectedness among students and between students and adults in school.We conducted a systematic search of peer-reviewed literature that reported on US-based research and were published in English from January 2010 through December 2019 to identify classroom management approaches that have been empirically tied to school connectedness-related outcomes in K-12 school settings.Six categories of classroom management approaches were associated with improved school connectedness among students: (1) teacher caring and support, (2) peer connection and support, (3) student autonomy and empowerment, (4) management of classroom social dynamics, (5) teacher expectations, and (6) behavior management.Prioritizing classroom management approaches that emphasize positive reinforcement of behavior, restorative discipline and communication, development of strong, trusting relationships, and explicitly emphasize fairness has potential to promote equitable disciplinary practices in schools.Classroom management approaches most linked to school connectedness are those that foster student autonomy and empowerment, mitigate social hierarchies and power differentials among students, prioritize positive reinforcement of behavior and restorative disciplinary practices, and emphasize equity and fairness.

Nonheterosexual (sexual minority) women report experiencing more sexual violence than heterosexual (sexual majority) women (1,2). Sexual minority women are often categorized as a collective whole, which fails to capture the nuances in sexual violence among subgroups of sexual minority women, such as bisexual and lesbian women (3). To estimate the prevalence of lifetime forced vaginal intercourse (forced sex) and of nonvoluntary first vaginal intercourse among women aged 18-44 years in the United States, CDC analyzed data from female respondents who were interviewed during 2011-2017 for the National Survey of Family Growth (NSFG); respondents were stratified by self-reported sexual identity, attraction, and behavior. Log-binomial regressions and analyses of variance (ANOVAs) were performed to compare experiences across each dimension of sexual orientation, controlling for demographic characteristics. Compared with sexual majority women,* prevalence of any male-perpetrated nonvoluntary first vaginal intercourse or forced sex (nonvoluntary or forced sex) was higher among women who identified as bisexual (36.1% versus 17.5%), reported attraction to the opposite and same sex (30.3% versus 15.8%), and reported sexual behavior with the opposite and same sex (35.7% versus 15.9%). These sexual minority women reported that their earliest experience of nonvoluntary or forced sex occurred at younger ages than did that of sexual majority women. Among women who were unsure of their sexual attraction, the prevalence of nonvoluntary first vaginal intercourse was also higher than among sexual majority women. These findings underscore the need for comprehensive prevention approaches tailored for sexual minority women and prevention of child sexual abuse, given the average ages at earliest nonvoluntary or forced sex experience among sexual minority women (range = 12.5-16.3 years). Additional research is needed into the circumstances of and norms or attitudes that influence perpetration of nonvoluntary or forced sex and broader sexual violence against sexual minority women. Prevention of nonvoluntary or forced sex victimization among sexual minority women will require comprehensive approaches to prevent sexual violence and child sexual abuse. Engaging sexual minority women in the development of sexual violence prevention efforts and research would help ensure that the experiences of sexual minority women across the spectrum are represented.

Introduction Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. Method Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. Results Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: 1 identity formation and sources of support, 2 challenges to obtaining sexual health information, 3 attitudes/beliefs about sex and sexual behaviors, and 4 barriers to HIV prevention. Discussion These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.

Purpose Transgender populations experience health inequities that underscore the importance of ensuring access to high quality care. We thematically summarize the health care experiences of transgender youth living in the southeast United States to identify potential barriers and facilitators to health care. Design and methods Transgender youth recruited from community settings in an urban area of the southeast United States participated in individual interviews (n = 33) and focus groups (n = 9) about protective factors. We conducted a thematic analysis of data from 42 participants who described their experiences seeking and receiving health care. Results Participants reported a wide range of gender identities. The individual interview sample was majority Black (54.5%) and the mean age was 21.7 years and focus group participants were all white and the mean age was 16.8 years. Participants described numerous barriers to health care, including limited availability of gender affirming care, logistical challenges, such as gatekeeping and cost, concerns about confidentiality in relation to sexual behavior and gender identity, and inadequate cultural competency among providers regarding gender-affirming care. Facilitators included intake procedures collecting chosen pronouns and names and consistent use of them by providers, and open communication, including active listening. Conclusions Findings underscore the need for a multi-component approach to ensure both transgender- and youth-friendly care. Practice implications Providers and office staff may benefit from transgender cultural competency trainings. In addition, clinic protocols relating to confidentiality and chosen name and pronoun use may help facilitate access to and receipt of quality care.

