Day Two: Workshop: Promoting Mental Health for Sexual and Gender Minority Youth: Evidence-Based Developmental Perspectives

Transcript

EVENT PRODUCER:  Welcome, everybody joining.  We will get started in about one minute.  Just waiting for more people to pile into the room.  Again, we will get started in about one minute.  Thank you for your patience. 

Okay.  Let's get started.  Welcome back, everybody, to Day 2 of Promoting Mental Health for Sexual and Gender Minority Youth:  Evidence‑Based Development Perspectives. 

Just a few reminders of housekeeping notes.  Participants have entered listen‐only mode; cameras off and mics muted. 

Please submit your questions via the Q&A box at any time during the webinar.  Questions will be answered during the discussion sessions of the workshop.  If you have any technical difficulties hearing or viewing the webinar, please note these in the Q&A box, and our technicians will work to fix the problem.  You can also send an email to NIMH Events.  That's NIMH@mn‑e.com. 

And with that, I will now turn it over to Dr. Irene Avila.  

IRENE AVILA:  Good morning, and welcome to Day 2.  I'd also like to wish everybody a happy Pride Month. 

As I shared, my name is Irene Avila, and my pronouns are she/her and Ella, and I am the Assistant Director for the Sexual and Gender Minority Research Office. 

First, thank you all who joined us yesterday.  It was a wonderful full day, and lots of information learned and taken in, and we're grateful that you all were able to join us again for the second full day.  We had wonderful speakers yesterday, and today we have another full day of wonderful speakers as well. 

So, before we begin our day, we're going to have some welcoming remarks, and I'm honored to introduce Dr. Allison Cernich, the Deputy Director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.  

ALLISON CERNICH:  Great.  Irene, thank you so much. 

And as she said, I'm Allison Cernich, my pronouns are she/her, and I just want to thank Dr. STACIA FRIEDMAN-HILL for organizing this important and needed workshop on promoting mental health for sexual and gender minority youth and for inviting me to speak today.  I really also want to thank the institutes and centers that helped make this event happen and support this work and to all the speakers who are sharing their experiences, expertise and research with us over these two days. 

NICHD's mission is to lead research and training to understand human development, improve reproductive health, enhance the lives of children and adolescents, and optimize abilities for all.  And this mission is inclusive of those with diverse gender and sexual identities. 

Yesterday's speakers, I think, shared critical information about the mental health of sexual and gender minority youth, and much of what they discussed is also a priority for our institute, including accurately and inclusively measuring sexual orientation and gender to improve our science in investigating social and structural determinants of health for this population. 

As discussed, sexual and gender minority youth experience significant mental health disparities compared to their cisgender heterosexual peers.  We also know that they are at higher risk for depression, anxiety, substance use and suicide, and factors such as discrimination and stigma, lack of access to culturally competent care, and social and structural barriers contribute to these disparities. 

And research shows that youth's developmental stage is a critical component of the development of mental health issues, and so taking that developmental perspective is really at the core of what NICHD does. 

We really do feel like more research needs to be done to fully understand the circumstances impacting sexual gender minority youths' mental health and identifying the evidence‑based strategies that better support them, and also, we know that researchers currently face barriers conducting this work, including challenges of including minors in this type of research. 

So really, we have, through our strategic plan and our goal of improving child and adolescent health in transition to adulthood, we've advocated for the inclusion of youth in research to ensure that we have a comprehensive understanding of sexual gender minority youths' experiences in addressing the health concerns that manifest for them in adolescence. 

We really do support quite a lot of this research, particularly through our population dynamics branch.  So, if you are interested, they would be a great first point of contact.  They really think about investigating health and well‑being of youth who are sexual gender minorities, including improving sexual orientation and gender measurement, gender identity measurement, developing inclusive educational curricula, and also dating and relationship violence prevention. 

So, we've also supported studies that investigate factors influencing youth mental health, including those related to the association between the stress of the pandemic and adolescent suicide, some of the issues related to cyberbullying, dissatisfaction with family relationships, and unmet medical needs.  And these are major contributors to the high rates of depressive symptoms that are seen among sexual and gender minority youth. 

I actually am really looking forward to hearing from the speakers today about their critical work around community engagement, risk and resilience, and prevention and services.  The incredible work that they are presenting at this workshop, along with the tireless efforts of the staff across NIH and institutes and centers that are co‑sponsoring, really will help us to further our understanding of sexual gender minority youth mental health and the pathways that we can take to address the associated health disparities. 

So, I want to thank all of you again, I look forward to the discussion today, and, again, really appreciate the organizers and all the effort.  Take care.  Thanks so much.
 

IRENE AVILA:  Thank you, Dr. Cernich. 

And now we have a prerecorded welcome from Dr. Helene Langevin, the director for the National Center for Complementary and Integrative Health.  
 

HELENE LANGEVIN:  Hello.  My name is Helene Langevin, and I am the Director of the National Center for Complementary and Integrative Health, or NCCIH, and (inaudible) like to thank NIMH for inviting us to participate in this workshop focused on research aimed at the promotion of mental health for sexual and gender minority youth. 

The workshop aligns well with NCCIH's strategic plan to expand the portfolio of research on complementary and integrative health to address and eliminate health disparities across the (inaudible) and our efforts to advance research on emotional well‑being.

Additionally, a central focus of NCCIH's strategic plan is whole person health.  This emphasizes that health exists across multiple interconnected body systems and domains, including biological, behavioral, social and environment.  Multicomponent and prevention intervention to reduce risk and/or enhance protective factors across multiple levels of influence align well with the whole person health framework and are of much interest to NCCIH. 

Expanding our portfolio of health disparities research is a priority for NCCIH.  We seek to expand research support for the development, efficacy and dissemination of complementary and integrative interventions to improve health outcomes for sexual and gender minorities and other populations impacted by health disparities.  We provide funding for training, career development, and research opportunities directed at minority health and health disparities. 

Here are two examples of health disparities research that we are interested in.  First, community‑engaged research on the efficacy and effectiveness of approaches to improve minority health and address disparities in mental, emotional, and behavioral health, obesity, and pain, and also support complementary and integrative approaches for health promotion, resilience, and disease prevention, as well as system management to address social determinants of health. 

I would like to briefly highlight two current NCCIH‑funded studies focusing on sexual and gender minority health. 

The first is entitled "Evaluating the Feasibility and Acceptability of Mindful Self‑Compassion Among Gender Minority Young Adults."  This was funded in response to a notice of special interest on the mechanisms ‑‑ excuse me, on research on the health of sexual and gender minority populations.  This study addresses an important research gap:  the need for intervention to address the gender minority stress among gender minority young adults and gender dysphoria or distress resulting from incongruence between one's body and identity.  This is a form of stress unique to gender minority individuals.  Mindful self‑compassion could potentially be a source of resilience to alleviate gender minority stress and rumination. 

The second study is entitled "Developing Internet‑Delivered Mindfulness Based Intervention to Reduce HIV Risk and Promote Mental and Sexual Health Among Young Adult Men Who Have Sex with Men."  This study is funded via the training mentor career development award mechanism.  The study will adapt, and pilot test the virtual delivery of a mindfulness‑based risk reduction intervention to promote mental and sexual health and HIV testing engagement among distressed high‑risk young men who have sex with men. 

Internet delivery was selected to increase reach, scalability and availability of the intervention to address the challenges experienced by the vulnerable population seeking in‑person counseling and health services. 

We very much look forward to the workshop.  
 

IRENE AVILA:  Thank you both, Dr. Cernich and Dr. Langevin, for NCCIH and NICHD support and collaboration for this workshop. 

And I'm now pleased to introduce Dr. Christopher Barnhart from the Sexual and Gender Minority Research Office who will moderate the Community‑Engaged Research session.  
 

CHRISTOPHER BARNHART:  Thanks.  Can everybody hear me?  
 

IRENE AVILA:  Yes.  
 

CHRISTOPHER BARNHART:  Okay, great. 

So good morning, everyone.  Happy Pride and thank you so much for joining us. 

I'm so grateful to NIMH for taking the lead on this effort.  My name is Christopher Barnhart, my pronouns are he/him and they/them, and I'm a health science policy analyst with the Sexual and Gender Minority Research Office. 

