Scientific Summary

Opening Remarks

Beshaun Davis, Ph.D., Program Director, Minoritized Populations Mental Health Research, NIMH

Dr. Beshaun Davis welcomed participants to Part 1 of a four-part series hosted by the NIMH Office of Disparities Research and Workforce Diversity. 

Part 1: Understanding Stigma and Discrimination as Drivers of Mental Health Disparities for Diverse, Rural, Sexual and Gender Minority (SGM) Communities

Sarah M. Murray, Ph.D., M.S.P.H., Johns Hopkins Bloomberg School of Public Health

Shoshanna L. Fine, Ph.D., M.P.H., Johns Hopkins Bloomberg School of Public Health

Kristen F. Siebach, M.S.W., Johns Hopkins Bloomberg School of Public Health

Mariah Valentine-Graves, M.P.H., Emory Rollins School of Public Health; Program, Research, Innovation in Sexual Minority Health (PRISM)

Savannah Winter, B.A., REALM, Emory Rollins School of Public Health

Dr. Sarah M. Murray explained the rationale of their study. Despite significant mental health disparities among sexual and gender minority (SGM) individuals, there was lack of research on SGM communities living in rural United States. Because stigma and discrimination may play a unique role in rural settings, it was important to better understand these nuances in order to develop targeted, culturally-appropriate interventions.

Approximately 3.8 million of the 46.1 million Americans living in rural areas identified as SGM. Fewer affirming spaces, higher religiosity, limited social connectedness, and limited access to care could contribute to poor mental health outcomes among rural SGM communities. Rural SGM communities also experienced a very different policy environment than other SGM communities, with a higher concentration of negative and harmful policies. Religiosity, while generally considered protective against suicide risk, might promote stigma and harmful practices in rural areas. Gun ownership, which provided access to lethal means, was also higher in rural areas. Despite these unique risk factors, rural areas could also offer unique protective factors such as close family ties and strong community networks.

The research team provided an overview of their Rural Engagement and Approaches for LGBTQ+ Mental health (REALM) study, which aimed to 1) determine whether classes of stigma, discrimination, and traumatic experiences varied across subgroups of rural SGM adults and whether these classes were associated with an increased prevalence of depression, suicidal ideation, and suicide attempts; 2) determine whether the classes identified in the first aim had a longitudinal association with depression, suicidal ideation, and suicide attempts; and 3) identify tailored technology interventions to mediate the relationship between minority stressors, mental health conditions, and suicidal behaviors using a discrete choice framework to identify preferences among rural SGM communities.

The research team aimed to recruit 2,500 SGM individuals living in rural areas who were diverse across SGM subgroups, race and ethnicity, age, and community experience. They also engaged a Community Advisory Board (CAB) that provided feedback and suggestions through the research process. The first recruitment phase used traditional social media advertising. The second recruitment phase was more targeted, using a list of participants from two other related studies. The final recruitment phase used non-traditional recruitment methods such as dating apps and social media influencers.

The research team reviewed preliminary results. To date, the research team had recruited nearly 1,500 participants. Although most participants had low depression scores, approximately 25 percent had moderately severe or severe depression scores—which represented more gender minority than sexual minority people. Suicidality was common across the SGM categories, ranging from 57 percent of cisgender sexual minority males to over 80 percent of transmasculine people. Suicide behaviors were more common among gender minority people, particularly among non-binary people. Daily discrimination was also more likely to be reported by gender minority than sexual minority people. Stigma was a common experience across all SGM participants.

The research team summarized their lessons learned. They found that attempted fraud was common because the study was compensated, which required a lot of time to manage. There was a need to constantly iterate recruitment approaches because AI and other fraudulent activities were very quick to evolve. They struggled to find diverse participants and had to shift their recruitment methods to fill those gaps. Spanish speakers were particularly hard to recruit, which could have been related to cultural rather than language barriers. The CAB was helpful with suggestions to increase diversity, such as partnering with the Association for Rural and Small Libraries to post flyers or recruiting in areas with meatpacking and poultry factories to find rural Hispanic participants. The classification of rurality was another challenge that led to many people living in rural areas falling through the cracks. The research team planned to continue evaluating their recruitment approaches to prevent fraud and increase diversity.

Question and Answer Session

Question: Have you considered publishing your experiences in managing fraudulent responses?

Answer: Ms. Valentine-Graves said they had submitted two manuscripts on their experience and will continue to try and publish their lessons learned.

Question: What should be considered for people with intersecting racialized and rural identities?

Answer: Dr. Murray said that it was an important question because many people viewed rural populations as primarily white. In reality, they were becoming increasingly diverse. They hoped to conduct stratified analyses with an intersectional lens, recognizing that stigma and discrimination could encompass a wide range of identities such as racial and ethnic identity and immigration status. They aimed to increase the diversity of their participants to be consistent with or exceed the diversity found in rural populations. It was also important to maintain diversity within their research team and continue to bring in people with a wide range of experiences and backgrounds.

Question: Morality is not homogenous across rural areas, where Appalachia might have differences from the Deep South. Have you considered conducting subgroup analyses to identify these differences?

Answers: Dr. Murray answered that they recognize the heterogeneity in terms of policy across rural areas, where some may have protective policies and others may have more harmful policies. They hoped to conduct region-specific analyses to determine how this shapes experiences.

Ms. Kristen F. Siebach talked about her research on this topic, which was in the planning phase. She hoped to interview participants in rural areas to understand how policy impacts their mental health and their intersecting identities.

Question: How do you recruit people when there is a history of mistrust in research?

Answers: Ms. Valentine-Graves said that it was a constant consideration. They quickly respond to people who express concern. They also use standard language to communicate through emails, social media responses, and FAQs. It was an iterative process, and they used A/B testing to evaluate which approaches were more effective. For example, they had to consider whether or not to include their university logos on communications.

Ms. Savannah Winter noted that there had been genuine harms perpetrated on these communities, and it was important to acknowledge their concerns and provide protections such as privacy and confidentiality. Participants were being asked to share a lot of personal information, so their concerns were valid. It was also important to realize that one comment on an influencer’s page could quickly blow up. Often, people’s fears or anger were based on not having enough information. Communication was therefore critical.

Dr. Shoshanna L. Fine added that they did not have previous experience recruiting SGM participants in rural areas, but they received a huge response—a testament to how little research there had been in this area. There were not many opportunities for these communities to share their voice, and it was important to establish and sustain their trust.

Question: Did you find any surprising outcomes related to flourishing?

Answer: Dr. Murray noted that this was one of the most exciting topics for the team to consider. There was often an idea that mental distress and flourishing were in complete contrast. But in reality, people could experience distress in one area of their life, and flourishing in another. When they first proposed their study aims, they realized that much of the focus was on the negative and risks. They did not feel good about putting out a survey that did not consider unique strengths and positive mental health outcomes. They wanted to understand what strengths people relied on or the unique resources they used to help inform the supports they needed to build on those strengths. The ultimate outcome should not just be the lack of distress; it should also be about thriving.