Purpose: The purpose of this study was to assess the feasibility and efficacy of using advertisements (ads) on Facebook, Instagram, and Snapchat to recruit a national sample of adolescent sexual minority males ages 13-18 and transgender youth ages 13-24 for a web survey. Methods: The Survey of Today's Adolescent Relationships and Transitions (START) used targeted ads as survey recruitment tools. We assessed the efficacy of these varied forms of recruitment ads in reaching our target population. To understand how our sample differed from a national probability sample targeting the general adolescent population, we compared START respondents with sexual minority men identified from the 2017 Youth Risk Behavior Survey (YRBS). Results: The use of targeted language produced higher rates of completes per click compared with ads without targeted language. Video ads (compared with static images) were more effective at recruiting younger respondents. START and YRBS samples differed along lines of sexual identity, race and ethnicity, and age. The START sample had a greater percentage of Hispanic/Latino and Other/Multiracial respondents relative to the YRBS sample, thus providing additional data on these underserved sexual minority youth. Conclusion: The factors associated with design decisions for a hard-to-reach, non-probability sample impact the likelihood that respondents engage in and complete a survey. The ads proved to be effective and efficient at recruiting the targeted population.

Transgender and gender expansive (TGE) youth experience elevated risk for substance use and other health inequities compared to cisgender peers. The purpose of this study was to examine associations between protective environments—perceived community tolerance, perceived family support, and housing stability—and recent binge drinking, lifetime high-risk substance use (HRSU; cocaine, methamphetamines, and/or heroin), and self-rated health in a sample of TGE youth. METHODS: This secondary analysis of 1567 TGE youth aged 13–24 years draws from the Centers for Disease Control and Prevention’s 2018 web-based Survey of Today’s Adolescent Relationships and Transitions, which used a nonprobabilistic recruiting strategy via social media. Logistic regression was used to test the associations between protective environments and substance use and health outcomes. RESULTS: Overall, 28.1% of participants reported that people who lived near them were tolerant of transgender people, 32.8% reported that their family was at least somewhat supportive of their TGE identity, and 77.0% were stably housed. In the logistic regression models, community tolerance and housing stability were associated with lower odds of self-rated poor health. Housing stability was associated with lower odds of recent binge drinking and lifetime HRSU. CONCLUSION: Perceived community tolerance and housing stability were associated with several health outcomes among TGE youth in this study. Protective factors, including safe, stable, nurturing relationships and environments, are critical to youth health and wellbeing. The findings in this study highlight the need for prevention strategies to promote protective environments and reduce known substance use and overall health inequities among TGE youth.

Sexual minority adolescents (SMA) report more suicide risk behaviors than heterosexual adolescents. Polyvictimization (co-occurrence of multiple types of victimization) may be an important, underresearched correlate of this disparity. With the 2017 national Youth Risk Behavior Survey (N = 13,179), national estimates of polyvictimization and suicide risk were assessed among high school students by sexual minority status (SM vs. heterosexual), and multivariate relationships between sexual minority status, polyvictimization, and suicide risk were tested. Additionally, risk profiles of those who experienced polyvictimization (2 + types of victimization; n = 1,932) were compared across sexual minority status. Results confirm that SMA are more likely to experience polyvictimization than heterosexual adolescents (31.8% v. 12.9%, respectively); however, also indicate that polyvictimization does not fully explain elevated suicide risk among SMA.

Lesbian, gay, and bisexual (LGB) youths continue to experience more violence victimization and suicide risk than heterosexual youths; however, few studies have examined whether the proportion of LGB youths affected by these outcomes has varied over time, and no studies have assessed such trends in a nationally representative sample. This report analyzes national trends in violence victimization and suicide risk among high school students by self-reported sexual identity (LGB or heterosexual) and evaluates differences in these trends among LGB students by sex (male or female) and race/ethnicity (non-Hispanic black, non-Hispanic white, or Hispanic). Data for this analysis were derived from the 2015, 2017, and 2019 cycles of CDC's Youth Risk Behavior Survey (YRBS), a cross-sectional, school-based survey conducted biennially since 1991. Logistic regression models assessed linear trends in prevalence of violence victimization and indicators of suicide risk among LGB and heterosexual students during 2015-2019; in subsequent models, sex-stratified (controlling for race/ethnicity and grade) and race/ethnicity-stratified (controlling for sex and grade) linear trends were examined for students self-identifying as LGB during 2015-2019. Results demonstrated that LGB students experienced more violence victimization and reported more suicide risk behaviors than heterosexual youths. Among LGB youths, differences in the proportion reporting violence victimization and suicide risk by sex and race/ethnicity were found. Across analyses, very few linear trends in these outcomes were observed among LGB students. Results highlight the continued need for comprehensive intervention strategies within schools and communities with the express goal of reducing violence victimization and preventing suicide risk behaviors among LGB students.

Social media recruitment is no longer an uncharted avenue for survey research. The results thus far provide evidence of an engaging means of recruiting hard-to-reach populations. Questions remain, however, regarding whether the data collected using this method of recruitment produce quality data. This article assesses one aspect that may influence the quality of data gathered through nonprobability sampling using social media advertisements for a hard-to-reach sexual and gender minority youth population: recruitment design formats. The data come from the Survey of Today’s Adolescent Relationships and Transitions, which used a variety of forms of advertisements as survey recruitment tools on Facebook, Instagram, and Snapchat. Results demonstrate that design decisions such as the format of the advertisement (e.g., video or static) and the use of eligibility language on the advertisements impact the quality of the data as measured by break-off rates and the use of nonsubstantive responses. Additionally, the type of device used affected the measures of data quality.