Our office is thrilled and proud to co‑sponsor this workshop, which we hope will provide actionable insights into the crucial, timely topic of mental health among LGBTQI+ youth, a public health concern that is both significant and, frankly, devastating.  I'm honored to serve as moderator for this session on community‑engaged research. 

There's a firm and ever‑growing appreciation for the importance of engaging affected communities in research.  This is true not only during the phase when research is being conducted but throughout the entire research process, from initially building relationships and developing research questions through dissemination, implementation, and achieving sustainable long‑term impact.  Who knows the key issues more intimately than the people experiencing them, who else is best positioned to provide input on potential interventions and strategies for prevention and health maintenance to address these issues, and who else knows better what will really work in the real‑world situations where these issues occur and how to make sure that positive impacts continue on even after the research is done. 

With this backdrop in mind, it is my pleasure to introduce a panel of exceptional researchers to further explore community engaged research to address the mental health needs of young SGM people. 

We'll hear from Dr. Sari Reisner of the School of Public Health at the University of Michigan who will talk about transforming health for gender‑diverse young adults using interventions to drive equity.  Then we'll hear from Dr. John Salerno from the School of Social Work at Columbia University.  We'll talk about a community engaged approach to conducting mental health research with LatinA, LatinX, and LGBTQ+ youth communities.  We'll hear from Anneliese Singh whose presentation is on theory to practice in community engaged research, feminist, womanist, intersectional and liberatory approaches.  We'll hear from Dr. Alessandra Angelino whose presentation is titled "Pride and Community Connection for Indigenous 2SLGBTQ+ Youth:  The Intersectionality of Identity for Indigenous and Adolescents in the U.S."

Finally, we'll hear from Dr. Jose Bauermeister on engaging SGM youth in clinical trial research, advancing their roles as an interventionist. 

Following this we'll hear remarks from our discussant, Dr. Terri Powell, Associate Professor and Vice Chair for Inclusion, Diversity, Anti‑Racism and Equity at the Bloomberg School of Public Health at Johns Hopkins University. 

And we'll cap it off with a question‑and‑answer session with our panelists and discussant where workshop attendees can ask their questions using the Q&A feature in Zoom. 

I realize I forgot everybody's affiliations. 

Sari Reisner is with the School of Public Health at the University of Michigan, Dr. John Salerno from the School of Social Work at Columbia University, Dr. Anneliese Singh from the School of Social Work at Tulane University, Dr. Alessandra Angelino of the Division of Adolescent Health and Young Adult Medicine and Center for Indigenous Health at Johns Hopkins University, and Dr. Jose Bauermeister from the University of Pennsylvania. 

So, our first presentation is by Dr. Sari Reisner. 

Dr. Reisner, when you're ready, please take it away.

SARI REISNER:  Good morning, everybody.  Thank you so much for the invitation to participate in this excellent workshop and session on community engaged research. 

Today I will share community engaged research that's part of an ongoing study currently funded by NIMH, which I'm co‑leading with Dr. Reena Shu at Boston Children's Hospital in collaboration with Harvard, Mass General Brigham, and the National LGBTQIA Health Education Center. 

This is funded through the NIH initiative Transformative Research to address health disparities and advance health equity which was initiated by the NIH common fund to support translational research projects to prevent, reduce, or eliminate health disparities and advance health equity. 

So, firstly, transgender, nonbinary, and gender‑diverse young people, those who have a gender identity or expression that differs from their assigned sex at birth, which today I'll refer to as trans young people or TGD young people, experience a significant mental health burden. 

These are data from a matched retrospective cohort study that I led of trans young people in primary care in Boston.  You can see on the X axis all mental health diagnoses, including depression, suicide ideation and attempts, all of which are elevated for trans versus cis youth, and this has also been replicated in other national probability sample studies such as the YRBS.  Intersectional minority stress is a conceptual framework for understanding the mechanisms driving this elevated mental health burden, and particularly in suicidality and depression. 

So societal stigma and depression occur at multiple levels ‑‑ individual, interpersonal, structural ‑‑ and result from oppression due to having minoritized identity. 

These processes are amplified for those facing multiple forms of oppression due to holding multiply marginalized social positions such as trans youth of color and trans youth who identify as sexual minority. 

Mental health inequities in trans youth are linked to the broader context of stigma, including lack of family support, bullying from peers, and gaps in culturally responsive clinic care to address mental health concerns.

We know that support from families, communities, and clinical providers have been associated with better mental health for trans youth, and these represent an important intervention target for mental health. 

So, the objective of our study is to test the effectiveness of an innovative intervention approach which aims to improve mental health of young trans people by building relationships and support from providers, community members and family members with a goal of ultimately reducing rates of suicidality and depression in trans and gender‑diverse young people. 

We seek to do this through two intervention components.  Intervention component 1 on the left is focused on healthcare provider training and support.  This is being done in partnership with Dr. Alex Grove at Harvard and the National LGBTQIA Health Education Center.  This is a free online training course for continuing education credit.  It teaches providers how to support and communicate effectively with trans young people and also seeks to enhance provider networks for increased psychosocial support. 

Intervention component 2 on the right focuses on trans youth in caregiver education and support.  This is an interactive digital platform for trans young people and caregivers where we provide expert generated knowledge via educational modules.  It also has interactive features to promote communication and strengthen relationships between trans young people and caregivers. 

So, for example, we have modules that are on coming out to extended family, finding peer support as a caregiver, strength‑based ways of managing intersectional stigma and effective communication strategies to manage conflict and promote connection. 

As part of this we're partnering with Boston Children's Hospital Simulation Center to create digital content that includes role plays and other interactive activities. 

So, for intervention component 1 we're fielding provider intervention with 100 healthcare providers using a pre/posttest design, and the goal ultimately is to increase knowledge, attitudes and competencies in caring for and addressing the mental health needs of trans young people. 

For intervention component 2 we plan to conduct a randomized controlled trial randomizing trans young adults and caregivers to an immediate versus a six‑month deferred arm with the goal of increasing support and, therefore, addressing mental health, particularly suicidality and depressive symptoms. 

Since the project's inception, we've utilized a community engaged research process, and this process seeks to ensure the relevancy and responsiveness of the intervention components as well as the process of implementation of our study. 

So, we convened two community advisory boards which we've worked intimately with for the last several years.  One is comprised of trans and gender‑diverse young people; the other is caregivers and providers of trans young people. 

Trans young people that are caregivers and providers have been actively engaged in the educational platform and content development of our modules, and the goal really has been to center the voices of communities and stakeholders as a way to maximize impact. 

I'll also note that all members are compensated for their time.  We've also conducted more than 20 consultations with key stakeholders, including organizations serving trans young people and families, to identify unmet needs in the ways that our project can catalyze rather than duplicate existing work that's in the field. 

In addition to our CAB and stakeholder consultations, we've conducted extensive formative research to engage communities in our project, and this helps us to assess community needs, to develop the content and also ensure acceptability of study procedures and processes. 

We also sought to identify barriers, potential barriers, and facilitators to implementation. 

So, the community engaged formative research was conducted from April to August of 2022.  It included a nationwide survey with 104 trans young people ages 18 to 25 and 33 in‑depth one‑on‑one interviews with healthcare providers, trans young people, and caregivers of trans young people. 

For the quantitative survey, a nationwide survey of trans young adults, this was fielded using the Prolific Platform, a digital platform with a panel of more than 150,000 active participants in the U.S. that asks about gender identity questions. 

Our goal was 100 trans and nonbinary young people.  50% were youth of color.  We ended up enrolling 104 youth.  The mean age was about 22 years.  Overall, 66 identified as nonbinary, 46% were trans or nonbinary young people of color of which 22% were mono‑racial and 24% were multiracial. 

The distribution by U.S. census region was well distributed with higher proportions slightly residing in the South and other areas.  We examined the prevalence and correlates of screening positive for elevated depressive symptoms using the validated Patient Health Questionnaire‑2.  This is a measure that's commonly used in clinical care to screen for depression, which is why we selected it. 

Overall, 42% of the sample had a positive screen.  We then assessed correlates of screening positive which we estimated adjusted prevalence ratios for.  The strongest correlate was family support, which we coded as low support, high support or not being out to family, i.e., they don't know I'm trans. 

So trans and binary youth who had low family support had 70% elevated prevalence relative to those with highest family support.  We saw no significant association with depression for those who were not out with their family. 

But this survey underscored the importance of our project as well as the vital role of family support which we do address by involving caregivers.  We also asked about which, if any, websites or social media platforms ‑‑ excuse me ‑‑ we also asked about young people's information‑seeking behaviors relative to gender and health. 

We asked, on the left, "From what types of people do you like to get information about gender and health?"  Information from trans people in general or from trans friends were the highest endorsed categories.  This informed our focus on trans community support and peer engagement as part of the app.

This also ‑‑ about half of the sample, 51%, reported liking to get information from medical professionals, which also supports our approach of working with providers who serve trans young people. 

On the right we also asked about which, if any, websites or social media platforms young people use to get information about gender and health.  YouTube and Reddit were the highest endorsed platforms followed by Twitter, TikTok, and Instagram. 

This information was used in creating extensive resources and linkages to content outside of our digital platform.  It also informed us of our recruitment plans. 

In terms of qualitative work, we did interview providers, trans young people and caregivers to inform the interventions.  I'm showing here themes from 14 interviews that we conducted with caregivers of trans young people.  We selected caregivers who considered themselves to be supportive because we wanted to know about the process and the steps that they took to get to that place of support. 

Caregivers described how support was fostered through profound interpersonal and intrapersonal reflection, connection, and community, and three predominant themes emerged. 

First was navigating relationships with self.  Caregivers navigated feelings of loss as they adjusted to their trans young person's changing identity and what they thought their lives were going to be like.  They also wrestled with worry for the trans young person and worried for their safety in the world. 

The second theme was about negotiating relationships with others.  This involved the process of disclosing their trans young person's identity to extended family and social networks and friends.

Thirdly, educating themselves and others through relationships.  Caregivers talked a lot about the importance of connecting through personal narratives with other caregivers, parents, and families.  Personal stories were crucial to their own process of getting support and, therefore, being able to better support their trans young person. 

In addition, learning to advocate for their trans young person was described as a very important element.  This included advocating for their trans young person in healthcare settings, educational settings, and in other contexts. 

In using this formative research, our intervention was developed to provide content on strategies for disclosure to family and networks.  We also emphasized the importance of linking with other caregivers, gathering information to educate themselves and others, and learning how to advocate.  We also incorporated simulation videos and content and role play of trans young people and their caregivers to enhance skills in more effective communication. 

So, our community engaged research has sought to put the community at the center of our work to work with, not on, communities to inform science, practice, and policy.  In our case communities includes not just trans young people, although this is the group whose mental health we're trying to improve, but we also involve caregivers and providers, the broader system surrounding trans youth. 

We've learned it's important to engage multiple communities and stakeholders in this work in order to effectively address young people. 

Now more than ever, this is more important given the current legislative context and onslaught of anti‑trans bills.  In 2023 more than 600 bills were introduced and 87 passed, many of which relate to healthcare access for trans young people.  Many organizations, including the American College of Physicians, have issued statements to support trans youth that oppose restrictions on healthcare, but this structural stigma and the current 
sociopolitical environment makes interventions to support trans youth and their mental health, as well as caregivers and providers, even more relevant than ever. 

I'd like to leave with a quote from the community, somebody who's one of our lost and fallen community members.  This was Leelah Alcorn, who unfortunately took her life.  And she said, "The only way I will rest in peace is if one day transgender people aren't treated the way that I was, they're treated like humans, with valid feelings and human rights.  Gender needs to be taught about in schools, the earlier the better.  My death needs mean something.  Fix society, please." 

We all they have an important role to play in addressing societal stigma and supporting trans young people.  Community engagement and putting community at the center is a vital part of doing this work. 

I'd like to thank the amazing team of the Trans Guide, many of whom are people of young trans experience.  I'd like to especially thank my co‑PI, Dr. Reena Shu, and thank you very much for allowing me to be here today.

CHRISTOPHER BARNHART:  Thanks, Dr. Reisner. 

Dr. Salerno, you're next.  Please go ahead.

JOHN SALERNO:  Hello, everyone.  I'm Dr. John Salerno.  I use he/him/el pronouns.  Thank you for having me.  I'm excited to present for you an intersectional community engaged approach to conducting mental health research with Latine/x‑LGBTQ+ communities. 

Really briefly, I'd like to go over the mental health status of Latine/x‑LGBTQ+ people in the U.S.  These are graphs that I made from The Trevor Project's national surveys of mental health among LGBTQ+ youth. 

What we can see here on the right‑hand side where the purple bars are is that the trend ‑‑ there's a declining trend between 2021 and 2023 in terms of depression symptoms among LGBTQ+ LatinX and LGBTQ+ youth.  However, across the years what we see here is that the rates are even higher among LGBTQ+ LatinX youth compared to LGBTQ+ youth. 

And we can see that this is also the case for suicidal ideation where LGBTQ+ LatinX youth have higher rates of suicidal ideation compared to LGBTQ+ youth between 2021 and 2023.  Both sets of rates for both of these communities are unacceptable and very high, and I've shown you this information today just to demonstrate that LGBTQ+ LatinX youth are a real community, and they have significant mental health needs as well. 

And so right now we're facing some critical challenges in addressing mental health among Latine/x and LGBTQ+ youth.  First is an overreliance on the health disparities framework in which we compare minoritized communities' mental health to a majoritized population.  And by focusing very much on this health disparities framework we're actually masking the drivers of the unique mental health inequities faced by communities situated at the intersections. 

There's also a very great focus on cultural explanations for health and mental health of Latine/x populations.  So here I'm talking about constructs like machismo and marianismo and also especially about the effects of acculturation on mental health. 

You've probably heard statements such as the longer a Latino immigrant lives in the United States, the unhealthier that they become.  This comes from the acculturation research, and it's known as the Latino and immigrant health paradox.  And so, focusing on these cultural explanations so much also contributes to the masking of the structural factors and other identity‑related factors that affect mental health in these communities. 

There's also been a siloed use of the sexual and gender minority stress framework for LGBTQ+ mental health.  As we all know, there's been very important knowledge that has been produced and continues to be produced through the use of a sexual and gender minority stress framework, but this can't account for all the stressors faced by a population situation at the intersection such as Latine/x‑LGBTQ+ youth and the negative effects of racial or ethnic minority stress on their mental health. 

There's also the scientific amalgamation of Latine/x and LGBTQ+ populations.  So here I'm talking about that Latina populations are often treated as a monolith, and so we don't really treat them as different communities.  And they are.  They come from various different countries and different socio‑historical political contexts. 

And we're facing similar problems in the LGBTQ+ scientific literature where we're amalgamating these communities when they are actually very diverse communities, and so there's a great need to think about how we disaggregate these different populations in research. 

And, lastly, there's a lack of community engaged studies about youth who are situated at the intersection of LGBTQ+ and Latine/x youth.  And we really need this community to be engaged in research since we know so little about the population. 

So how do we counter these challenges?  One way is through the use of the Intersectionality Theoretical Framework.  So, this is the idea that those who hold multiple marginalized identities can have complex experiences with multiple systems of oppression.  And in public mental health we're interested in how such intersectionality has a negative effect on their mental health. 

I also like to consider the principles of intersectionality as per Dr. Patricia Hill Collins, so first thinking about power and social inequality.  So, the oppressive experiences that you're measuring in your study, do they relate to imbalances in power dynamics and how that creates these social inequities, relationality, and complexity.  This is one principle that we're good at in public health, looking at the intersection or interactions between oppressive experiences and using other types of statistical models where we can examine the intersections of these factors. 

The social context.  So what is going on outside of the research, what is going on with this community that you're investigating. 

And then lastly is the social justice principle where true intersectionality work is supposed to end with a social justice intervention. 

But this is a lot, right?  So, there are a lot of principles to consider in public health research studies.  So how can we implement all of these principles? 

And so, enter community engaged research.  So, community engaged research is research that involves the community you're investigating in at least one of several ways, and it means that you're using some of the principles of CBPR or participatory action research, and this is okay, and it's encouraged. 