BackgroundThere are known associations between mental health symptoms and transgender identity among adults. Whether this relationship extends to early adolescents and to gender domains other than identity is unclear. This study measured dimensions of gender in a large, diverse, sample of youth, and examined associations between diverse gender experiences and mental health.MethodsThe ABCD study is an ongoing, longitudinal, US cohort study. Baseline data (release 2.0) include 11,873 youth age 9/10 (48% female); and the 4,951 1-year follow-up visits (age 10/11; 48% female) completed prior to data release. A novel gender survey at the 1-year visit assessed felt-gender, gender noncontentedness, and gender nonconformity using a 5-point scale. Mental health measures included youth- and parent-reports.ResultsRoughly half a percent of 9/10-year-olds (n=58) responded 'yes' or 'maybe' when asked, 'Are you transgender' at baseline. Recurrent thoughts of death were more prevalent among these youth compared to the rest of the cohort (19.6% vs. 6.4%, χ2 =16.0, p&nbsp

Sexual minority youth are disproportionately exposed to school violence compared with their heterosexual peers. It is unknown whether the associations between school absence and exposure to school violence vary by sexual identity.In 2021, data were combined from the 2015, 2017, and 2019 national Youth Risk Behavior Surveys to produce nationally representative samples of U.S. high-school students who identified as gay/lesbian (n=1,061), identified as bisexual (n=3,210), were not sure of their sexual identity (n=1,696), or identified as heterosexual (n=35,819). Associations were examined between 3 school violence exposures (being threatened/injured with a weapon at school, being bullied at school, and being in a physical fight at school) and school absence due to safety concerns. In each sample, multivariable logistic regression models were used to calculate adjusted prevalence ratios adjusted for sex, race/ethnicity, grade, current substance use, being offered/sold drugs at school, feeling sad/hopeless, and suicidal thoughts. Adjusted prevalence ratios were considered statistically significant if 95% CIs did not include 1.0.Exposure to school violence and school absence due to safety concerns were more prevalent among sexual minority students than among heterosexual students. Associations between exposure to school violence and school absence due to safety concerns were similar across sexual identity groups. For example, school absence was associated with being threatened/injured with a weapon at school among gay/lesbian (adjusted prevalence ratio=3.00), bisexual (adjusted prevalence ratio=3.66), those not sure (adjusted prevalence ratio=4.56), and heterosexual (adjusted prevalence ratio=3.75) students.Associations between school absenteeism and school violence exist in each sexual identity group. Therefore, programs providing safe and supportive school environments may result in reduced absenteeism among all students.

We aimed to assess Centers for Disease Control and Prevention (CDC) data systems on the extent of data collection on sex, sexual orientation, and gender identity as well as on age and race/ethnicity. Between March and September 2019, we searched 11 federal websites to identify CDC-supported or -led U.S. data systems active between 2015 and 2018. We searched the systems’ website, documentation, and publications for evidence of data collection on sex, sexual orientation, gender identity, age, and race/ethnicity. We categorized each system by type (disease notification, periodic prevalence survey, registry/vital record, or multiple sources). We provide descriptive statistics of characteristics of the identified systems. Most (94.1%) systems we assessed collected data on sex. All systems collected data on age, and approximately 80% collected data on race/ethnicity. Only 17.7% collected data on sexual orientation and 5.9% on gender identity. Periodic prevalence surveys were the most common system type for collecting all the variables we assessed. While most U.S. public health data and monitoring systems collect data disaggregated by sex, age, and race/ethnicity, far fewer do so for sexual orientation or gender identity. Standards and examples exist to aid efforts to collect and report these vitally important data. Additionally important is increasing accessibility and appropriately tailored dissemination of reports of these data to public health professionals and other collaborators.

INTRODUCTION: Limited research exists about how receiving/seeking sexual and reproductive health (SRH) information differs by sexual orientation. Our goal was to identify how sources and topics of SRH information differed by sexual orientation during adolescence in a sample of U.S. women. METHODS: A sample of 8,541 U.S. women ages 22–35 years from two cohorts of the Growing Up Today Study completed a 2016 questionnaire measure about receiving/seeking SRH information before age 18 years. Adjusted log-linear models assessed differences in SRH information topics and sources by reported sexual orientation (completely heterosexual with no same-sex partners [reference]; completely heterosexual with same-sex partners; mostly heterosexual; bisexual; lesbian). RESULTS: Compared to the referent, most sexual minority subgroups were more likely to receive/seek information from peers, media, and other sources (e.g., community centers). With the exception of lesbians, sexual minority subgroups were more likely to receive/seek information about contraception, and mostly heterosexual and bisexual women were more likely to receive information about sexually transmitted infections. Conclusions: Findings indicate women of diverse sexual orientations need access to SRH information from sources like schools, peers, and media. Sexual minority women receive/seek information about many SRH topics, which indicates that opportunities to tailor educational resources within and outside of schools are needed so SRH benefits to these populations are maximized. POLICY IMPLICATIONS: Specifying sexual minority-sensitive educational materials in sex education policy can meet information needs and aid sexual minority women in making informed sexual health decisions.