And so, at the most basic level when you're doing community engaged research, this is when community members are study participants in a research study.  But community engaged researchers would like others to take community engaged research a step further or many steps further in which the community members are actually involved in all of the different phases of the research process. 

And so, this is this idea of co‑collaboration with members of the community.  And doing this kind of research can be very powerful.  And so, in terms of the principles of intersectionality together with community engaged research, by using these community engaged research methods you're able to go further than only analyzing intersecting identities and oppression, so this principle of relationality, and complexity. 

By doing research in and with a community, you can identify and understand the power imbalances and social inequalities that are happening in that specific community that you're investigating as well as the social contexts, and you're able to deliver on social justice as defined by that specific community. 

And so now I'd like to shift a little bit to speak about our student organization, LGBTQ+ Students and Allies in Public Health, and this slide is really about the community engagement process for the research studies that I'll be presenting today. 

And so, this group's mission was to promote LGBTQ health equity and social justice through research, advocacy, and education and leadership projects and initiatives at the University of Maryland and beyond.  And this is an idea that the founding team had, and we went through this community engagement process as part of the group and as part of the research that I'll be speaking about today. 

We started with a university‑wide community meeting with LGBTQ+ college students.  And the purpose of the meeting was really to represent the idea for this new organization to LGBTQ+ college students and also to see if there was a need, if this was a need that others identified with as well. 

We officially founded the group in February 2020, and what it turned out was that we wanted to, as a group, work together on a national survey looking at the minority stress impacts on mental health among LGBTQ+ college students. 

And so, you can see from this figure here at the bottom that the student organization and the students themselves who were part of the organization were involved in all of the phases of the research process from study development to dissemination of findings and the social justice work as well.  And so, I'm going to present briefly findings from two research studies that came out of ‑‑ that have come out of the work from LGBTQ+ students and allies in public health. 

This first study is a study that I'm not going to use intersectionality.  So, I'm calling it a non‑intersectional study.  So, the first aim in this study is to examine the impact of LGBTQ‑related minority stressors on psychological distress among LGBTQ+ college students. 

And the second aim was to understand whether Latine/x identities moderated any association between LGBTQ‑related minority stressors and psychological distress among LGBTQ+ college students. 

And so, the sample was an equal 565 LGBTQ+ college students.  We're looking at the effects of different minority stressors on psychological distress, and then we're looking at how Latine/x identity moderates these associations potentially. 

And for the study's cross‑sectional we used national 
non‑probability sampling strategies and, again, 565 students. 

And the main analytic method we're using here is multiple linear regression to achieve our study aims.

And so, the majority of the sample identified as White or Hispanic/Latine/x, and in this first set of analyses we looked at the bivariate associations between racial and ethnic identity categories and psychological distress.  It turns out that only Asian identity and multiracial identity were significantly associated with psychological distress. 

And I want to draw your attention to the first line, Hispanic or Latine/x, where this p‑value was very non‑significant.  And so, this nullified our ability to be able to analyze the moderation effect of Latine identity on Aim 1, which is the association between LGBTQ+ minority stressors and mental health. 

The average psychological distress score in the sample was 17.81, which a signifies high and clinically significant level of psychological distress.  And when we looked at the bivariate associations between LGBTQ‑related minority stressors and psychological distress, it turned out that every type of minority stressor that we measured was significantly associated with psychological distress, and so we included all of these different minority stressors in the multiple linear regression model. 

And here's what came out of that multiple linear regression model.  It turned out that internalized LGBTQ+ phobia, family rejection, and victimization were all significantly associated with greater psychological distress.  And this is ‑‑ these are important findings because they tell us that minority stress is happening on college campuses and we need to address that, and so we need to think about how we can implement or adapt current minority stress reduction intervention in the college setting. 

And so now for Study 2 which‑‑ 
 

CHRISTOPHER BARNHART:  Dr. Salerno, can you begin wrapping it up?  We need to move through the other presenters too.  
 

JOHN SALERNO:  I just have a couple of slides left. 

So, in this study the main aim was to examine the impact of racist microaggressions on psychological distress as well as minority stressors on psychological stress among LatinX college students.  And basically, I'm using here the intercategorical intersectionality framework, and so thinking about the different identities and positionalities that these students are holding.  So, they're at the intersection of LGBTQ+ identity and Hispanic identity but then also considering the social context, that they're college students in transition to adulthood, and so they're in developmental transitions, internal and external. 

The data was collected during COVID‑19, also during the Trump Presidency when there with high anti‑immigrant sentiment and near the time of the killings of George Floyd and trans women of color.  And I also used critical race theory to frame this study, so thinking about racism as a main determinant of mental health. 

And so, when we looked at the effects of racist microaggressions on LGBTQ minority stressors, only family rejection and racist microagressions were significantly associated with psychological distress.  And when we included those two in the multiple linear regression model, it turned out that only racist microaggressions were significantly associated with psychological distress. 

And so basically what this is showing you is that the SGM minority stress framework alone isn't sufficient for explaining mental health among Latine/x‑LGBTQ+ college students, and there's a salient impact of racism and family rejection, and that the implementation of the intersectionality minority stress framework creates an opening to reveal the unique inequities experienced by multiple marginalized populations. 

But we also need new frameworks that can really tell us what the intersectional experience of these populations are, and so more psychometric and qualitative research in this area. 

And, lastly, the utility of community engaged research methods can be used to promote this kind of research and scholarship. 

Thank you very much.  
 

CHRISTOPHER BARNHART:  Thank you so much, Dr. Salerno. 

Dr. Singh, you're next, please.  Take it away.  
 

ANNELIESE SINGH:  I just want to keep listening to all these presentations.  I want more. 

Thank you so much, Dr. Salerno and Dr. Reisner and all of the folks that are to come. 

My name is Anneliese Singh, and I use she and they pronouns.  I serve as Tulane University's Chief Diversity Officer.  I'm a counseling psychologist and professor here.  And just thank you to Dr. Stacia Friedman-Hill ‑‑ it's been an incredible two days ‑‑ and to everyone who has organized today. 

I needed this.  I needed to feel hopeful in our future and to feel hopeful about the work that we're doing.  I know we get to read each other's papers and to know that we're out there at work, but the last day and a half has felt like the family is coming together.  So, it's just been so wonderful.  Thank you. 

And so, I wanted to do something a little different today.  I know that research is why we're here, but we often don't talk about why we do the research or what frames our research. 

And so, I came to this presentation with a lot of cultural humility because I'm already ‑‑ I'm learning, I make mistakes, I step into the metaphorical stuff, and I'm grateful for all of it because I get to learn with and from young people. 

And so, I think we often teach what we need to learn and how we need to grow.  And when I think about the experiences I've had working with queer and trans young people, I just feel I'm a better person for learning to change what and how I am and lean into different areas of growth. 

And so, with that cultural humility I will share a snapshot of some of my experiences.  They're just a snapshot.  I hope they inspire you to think about the stories you have, the potential liberation that exists in your work, the things you might be ready to free up or change in your research and how you theoretically frame that. 

I'm also going to share some lessons learned.  You'll hear me alternate between queer and trans, LGBTQI+, 2S+, and you'll hear me say "young people" a lot. 

The W.T. Grant Foundation, a while back, did a study on what words help us really see young people as people.  And you guessed it.  It's just instead of maybe saying "youth" saying "young people" to remind ourselves that young people are people.  So, I'll just leave that there. 

I do want to give some gratitude to the land, the air, the water, the sky, that I'm presenting on and under.  I'm in New Orleans, which was originally ‑‑ the Choctaw word for New Orleans was Bulbancha, land of many tongues.  And I do this research now in Bulbancha, which was the epicenter of anti‑Black racism in this country.  You'll see an image on the bottom left of Congo Square where the all the Black liberation, resistance and abolitionist movement started.

And I also, in addition to that land and labor, sky, air, water acknowledgment, I wanted to give some really deep gratitude to the people I get to work with every day, Tochukwu Awachie, who is about to be a doc student at the University of Miami, Heidi Breaux there at LSU in Tulane, Dr. Bekah Estevez, who is at Georgia Southern University, and Robin Mathy.  So, I'm grateful for and grow with these folks every day. 

And I think I really appreciate the presenters so far because they definitely have jumped in and just defined what community engaged research is.  And I want to just kind of layer onto that, where does it start? 

And I think as researchers we don't always get to start with ourselves.  Like we know that whole me search thing.  We know that.  But I think it's deeper than that.  I think community engaged research helps us remember who we are, were, as young people and how we got shaped in terms of theory, research, practice, et cetera.

And you'll see in the bottom left image that I identify as a South Asian, mixed‑race, gender queer fem person.  I have a job.  I have lots of educational and financial privileges.  I have a partner.  So, I've got lots of safety networks.  But if I'm not careful in terms of how I think about theory, I'm kind of operating out of the theory my mom and dad taught me, the theory that I learned in this city of New Orleans, of Bulbancha.  That's an image of my interracial family growing up here.  And I think this is so important at this moment in time where we're talking about all the attacks on trans, nonbinary and/or queer folks. 

For myself, I feel very, very fortunate.  One of my pieces of resilience is resistance was that I did and was exposed to trans community members as not being a new phenomenon or fad or trend but just as a deeply embedded part of South Asian community.  And so, I'm sharing my story because I hope you're starting to think about your story as a community engaged researcher or someone who might engage in this type of research. 

And I wanted to talk about who we are as researchers, as practitioners, as advocates, because the work that we do usually kind of transcends settings. 

And I'll talk about three projects today:  The Georgia Safe Schools Coalition, which was founded in 2009; Project Affirm, which is an NIH grant I have with Walter Bockting and Allen LeBlanc, started in 2014 ‑‑ we're in our tenth year of a longitudinal study ‑‑ and the Trans Resilience Project, which was started around 2014 and is undergoing a massive reboot. 

And so, my section is really on theory.  If we don't articulate that theory, and we know what we do in quantitative methods and usually in mixed methods, too, is ‑‑ we even do it in qualitative methods ‑‑ we're like, oops, we forgot to use theory.  And then whose theory am I using?  I've already kind of shared that. 

I'm using Anneliese's theory which, you know, might be a good theory, but there are some limitations of those principles I'm working with if I'm not articulating them. 

And so, I think, you know, I'm about to talk about the Georgia Safe Schools Coalition.  And so much of that work was in the roots of intersectionality theory, especially as Crenshaw defines it. 

And so, I think many of you may be familiar with Crenshaw's work.  It's really about power.  It's not about intersecting identities; it's about those interlocking oppressions. 

And as we began the Georgia Safe Schools Coalition, it really began when a school counselor called me and said, hey, there's a middle school student that was bullied at school had to ride the bus home with the person who perpetrated those bullying behaviors. 

And so, at the time Lisa Bowleg was publishing her famous article about black doesn't equal lesbian.  Hopefully you have read her work and followed her work. 

But the thing about that time is that young people were already tracking Patricia Hill Collins' work, Kimberle Crenshaw, Alex Walker's work, and I think that really shaped how we formed the Georgia Safe Schools Coalition. 

We had a small baby grant from UGA at the time, a public university, and we had those leftover funds.  And based on 
all of the folks we had polled around the table, about 38 organizations that served queer and trans youth in different ways, we used that leftover remaining funds that had no restrictions on it to start the Georgia Safe Schools Coalition. 

And we did deep listen and dialogue in Georgia schools, and we heard a lot of things when we got in there like, hey, if this was racism, queer and trans oppression wouldn't be happening in Georgia schools.  And we had to be prepared from that interlocking oppression perspective to be like, really?  Do you really think racism is gone in Georgia schools. 

And then we learned very quickly from young people about the importance of having role expertise.  So, for instance, we had young people in certain schools that work with young people in other schools, we had principals in schools that were trained by the Georgia Safe Schools Coalition who had come when there were crises in other schools, school counselors to school counselors, faculty to faculty.  And so there was just a lot of work on building authentic partnerships with queer and trans young people.  That authenticity was not defined by us but really by their voices. 

And in addition to that deep listening dialogue and kind of authenticity of young people's voices, that helped us understand the true sites of change.  So many times, we were tempted to work with principles or the faculty, but what we heard from young people, that it was really the school counselors and custodial staff when they were having trouble with bathroom access, getting into the faculty bathroom, which was really f'd up to have to do that.  Right?  It was the custodial staff and the school counselors who were like I'm all in for you, baby, and I'm gonna protect you while you're in this school. 

They also gave us huge amounts of information about how they were already navigating queer‑ and trans‑negative sociopolitical environments.  Even though I'm hella depressed right now about everything that's going on, I feel very clear from everything I learned about young people way back to 2009 and ever since.  We had national orgs that would come in and talk to us and be like, Anneliese and crew, you can't talk about religion.  You need to keep this professional. 

Y'all, I was raised in the Sikh religion.  I feel like I developed so much expertise, not an expert, but expert behaviors at knowing how to talk about religion, Christianity and other religious doctrines, inside and out, because that's exactly what young people were experiencing and what they needed. 

And then became really curious about how to embed community based participatory action research into change mechanisms.  And with some of that leftover funding we had, which, again, were baby dollars, right, we worked with young people to create two documentaries.  And it was really their research design using a collective memory work model of their negative and positive experiences in schools and really kind of turning that into curriculum. 

And so, as I talk about the next project, Project Affirm, which is an NIH‑funded project, I just wanted to highlight one tool we used as a lifeline kind of data collection methodology and protocol. 

So, our youngest participant in Project Affirm is 16; our oldest is 89.  And you can see this is a sample.  This is not someone's real data.  But the project was originally studying trans identity development, which had only been written about conceptually. 

And so, one of the most important things about this type of community engaged research was really making sure to not just put research in participants' hands, but they are actually the theory builders. 

And so, in the lifeline protocol you can see they put ‑‑ it's kind of an intense thing to do.  You put the date of your birth and when you think your death may be and then kind of talking about all the ways ‑‑ I see Christopher ‑‑ all the way that they wanted to kind of think about how resilience and identity development would show up in their life. 

And there are really three questions I would ask us all to think about when we're using methods, theory, theory‑to‑practice community engaged research.  Slowing down a really ‑‑ a lot, actually, in asking ourselves who benefits from the decisions we make in theory practice and community engaged research, what might we have missed, and what are the pathways and material resources we can use. 

The next thing I'll just talk about briefly with feminist, womanist, and critical race theory approaches is that our community advisory board ‑‑ we know CABs aren't everything, but I think there are things that get complicated, like secondary analyses, what happens when you don't have enough BIPOC community members ‑‑ Black, Indigenous, People of Color ‑‑ research participants.  What do you do with hidden and vulnerable populations? 

And so, some of these theories our CAB and our young people on the CAB were already working with and actually led theoretical reanalysis of existing data.  And I think those types of interventions actually created pathways for many of our community members we worked with to go on to apply to Ph.D. programs. 

And I'm going to try to do the next part in two minutes, Christopher, so ‑‑ 
 

CHRISTOPHER BARNHART:  We want to have time for everybody.  Thanks. 

ANNELIESE SINGH:  Thank you. 

Where we've ended up is with really thinking about mutual aid theory principals in the Trans Resilience Project.  And I'll just leave this up on the slide so you can read through it yourself.  But I think we know what's going on in our kind of current sociopolitical context right now is that legislators aren't always reading our research, and we know that young people continue to support themselves and one another. 

And so, the thing I would ask you to think about is something that we have started to do is how do you put mutual aid theory into practice.  And so, the Trans Resilience Project is really about making research about trans and nonbinary communities' lives, putting it in their hands.  The young people that we work with are encouraging us to look at AI, ChatGPT and a lot of things that we never would have looked at. 

And the last thing I'll say is so much of our work tries to look at upstream, downstream influences on queer and trans young people's lives.  I think we end up building a lot of affirmative work, which is good; but I would just ask us to think about liberation.  What is the way that we can free up our methods, free up our theories, and unabashedly listen to young people.  What is the world they want to live in, what is the world they want to dream up for themselves, because they're already doing that. 

And thank you, Christopher, for that grace. 

And I'm excited to introduce Dr. Alessandra Angelino.

ALESSANDRA ANGELINO:  Thanks so much for the introduction and that brilliant presentation. 