Background Transgender youth report high rates of negative experiences in schools. Using a lens of minority stress, this study sought to examine in-school experiences of transgender youth to understand youth coping and to identify key opportunities for improving school environments for transgender youth. Methods Participants included 41 youth across 33 in-depth interviews (Mage = 21.7) and two focus groups (N = 8; Mage = 17.3). Thematic analysis was used to analyze data. Themes related to stress, coping, and facilitators/barriers to stress/coping were derived and coded. Results Distal stressors, such as structural discrimination and prejudice events, were found to contribute to the exclusion of transgender youth from school life, while proximal stressors, such as concealment and expectations of rejection, reinforced transgender youth's feelings of personal isolation. Participants expressed coping with both challenges by advocating for inclusion through direct action with teachers and administrators and seeking/finding connection with trusted staff and peers. Conclusions Findings suggest that creating safe and supportive environments at school for transgender youth is an attainable goal, as all identified barriers to inclusivity and connection were modifiable. By considering the needs of transgender youth in policies and programming, schools may improve climate for and wellbeing of transgender students.

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) adolescents face well-documented health disparities in suicide risk, substance use, and sexual health. These disparities are known to stem, in part, from stigma directed toward LGBTQ youth in the form of minority stressors such as violence, discrimination, and harassment. Given the proportion of time that LGBTQ students spend in school, schools provide a critical context within which protective factors may be developed and leveraged to improve the health and wellbeing of these populations. This article provides a summary of key findings from a discussion among researchers, practitioners, and community members who participated in "The State of LGBTQ Youth Health and Wellbeing: Strengthening Schools and Families to Build Resilience," a public symposium held in June 2017. We detail emerging science on and future priorities for school-based research with LGBTQ youth which were identified by attendees at this meeting, with a particular focus on intersectionality, supportive adults in schools, and in-school programs. We call for more school-based research on priority gaps such as how LGBTQ students' intersecting identities affect their in-school experiences, how to design professional development programs that cultivate supportive educators, and how to leverage gay-straight alliances/gender and sexuality alliances as sites of health programming for LGBTQ students.

This study used self-administered survey data from seven high schools in Florida with a majority Black and/or Hispanic sample to examine transgender students’ perceptions and experiences related to school climate in comparison to cisgender students. Using propensity score matching, a matched analytic sample was created of transgender and cisgender students ( n = 542, including 186 transgender youth). Adjusted weighted logistic regression models indicated that transgender students were significantly more likely to report ever being bullied at school, being bullied in the past 3 months, and not going to school ≥3 days during the past 30 days. Transgender students were significantly less likely to report feeling safe at school and having positive perceptions of all five school connectedness items compared to cisgender students. Recent bullying experiences moderated the association between transgender status and past month absences. Findings can inform potential roles for school nurses in improving school climate for transgender youth.

The Adolescent Brain Cognitive DevelopmentSM (ABCD) study is a longitudinal study of adolescent brain development and health that includes over 11,800 youth in the United States. The ABCD study includes broad developmental domains, and gender and sexuality are two of these with noted changes across late childhood and early adolescence. The Gender Identity and Sexual Health (GISH) workgroup recommends measures of gender and sexuality for the ABCD study, prioritizing those that are developmentally sensitive, capture individual differences in the experience of gender and sexuality, and minimize participant burden. This manuscript describes the gender and sexuality measures used in ABCD and provides guidance for researchers using these data. Data showing the utility of these measures and longitudinal trends are presented. Including assessment of gender and sexuality in ABCD allows for characterization of developmental trajectories of gender and sexuality, and the broad scope of ABCD data collection allows examination of identity development in an intersectional manner.

Purpose: We assessed the association of receipt of medical gender affirmation services (e.g., hormones, surgery) with HIV and other sexually transmitted disease (STD) prevention and knowledge indicators among transgender youth. Methods: A United States online sample of sexually experienced transgender youth ages 13–24 years (N = 1029) in 2018 completed a cross-sectional survey, including questions about sociodemographics, medical gender affirmation, and HIV and STD prevention outcomes (HIV testing, STD testing, pre-exposure prophylaxis [PrEP] awareness, and nonoccupational postexposure prophylaxis [nPEP] awareness). Logistic regression models were fit to assess the association of medical gender affirmation with HIV and STD prevention outcomes. Interaction terms and stratified models assessed differences in the association between medical gender affirmation and outcomes by gender identity. Results: Participants' mean age was 19.1 (standard deviation = 2.7), 45% were transgender female, 29% transgender male, 26% nonbinary, 53% were youth of color, and 19% accessed medical gender affirmation services. Medical gender affirmation was associated with increased odds of STD testing (adjusted odds ratio [aOR] = 1.90; 95% confidence interval [CI] = 1.33–2.73) with no significant interactions by gender identity. Associations between medical gender affirmation and awareness of PrEP and nPEP varied by gender identity. Among transgender male youth, medical gender affirmation was associated with awareness of PrEP (aOR = 2.65; 95% CI = 1.50–4.71) and nPEP (aOR = 2.03; 95% CI = 1.12–3.71). Among nonbinary youth, medical gender affirmation was associated with awareness of PrEP (aOR = 3.47; 95% CI = 1.26–11.27). Conclusion: Medical gender affirmation was associated with uptake and awareness of sexual health services. Bolstering medical gender affirmation for transgender youth may also bolster preventive health services broadly.

School connectedness is an important factor in the lives of youth and are a leverage point for optimizing youth’s social, emotional, and physical health. This study presents a meta-analysis examining the relationship between school connectedness and four health domains that are prevalent in adolescence, have implications for adult health, and often co-occur: mental health, sexual health, violence, and high-risk substance use. Ninety articles published between 2009 and 2019 were included in the analysis. The study found that school connectedness had a protective average effect size across all health domains (Hedges’ g = −0.345, p-value

Transgender youth are more likely than cisgender youth to report health risks related to violence victimization, substance use, mental health, and sexual health. Parental support may help foster resilience and better health outcomes among this population. However, limited research has characterized parental support among transgender youth. To address this gap, we conducted a thematic analysis of 33 in-depth interviews with transgender youth. We coded interviews using the dimensions of the social support framework (i.e., emotional, instrumental, appraisal, and informational) as well as inductive codes to identify emergent themes. Almost all participants described some form of general parental support (e.g., expressions of love, housing, advice, and affirmation). Parental support specific to gender identity was also noted (e.g., emotional support for coming out as transgender and chosen name and pronoun use) but was more limited. Parents may benefit from resources and programming to promote acceptance and gender-affirming behaviors.

Purpose To synthesize the diverse body of literature on sexual and gender minority youth (SGMY) and sexual health education. Methods We conducted a systematic search of the literature on SGMY and sexual health education, including SGMY perspectives on sexual health education, the acceptability or effectiveness of programs designed for SGMY, and SGMY-specific results of sexual health education programs delivered to general youth populations. Results A total of 32 articles were included. Sixteen qualitative studies with SGMY highlight key perspectives underscoring how youth gained inadequate knowledge from sexual health education experiences and received content that excluded their identities and behaviors. Thirteen studies examined the acceptability or effectiveness of sexual health interventions designed for SGMY from which key characteristics of inclusive sexual health education relating to development, content, and delivery emerged. One study found a sexual health education program delivered to a general population of youth was also acceptable for a subsample of sexual minority girls. Conclusions Future research on SGMY experiences should incorporate populations understudied, including younger adolescents, sexual minority girls, and transgender persons. Further, the effectiveness of inclusive sexual health education in general population settings requires further study.

INTRODUCTION: Exposure to violence victimization may help explain disparities of substance use among gender-nonconforming youth (i.e., those whose gender expression differs from societal expectations). METHODS: In 2015, three large urban school districts (2 in California and 1 in Florida) conducted a Youth Risk Behavior Survey that included the assessment of gender expression among a racially/ ethnically diverse population-based sample of 6,082 high school students. Five categories of violence victimization were assessed (felt unsafe at school, threatened or injured with a weapon at school, bullied at school, electronically bullied, and forced sexual intercourse). In 2019, the effect of violence victimization on substance use disparities was examined by calculating sex-stratified prevalence ratios by gender nonconformity, adjusted for sexual identity, race/ethnicity, and grade (adjusted prevalence ratio 1 [APR1]), and comparing these with prevalence ratios adjusted for those variables plus violence victimization (adjusted prevalence ratio 2 [APR2]). RESULTS: Among female students, only being threatened or injured with a weapon was significantly (p

BACKGROUND: Transgender adolescents are at increased risk for negative sexual health outcomes compared to their cisgender peers. METHODS: Using data from 10,231 students from 7 high schools in a large, urban school district, our analysis compared sexual behaviors, referral to sexual health services by school staff, and use of sexual health services between transgender and cisgender students. We used propensity score matching to create a comparable sample of transgender and cisgender students and logistic regression models to examine how gender identity was associated with aforementioned outcomes. RESULTS: Transgender students were more likely to have ever had sex, less likely to have used a condom at last sex, and more likely to have been referred for human immunodeficiency virus (HIV) testing, sexually transmitted disease (STD) testing, and other sexual health services than cisgender students. Transgender students were no more likely than cisgender students to have tested for HIV or STDs. CONCLUSIONS: These findings underscore the need for understanding the risk perceptions held by transgender students and for prevention efforts that are inclusive for all gender identities. Research is needed to understand if school-based sexual health interventions such as staff referrals for sexual health services are effective for transgender students.