Hi, everyone.  My name is Alessandra Angelino, and I use she/her pronouns, and I'm really grateful to be here with you all today to share some information about the intersection of Indigenous youth ‑‑ sorry, let me take off these captions here ‑‑ the intersection of identity for Indigenous adolescents in the United States. 

I first want to acknowledge the history of genocide and systemic inequities that are ongoing in the United States and a step towards reconciliation and strengthening our relationships with Indigenous peoples.  And I call on us all to think about the Indigenous peoples of the homelands that you're from and the lands on which you live and work, especially as we're gathering from across the country and the globe. 

Lastly, I want to acknowledge and honor the strength and resilience of the youth and their relatives who contributed to this work and think about action steps that we can take moving forward to better include Indigenous youth in the work that we're doing. 

And so, to begin, before I start talking about our work in particular, I just want to define what Two Spirit is.  Two Spirit is a unifying term that was created in the 1990s by Indigenous individuals and is used specifically to describe someone in either the United States or Canada ‑‑ so someone who's American Indian or Alaskan native, which I'll denote in the slides AI/AN, or someone who's first‑nation, so an indigenous individual from Canada ‑‑ to describe gender, sexual, or spiritual identity.  So, this term really goes beyond western concepts of a binary gender and focuses on one's role in the community.  I'd like to draw your attention to the bottom half of the slide, where you'll see some indigenous individuals who've displayed gender diversity and two‑spirit identity over history and call your attention to the fact that they were seen as celebrated people in their communities.  They were chieftains, medicine people, healers.  And so there was this concept of not only support but celebration and reverence.

This work is significant because, of course, it's critical to understand the history and context behind gender diversity, especially with attacks via legislation in present day, but really to understand the unique needs of this population, as they face a disproportionate burden of poor physical and mental health outcomes.  We also need to better understand that intersectionality that folks have been discussing today, but in particular, the purpose and benefits of community connection and pride as they relate to health outcomes for this population.  So, getting into a little bit more of the context, there's a number of barriers to accessing healthcare in this community.  And if we look at this diagram, of course you see in the center there are provider‑side and patient‑side barriers to care that can be moderated by focusing on trends in resilience, but looking at the outer rings, they're all set up within this system of structural inequity that's really rooted in both historical trauma and colonization.  So, we see these historical roots in this diagram.  Looking at the bottom, really the roots of binary gender focused on oppression or justification of violence, all within this process of colonialism that occurred within this nation and many other nations, leading to violence.  And so that reverence and celebration of gender diversity that existed in indigenous communities historically was stripped away and ultimately led to discrimination, violence and then poor health outcomes.

So, with this in mind, we wanted to think about how to combat these historical concepts and really think about pride and positive protective factors that exist today.  So, this project specifically focused on understanding those feelings of pride, both in two‑spirit identity and indigenous identity, and then exploring connectedness among these adolescents and young adults.  And then we also wanted to explore differences between adolescence and young adults that had cisgender identities and gender‑diverse identities, and then examine opportunities to improve health outcomes with them as the lead on this work.  So, the majority of this work took place out of the Northwest Portland Area Indian Health Board, which is based in Portland, Oregon, but is a national organization that recruits and works with two‑spirit and LGBTQ individuals, youth included, throughout all of their work.  So, we had a number of folks who identified as two‑spirit or gender‑diverse on the team to create this project, and then using the principles of CBPR, as was mentioned before, and tribal sovereignty, we really had an iterative process in terms of what our research process looks like.  So, the cool part about the northwest Portland area is that they have a wonderful social media presence, for youth in particular.  And so, we utilized their Instagram and then this great text program to reach out to indigenous youth across the nation, and folks who identified as both indigenous and two‑spirit and gender‑diverse as well as those who lived in the U.S. and were older than 15 were able to participate in the study.  So just looking at the subset of adolescent and young adults, because it relates to the topic today, we ended up with about 120 folks and then asked them some questions related to health status and access, but, again, really wanted to focus on pride and community connection.

I should mention that this was a mixed methods approach.  The data I'll share today are primarily the quantitative data with some free‑response questions, but we were able to also have really rich in‑depth interviews as well as focus groups with these individuals as well.  And so, as I mentioned before, all of this work was done to uphold the principles of tribal data sovereignty, really thinking about the fact that they own the historical context as well as these data that are being produced, and anything that we did ‑‑ writing up projects, this presentation ‑‑ has been approved by the youth and directed in that form.

So, moving into the results, I just wanted to highlight some of our participant characteristics.  So, as I mentioned before, we had about 120 participants in total.  The majority were 19 to 22 years old and lived in urban settings and off reservations, which I think is important because there's that misconception that most native individuals live on reservations.  And then I want to draw your attention to the bottom box, where you'll see that folks identified as two‑spirit as well as identifying as both cisgender and gender‑diverse.  So, this highlights that two‑spirit identity spans gender identities and dispels the common misconception that two‑spirit is someone who is native and transgender.  So just really beautiful to see that come out in our data.

Looking specifically at pride, so this chart looks at pride and gender identity ‑‑ I just want to quickly highlight the color.  So light blue is cisgender, navy blue is gender‑diverse, and then the orange is all.  So, we see there's strong pride in two‑spirit identity and in the idea that two‑spirit identity helps folks do good things for the community.  I also want to highlight community support.  So, this is two‑spirit folks feeling they have indigenous community support, and we see those numbers are still high, but there is a drop‑off in folks who are gender‑diverse and reporting support.  So that's just something for us to think about.  Looking specifically at pride and indigenous identity, again there's this concept that there's strong pride in indigeneity.  Folks feel that being indigenous helps them do good things for their community, but looking at "My family thinks I'm important," again, we see that drop‑off for folks who are identifying as gender‑diverse.  I think 80% is still relatively high, but when we stratified by age, we saw that the 15‑ to 18‑year‑old respondents showed the lowest rate of family support, and given we know how critical this is for affirmation and just improving health outcomes in general, I think it's something for us to be thinking about.

We then wanted to understand how two‑spirit folks felt in non‑indigenous spaces.  And so, across the board we see that there's lower support here, numbers ranging within the 40s to low 60s compared to those 80% numbers in the indigenous communities.  And again, we stratified this by age and saw that that early adolescence or that 15‑ to 18‑year‑old age group showed lower support.  So, this has implications for interventions in research clinical care, especially if we're non‑indigenous folks working with indigenous folks in our communities. 

Lastly, I just wanted to show this diagram, which highlights perspectives on indigenous traditional practices.  We asked questions about connection to the land, community, healing practices, and as you can see across the board, there's strong connection. 

Interestingly, if we look at the navy columns and where I've starred, folks who are gender‑diverse have the highest rates of connection, and this was really beautiful because it echoed the sentiments from that definition, I shared with you earlier.  Individuals who are gender‑diverse often held those roles as healers, chieftains, the people who were carrying on tradition and practices.  And so, the fact that this is carrying on today shows really strong resilience and just echoes that importance again of ceremony and role in the community for folks who are two‑spirit and gender‑diverse.

I also briefly want to share some quotes, really the first one showing that two‑spirit identity is something that is connected to colonization in the ways that I mentioned earlier.  And then the last two quotes highlighting that connection to the community, the importance of ceremony for healing and wellness, and the ability of two‑spirit to help build relationships, not only to ancestors in the past and that history but to build relationships with elders and the youth presently.  So those were really special for us to see as well.  The free‑response results really mirrored the findings I showed earlier, where adolescents and young adults really highlighted the need for questions, community awareness and moving beyond trauma, as well as advocacy.  So, this quote, again, just briefly highlighted that need for connection to improve mental and physical wellness.

As providers and folks doing research with sexual and gender minority youth, I think the two‑spirit identity and indigenous gender diversity is really important, because it allows us to, again, show that gender diversity has been present historically and that it's not a trend.  I've used history, little history lessons and clinical encounters with non‑indigenous folks and showed them the diagram I show here, and it's really changed parents' perspectives on what their child is going through.  Just other quick points, just thinking about the historical context, ways we can include indigenous traditional practices and just history in our education as well as research, thinking about just including two‑spirit people in the work we're doing and, in the acronyms, we're using and in policy, of course, as well with legislative efforts.  Briefly, this graphic we created from one of the participant quotes:  "We go by many names.  We are known for many roles.  We are sacred, ancient, prophesied.  We have always been here, and we will always be here."  