Purpose Sexual and gender minority youth (SGM), an umbrella term encompassing gay, bisexual, and transgender youth, experience disproportionately high rates of new HIV infections, and recent advances in biomedical HIV prevention modalities hold promise in reducing new infections. However, the extent to which SGM youth are aware of and willing to use these modalities is unknown. Methods Using data from the Survey of Today's Adolescents Relationships and Transitions, we analyze awareness of and willingness to take HIV pre-exposure prophylaxis (PrEP), nonoccupational HIV post-exposure prophylaxis, and rectal microbicides among adolescent sexual minority males aged 13–18 years and transgender youth aged 13–24 years. Results Overall, we found a majority of our respondents were not aware of any of these prevention modalities. Across both subsamples, age and outness to a health care provider were associated with increased PrEP awareness, and any anal sex was associated with PrEP willingness. Conclusions These findings highlight the importance of provider education on how to discuss SGM issues with patients and educate them about HIV prevention options.

Introduction Hispanic adults make up a growing share of US adult smokers, and smoking is a major preventable cause of disease and death among Hispanic adults. No previous study has compared trends in smoking cessation behaviors among Hispanic adults and non-Hispanic white adults over time. We examined trends in cessation behaviors among Hispanic and non-Hispanic white adult cigarette smokers during 2000-2015. Methods Using self-reported data from the National Health Interview Survey, we compared trends in quit attempts, receipt of advice to quit from a health professional, and use of cessation treatment (counseling and/or medication) among Hispanic and non-Hispanic white adult smokers. We also assessed these behaviors among 4 Hispanic subgroups. We conducted analyses in 2018-2019. Results Past-year quit attempts increased during 2000-2015 among both non-Hispanic white and Hispanic smokers, with no significant differences between these groups. Receiving advice to quit increased significantly among non-Hispanic white adults but did not increase significantly among Hispanic adults. Cessation treatment use increased among both non-Hispanic white and Hispanic adults. Throughout 2000-2015, the prevalence of receiving advice to quit and using cessation treatments was lower among Hispanic adults than non-Hispanic white adults. In 2015, a higher proportion of Hispanic than non-Hispanic white smokers visited a health care provider without receiving advice to quit. Conclusion Hispanic adult smokers are less likely to receive advice to quit and to use proven cessation treatments than non-Hispanic white smokers, and this pattern persisted over time. Culturally competent educational initiatives directed at both providers and Hispanic communities could help eliminate this marked and persistent disparity.

Youths identifying as lesbian, gay, bisexual, or another nonheterosexual identity (sexual minority youths) report more violence victimization, substance use, and suicide risk than do heterosexual youths (1). These disparities are generally attributed to minority stress (the process through which stigma directed toward sexual minorities influences health outcomes) (2,3). Sexual minority youths might experience negative outcomes associated with minority stress differently across sexual identities, but to date, no nationally representative study has examined differences in victimization, substance use, and suicide risk within sexual minority youth. Using pooled data from the 2015 and 2017 national Youth Risk Behavior Surveys (YRBS), relationships between sexual identity groups and victimization, substance use, and suicide risk were evaluated with sex-stratified logistic regression models. Compared with heterosexual students, bisexual females and all sexual minority males reported more victimization; lesbian and bisexual females reported more use of alcohol, cigarettes, and marijuana; and all sexual minority youths reported elevated high-risk substance use and suicide risk. Programmatic efforts to reduce and prevent victimization, substance use, and suicide risk among sexual minority youths might benefit from consideration of issues within group differences.

Sexual minority youths (i.e., those identifying as gay, lesbian, bisexual, or another nonheterosexual identity or reporting same-sex attraction or sexual partners) are at higher risk than youths who are not sexual minority youth (nonsexual minority youth) for negative health behaviors and outcomes, including human immunodeficiency virus (HIV) infection, other sexually transmitted diseases (STDs), pregnancy (1),* and related sexual risk behaviors (2). Less is known about sexual risk behavior differences between sexual minority youth subgroups. This is the first analysis of subgroup differences among sexual minority youths using nationally representative Youth Risk Behavior Survey (YRBS) data. CDC analyzed pooled data from the 2015 and 2017 cycles of the national YRBS, a cross-sectional, school-based survey assessing health behaviors among U.S. students in grades 9-12. Analyses examined differences in eight sexual risk behaviors between subgroups of sexual minority youths and nonsexual minority youths, as well as within sexual minority youths. Logistic regression models controlling for race/ethnicity and grade found that bisexual females and "not sure" males reported higher prevalences for many behaviors than did heterosexual students. For behavior-based subgroups, the largest number of differences were seen between students who had sexual contact with both sexes compared with students with only opposite-sex sexual contact. Findings highlight subgroup differences within sexual minority youths that could inform interventions to promote healthy behavior.

Transgender and gender variant (GV) youth experience elevated risk for poor health and academic outcomes due mainly to social experiences of stigma and discrimination. To supplement the growing evidence on health risks encountered by transgender/GV youth, we identified factors theorized to be protective for these youth across all four levels of Bronfenbrenner’ s socioecological model (individual, relationship, community, societal). We conducted a systematic search of peer-reviewed research. The articles included in this review were published in peer-reviewed journals in English or Spanish between 1999 and 2014, analyzed data from a sample or subsample of transgender or GV participants with a mean age between 10 and 24 years, and examined the relationship of at least one theorized protective factor to a health or behavioral outcome. Twenty-one articles met inclusion criteria. Transgender/GV youth in included articles ranged from 11 to 26 years of age, were racially/ethnically diverse, and represented varied gender identities. Within these articles, 27 unique protective factors across four levels of the ecological model were identified as related to positive health and well-being. Self-esteem at the individual level, healthy relationships with parents and peers at the relationship-level, and gay-straight alliances at the community level emerged as protective factors across multiple studies. Our findings underscore the relative lack of research on transgender/GV youth and protective factors. Novel recruitment strategies for transgender/GV youth and better measurement of transgender identities are needed to confirm these protective relationships and identify others. Growth in these areas will contribute to building a body of evidence to inform interventions.

Limited information exists on heterosexual youth with sexual contact with same-sex partners in the United States (i.e., discordant heterosexual). We compared the prevalence of health risks between discordant heterosexual, heterosexual with only opposite-sex sexual contact, lesbian/gay, and bisexual students using the 2015 national Youth Risk Behavior Survey (YRBS). Nationwide, 3.2% of students were identified as discordant heterosexuals. The prevalence of several risk behaviors was significantly higher among discordant heterosexual students than their heterosexual peers with only opposite-sex sexual contact. Clinicians should consider sexual identity and sex of sexual partners when conducting risk-assessments to ensure they appropriately target populations for intervention.

Sexual minority youth often experience increased social stress due to prejudice, discrimination, harassment, and victimization. Increased stress may help explain the disproportionate use of substances like tobacco, alcohol, marijuana, and other illicit drug use by sexual minority youth. This study examined the effect of social stress on substance use disparities by sexual orientation among U.S. high school students.In 2016, data from the national 2015 Youth Risk Behavior Survey, conducted among a nationally representative sample of 15,624 U.S. high school students, were analyzed to examine the effect of school-related (threatened/injured at school, bullied at school, bullied electronically, felt unsafe at school) and non-school-related (forced sexual intercourse, early sexual debut) social stress on substance use disparities by sexual orientation, by comparing unadjusted prevalence ratios (PRs) and adjusted (for social stressors, age, sex, and race/ethnicity) prevalence ratios (APRs).Unadjusted PRs reflected significantly (p0.05 or 95% CI did not include 1.0) greater substance use among students who identified as lesbian/gay or bisexual than students who identified as heterosexual. APRs for injection drug use decreased substantially among lesbian/gay (PR=12.02 vs APR=2.14) and bisexual (PR=2.62 vs APR=1.18) students; the APR for bisexual students became nonsignificant. In addition, APRs among both lesbian/gay and bisexual students decreased substantially and were no longer statistically significant for cocaine, methamphetamine, and heroin use.School-based substance use prevention programs might appropriately include strategies to reduce social stress, including policies and practices designed to provide a safe school environment and improved access to social and mental health services.

Objective Sexual minority girls (lesbian/bisexual) and girls with overweight/obesity experience high rates of discrimination and mental distress. This study explored whether BMI or perceived weight status might compound sexual minority girls’ risk for harassment and mental distress. Methods Data on female students from the national 2015 Youth Risk Behavior Survey (n = 7,006) were analyzed. Logistic regression was used to examine differences in bullying, harassment, and mental distress across sexual identity/BMI groups: heterosexual/normal-weight, heterosexual/overweight, sexual minority/normal-weight, and sexual minority/overweight. Procedures were repeated with four analogous groups created from sexual identity and perceived weight. Results Across sexual identity/BMI groups, being overweight increased heterosexual females’ odds of being bullied or experiencing suicidal thoughts and behaviors. Regardless of weight status, sexual minority females had greater odds for each outcome than heterosexual females. Sexual minority females who perceived themselves as overweight had greater odds of suicidality than all other sexual minority/perceived weight groups. Conclusions Double jeopardy may exist for sexual minority female students who perceive themselves as overweight. Professional development with school staff on how to create a positive climate for sexual minorities and those with overweight/obesity and addressing positive identity and body image within school-based suicide prevention efforts may be important to the well-being of adolescent girls.