So, in conclusion I just want to remind us of all that gender and sexual identities are fluid for indigenous folks.  Two‑spirit does not necessarily equal gender‑diverse or trans.  High levels of pride and connectedness are present in this community and serve as protective factors.  There are, of course, those variations by age, which have implications for the work that we all do.  And of course, intersectionality between cultural identity and gender and sexual orientation is important and can be applied across all communities.  So, I just wanted to close with some resources for everyone.  You can scan the QR code here or just take a photo, but the Paths Remembered Project is the main group of folks that I work with out of the Northwest Portland Area Indian Health Board, and we have beautiful resources, including free mental health care for two‑spirit and indigenous folks offered in 42 states now.  So, you can find the link for that here, as well as the Celebrating Our Magic toolkit, which compiles culturally safe resources for youth, relatives and providers that are taking care of indigenous youth.

And with that, I'd like to thank you all and introduce Dr. Bauermeister for the next presentation.

JOSÉ BAUERMEISTER:  Thank you so much.  Now let me go ahead and share my screen. 

Hi, everybody.  I want to echo my colleague's sentiments and welcome you to this wonderful workshop.  I'm going to talk a little bit about how we can engage sexual and gender minority youth and young people in clinical trial research, particularly thinking about the lived experience and the expertise they bring to perhaps serve as interventionists in our interventions.  So, to kind of set up the stage, I usually think about community engagement using Arnstein's ladder of citizen participation, which you can see here on your right.  It actually is a longstanding framework for us to understand how we're engaging with different members and stakeholders in the community, and you can see that it goes from bottom to top, where we really are trying to get closer to the ladder rungs around partnership, delegation, and ultimately control, a true definition of empowerment.  And I think young people are actually really wonderful to help us push our own understandings of engagement and really come back to this ladder and make us question where we are and what are we trying to do through our science.  I think of engagement as a pathway for SGM youth to become our leaders in the future, to be really well‑equipped to tackle the challenges that my generation and older generations haven't been able to address.  It's an opportunity for us to co‑learn from each other and think about skill development, problem‑solving, critical thinking, as well as personal growth.  It can really kind of push us to think differently about the world.  So, innovation, to me, is so much of what young people bring to the table.  I'd also make sure that the programs that we're building and trying to test in clinical trials are relevant and representative of the need. 

So, you've heard a number of roles that we tend to associate with young people in community‑engaged research.  It can go from subject matter experts to participants, to advisors, to informants, but I want to talk about peer mentors as a new role or a different role where they're actually part of the intervention team, and to do that, I'm gonna talk about an ongoing project called STARS.  It is a suicide prevention/intervention for sexual and gender minority youth ages 18 to 24 ‑‑ so that emerging adulthood period ‑‑ here in Philadelphia.  And I'm not gonna go through the risk factors.  I think we're all pretty familiar with them, but we were really interested, instead, in flipping the narrative and thinking about how young people could also help us think about new solutions to promote suicide prevention in our own communities by serving as a source of social support, a place where other folks could come together and talk about challenges in their lives and receive positive affect and opportunities and skills to be able to cope with discrimination.

So really quickly, STARS is a safety planning intervention, and in this trial ‑‑ which is part of a NIMH‑funded implementation science trial to reduce suicide ‑‑ we are assigning everybody to a safety plan intervention.  It's a clinically delivered intervention to reduce some of the environmental and interpersonal cues that may promote suicidal ideation or suicide behavior.  And then if you are randomized to STARS, you get access to a web app and to this peer mentor support system that really pushes you to think about the safety plan that you work with your clinician, make modifications to it if necessary, or in this particular trial, you get assigned to the control arm, which is standard of care; so the safety plan intervention with assessments at two, four and six months.  This is just a very small snapshot of the safety plan pages, as well as some of the content we work on.  We really think about it from a life skills perspective.  So, we really try to encompass everything that is happening in a young person's life in this moment in time and not just the fact that they have screened positive for suicidal ideation or intent.

And if they are assigned to STARS, they then get access to six weeks of peer mentorship.  You can see here the six sessions that are weekly in terms of topics.  So, the first one is just a check‑in on how has it been building the safety plan, any modifications they want to make.  And in the following weeks we talk about how we integrate your values, how do we address negative self‑talk, how do we make sure that you're also thinking about positive events in your life and scheduling pleasant events, and then building support and addressing the folks that hurt you in your life.  So, in order to do that, we both hire young people and treat them as members of our research team.  They get compensated commensurate to any other research assistant on our team, and they get access to standardized training, which includes booster sessions and group discussions of their sessions.  And because it's an implementation trial, we also wanted to get their experiences, and so peer mentors are randomized to a participant.  They carry out the six sessions with that participant, and then at two months we ask them for their ratings, as well as at the end of their process, we do an in‑depth interview with them kind of as an exit interview, as well as some implementation questions.  We look at fidelity really closely, and you can see here the first two participants that a peer mentor has are fully rated for fidelity, in all six sessions.  And then after that, we start doing kind of a random selection of sessions per participant.  You can see the fidelity is actually pretty high, as both of them relate to the content that was supposed to be covered in these sessions, as well as the style that we want them to have when working with their participants.  And at the end when we asked about the comfort for sessions, you can see that out of a 10‑point scale where 10 is mostly comfortable, we're pretty good at keeping high comfort with delivering the sessions, as well as not experiencing distress during the sessions. 

From an implementation standpoint, we use three evidence‑based measures in the field, the AIM, the FIM and the I mean, and you can see here that we have a fairly great ‑‑ I'd dare say even a ceiling effect on both acceptability and feasibility from the perspective of peer mentors for delivering the intervention, and then a little bit more variability but still very high as it relates to the appropriateness of the intervention.  In the in‑depth interviews, we ask peer mentors to tell us why they chose to become a peer mentor in the study, and there's both a personal professional development opportunity to learn about the clinical experience, but there's also this altruistic, I think, drive to be committed to being a change in their own communities.  So, we were really excited by this.

We just finished data collection for the second‑month and four‑month follow‑ups.  And so, at the two months, which is kind of the one we've closed and been able to clean, we're actually already seeing a signal that the STARS intervention is encouraging participants to use a safety plan more often, which is our end point, but please don't cite this.  Let's wait till the six months, and I promise I'll come back and share more.  But, in summary, we have to start thinking about agents of change and thinking about how we can leverage the lived experience and expertise of young people themselves in designing and implementing these interventions.  Really thinking about how we structure grants and other funding opportunities to not only ensure compensation that is fair and equitable, but it also helps teams think about how to avoid getting stuck in Arnstein's ladder, if that is a framework that would be of help.  And then how do we think about scale?  How do we ensure that peers have the opportunity to contribute to this larger kind of scientific enterprise.  

So, with that, I will stop here and pass it over to 
Dr. Powell.

TERRI POWELL: Thanks so much.  Wow, this has been great.  So hopefully everybody's been as excited as I've been in listening and learning.  So, I had the very unique pleasure of being able to see these before everyone else, and so I have a few remarks and then I'm gonna open it up for the questions.  And many thanks to everybody who's already been adding questions to the chat. 

All right, so let's start off.  So, some common things that I've observed ‑‑ and perhaps you did as well ‑‑ is that community‑engaged approaches allow us to expand our thinking and domain.  So, as we started off today, we know that there are elevated mental health challenges among minority and marginalized young people.  So, three big things that I've heard from these presentations is that one, it calls for ‑‑ like, this work really does call for integrative theories and perspectives.  So, we've heard about intersectionality, feminist, womanist, Critical Race Theory, lifeline theories, even bringing in religion.  So, as we are moving forward and thinking about how we address mental health challenges among minoritized and marginalized young people, its time, like let's allow ourselves to rethink what we've learned before, build on what we already know, and really invite some of the newer or less common theories into the practices that we have.