Sexual minority women (SMW; i.e., women who identify their sexuality as lesbian, bisexual, or something other than heterosexual) report greater smoking behaviors than their heterosexual counterparts across all ages. We conducted a multivariable regression to examine the correlates of prior smoking cessation attempts and smoking cessation intentions in a sample of young SMW who smoke (N = 338; aged 18-24 years). Covariates included sociodemographic characteristics (i.e., race/ethnicity, sexual identity, age, urbanity), general (i.e., perceived stress), and sexuality-specific (i.e., internalized homophobia) stressors, as well as smoking attitudes and subjective norms. Bisexual women (OR = 1.92, 95% CI: 1.11, 3.31) were more likely than lesbian counterparts to report a prior smoking cessation attempt. Prior cessation attempts were associated with less internalized homophobia (OR = 0.44, 95% CI: 0.27, 0.69) and positive attitudes toward smoking (OR = 2.17, 95% CI: 1.27, 3.70). Smoking cessation intentions in the next month were negatively associated with being a daily smoker (β = -0.14) and attitudes toward smoking (β = -0.19). Based on these findings, we underscore the need to address the risk correlates associated with SMW's quit attempts and include these in cessation interventions.

Introduction HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education. Methods Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study. Results Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools. Discussion Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) adolescents face well-documented health disparities in suicide risk, substance use, and sexual health. These disparities are known to stem, in part, from stigma directed toward LGBTQ youth in the form of minority stressors such as violence, discrimination, and harassment. Given the proportion of time that LGBTQ students spend in school, schools provide a critical context within which protective factors may be developed and leveraged to improve the health and wellbeing of these populations. This article provides a summary of key findings from a discussion among researchers, practitioners, and community members who participated in “The State of LGBTQ Youth Health and Wellbeing: Strengthening Schools and Families to Build Resilience,” a public symposium held in June 2017. We detail emerging science on and future priorities for school-based research with LGBTQ youth which were identified by attendees at this meeting, with a particular focus on intersectionality, supportive adults in schools, and in-school programs. We call for more school-based research on priority gaps such as how LGBTQ students' intersecting identities affect their in-school experiences, how to design professional development programs that cultivate supportive educators, and how to leverage gay–straight alliances/gender and sexuality alliances as sites of health programming for LGBTQ students.

BACKGROUND: In the United States, transgender youth are at especially high risk for HIV infection. Literature regarding HIV prevention strategies for this vulnerable, often-hidden population is scant. Before effective, population-based HIV prevention strategies may be adequately developed, it is necessary to first enhance the contextual understanding of transgender youth HIV risk and experiences with HIV preventive services. METHODS: Two 3-day, online, asynchronous focus groups were conducted with transgender youth from across the United States to better understand participant HIV risk and experiences with HIV preventive services. Participants were recruited by using online advertisements posted via youth organizations. Qualitative data were analyzed by using content analysis. RESULTS: A total of 30 transgender youth participated. The average age was 18.6 years, and youth reported a wide range of gender identities (eg, 27% were transgender male, 17% were transgender female, and 27% used ≥1 term) and sexual orientations. Four themes emerged: (1) barriers to self-efficacy in sexual decision-making; (2) safety concerns, fear, and other challenges in forming romantic and/or sexual relationships; (3) need for support and education; and (4) desire for affirmative and culturally competent experiences and interactions (eg, home, school, and health care). CONCLUSIONS: Youth discussed experiences and perspectives related to their gender identities, sexual health education, and HIV preventive services. Findings should inform intervention development to improve support and/or services, including the following: (1) increasing provider knowledge and skills to provide gender-affirming care, (2) addressing barriers to services (eg, accessibility and affordability as well as stigma and discrimination), and (3) expanding sexual health education to be inclusive of all gender identities, sexual orientations, and definitions of sex and sexual activity.

Objective Limited information exists on whether associations between substance use behaviors (SUBs) and sexual risk behaviors (SRBs) vary by sexual identity. Methods Data from the 2015 national Youth Risk Behavior Survey (n = 15,624), were analyzed to assess associations between SUBs (cigarette smoking, alcohol use, binge drinking, marijuana use, prescription drug misuse, injection drug use, illicit drug use) and SRBs (sexual activity, number of partners, condom use). Logistic regression models calculated adjusted prevalence ratios (aPR), stratified by sexual identity, and interaction effects for sexual identity were introduced to models to determine if associations varied by sexual identity. Results All SUBs had significant associations with current sexual activity and 4+ sexual partners for both heterosexual and LGB students. No condom use during last sexual intercourse was significantly associated with all SUBs except alcohol use among heterosexual students, while no condom use was only significantly associated with injection drug use among LGB students. Associations between current sexual activity and SUBs were significantly stronger among heterosexual compared to LGB students for smoking (aPR = 2.39;95% CI:2.15,2.65 vs aPR = 1.49;95% CI:1.14,1.95), marijuana use (2.41;2.15,2.71 vs 1.86;1.58,2.19) and prescription drug misuse (2.10;1.93,2.28 vs 1.60;1.28,2.00). Associations between no condom use and SUBs were significantly stronger for heterosexual compared to LGB students only for smoking (1.32;1.16,1.50 vs 0.96;0.73,1.25) and marijuana use (1.22;1.07,1.38 vs 0.90;0.72,1.12). Conclusions The relationship between most SUBs and SRBs did not vary significantly by sexual identity. These findings underscore the importance coordinating school-based programs to prevent substance use and promote sexual health.