I think the second thing that I noticed is that using community‑engaged approaches offers a menu of options for addressing mental health challenges.  So, our presenters talked about interventions involving young people at all phases of the research, involving partners, community partners, tribal leaders, two‑spirit.  Like there's no one way to do this, and that is exciting news, or it should be exciting news.  It's always exciting news for me, because I think sometimes, we can get ourselves caught up in doing it the right way, rather than just doing it the best way that we can with the resources that we have.  And so, our presenters really shared, like, a range of opportunities and ways that we might be able to involve young people and other community partners in addressing mental health challenges. 

Finally, ‑‑ and this is maybe the most exciting thing for me, because I do a lot of work with young people ‑‑ is that we've heard throughout each presentation that this approach allows young people to both give and receive support.  The idea of peer mentoring really uplifts this idea that it's not just parents or teachers or the adults who can give support.  Young people are excited about it, and if we are able to give them the proper training, they do well.  We just heard it and talked about in Bauermeister's presentation; they do well when they're excited and will continue to give.  And I think that that spirit of giving allows them to come to the table as their full selves and it also allows them to build a community of support.  As we know, right, we are in this work together.  I think allowing young people to develop that skill of both giving and receiving, always being in the position of giving and receiving support is really important, because as they go on in their careers, wherever they land ‑‑ maybe they'll be researchers, maybe they'll be doctors, lawyers, judges, politicians, wherever they are, like understanding that we should be always cultivating a space of giving and receiving support.  So, I'm really appreciative of the presenters for talking through that and showing us the many examples of which that can happen. 

And so, for me, I'm always like so what, so now.  What now?  Why do we care?  So, what I'd like to say is that it is time for us to invite others to the conversation.  Let's continue to ask who's missing.  It's clear that many people are at the table and that's great.  Like, we are adding more and more voices, whether it's from community partners or young people or traditionally ‑‑ historically marginalized groups.  Let's continue to do that thing, because it will only enrich our research and help the findings be relatable and much more easily disseminated.  And let's continue to share best practices.  What an opportunity it is.  I've been looking at the count of participants.  At our height we were at 226 participants, minus our presenters.  And so, let's continue to thank you, NIMH, for this opportunity to learn about some of this research, because we know combing through articles can be daunting.  I mean, every second there's a new article, and our community partners and young people may not be reading them.  So having spaces like this, whether it's webinars ‑‑ I saw like if you haven't seen it, the webinar will be recorded.  So being able to share what's working and allowing us to all see that and be able to tailor it to the contexts in which we're in is really important, and I'm appreciative of this space to be able to do that.

And then last but not least, for me, the big thing about so what, what now, we've heard some amazing ‑‑ we've heard about some amazing approaches, strategies and interventions today.  It will always be my soapbox to help figure out, like for myself and other researchers, how do we decrease the time from testing to widespread dissemination?  Our young people are telling us they don't have time to wait, right?  What is it, maybe ‑‑ I've heard somebody, it takes like 17 years from idea to widespread dissemination.  Our young people don't have 17 years to wait.  And so, as we're continuing to share best practices, we should also be focusing on figuring out how do we expedite the good work that is being done, so that folks from across the country and world can be able to experience and benefit from some of the knowledge we are gaining. 

So, I will stop there, right at five minutes, and I will start our discussion.  So, there are a few questions that ‑‑ I told our presenters before we started that I think any time we're talking about community‑engaged research, these kinds of questions come up.  I see that some versions of them have been asked in the Q&A, and I'm still gonna land on them so that I can give everybody an opportunity to answer them.  So, they land on three domains.  First is engagement, the second is transitions, and the last is compensation.  So, for engagement, several of you talked about having youth involved, having CAB.  So, we know what.  Talk about the how.  So, tell us about some of the strategies you use to recruit and retain partners, especially the young people on your teams to keep them at the table.  Anybody can start. 

JOSÉ BAUERMEISTER:  I can jump in, if you want.

So, we hire people.  I mean, maybe that's part of the compensation, but like knowing and being really structural about a pathway towards employment.  This might be their first job, it might be part‑time, but if they're part of a university, they get to put it on their resume.  We look at what they are trying to achieve, whether they want to engage in secondary education or not.  It really has, over the years that I've been doing community‑engaged research, changed how people's resumes get read after they're finished working with us.  It gives them an opportunity to understand also what science is about, at least what a type of science is about and gives them that standpoint.  And I think it raises the credibility of what they're interested in ‑‑ "So what I'm interested in actually matters and there's a group of folks somewhere in a weird dark dungeon at a university that also cares about this."  So that credibility, I think, can go a long way to maintain momentum on a team on the academic side but also reinforce what young people are looking for, which are models, especially in our communities. 

ALESSANDRA ANGELINO:  Something that the Northwest Portland Area Indian Health Board has been doing well that I've been trying to model is just thinking about research more broadly.  So recognizing that in order to get funding and to be compensated, there are certain things that we, as researchers, need to be doing, but in order to be engaging youth there are other modalities that they find important, and I think especially for indigenous youth, in thinking about storytelling and oral history and how critical that is for them to be able to tell their stories.  So, what we've been doing a lot of, and I think has been working well is, of course, engaging folks through hiring and things of that nature, but really pairing things.  So, if we're doing interviews, also allowing youth to submit something that they've drawn or that they've beaded and thinking about ways to then share that in a platform.  And I've actually seen some academic journals like being open to some of that multi‑modal work too, but thinking about ways to foster other talents and skills and elevate those has really been helpful too, because then youth are getting the mentorship, thinking about different ways that they can share their work but also getting folks outside of the community to be thinking, hey, this is another way for youth to be sharing their passion and their ideas, which is really rich.

SARI REISNER:  Yeah, creating jobs and hiring people is a really big thing.  You know, getting people insurance and doing that and then being able to do the work.  That has been ‑‑ and it's also been some of the most enriching and invaluable part, for me, of doing the work.  In terms of community advisory boards, you know, payment for community advisory boards is incredibly important.  People always ask, like how do you find people for a CAB?  We do kind of a mix of open calls and networking to find people who might be interested, and the sort of ongoing engagement, I think, really occurs by trying to get to know each other.  You know, we make it more about getting to know each other.

I will say, with our project we started out and we thought we would have one combined CAB with youth and providers and caregivers, and we thought we might dip in and out where the youth might meet separately and the others ‑‑ and it was like very clear after one meeting, the youth were like "Nope."  The young people were like, "We don't even want to do that."  And it was great, because it was one of those examples where it's like we had one idea and it just, in practice, turned out to be different.  And so, we've had like ‑‑ we meet every other month with our CAB, and they have their own space and their own voices and can riff and give us ideas, and then the providers and the caregivers really seem to work well together too.  So, it's being open also to like the evolving of the process and like responsive to the needs of the folks that we're engaging.  So, some of that co‑learning, I think, goes a really long way. 

ANNELIESE SINGH:  I'm gonna just add, you know, long‑term relationship‑building.  I think material resources, payment, insurance, as Sari was just talking about, it's important, and then there are those reparative acts that might be pathways in the academy or away from the academy or to mental health, financial resources that don't have anything to do with your grant.  I just think it's being prepared to ‑‑ if you haven't built those relationships, to start building them authentically with that deep cultural humility, and just strong, strong relationships with people who've already been out there doing the work.  I think we've talked a lot about the difference between mentors and sponsors, like what you'll put on the line for people.  And so that's what I mean, I definitely like CAB, paying people stipends and all that, and then there's all the things that tie our hands that are gross and ridiculous.  And so, really, I think that's so much of the lesson after the murder of George Floyd, is to really look at reparations in every single way we can look at them, from actual cash money to stipends, to other things that actually help people build the life they want to build.

JOHN SALERNO:  And just some final comments on this.  I think that one way to keep youth interested and wanting to participate is through doing some social justice and advocacy as part of your work.  I think this is something that young people really want to do.  And also, I want to emphasize this idea of co‑collaboration in community‑engaged work.  If they feel that they have some ownership, that the project is theirs as well, I find that they're more likely to stay and to want to see it through.

TERRI POWELL: Yeah, these are all great ideas, and just like the building of long relationships.  Sometimes those long relationships begin to speak for themselves, right.  So, people are like, "Yeah, yeah, yeah, I know Dr. Singh's group.  Good people, good people."  Being at Hopkins, you'd be surprised how far just letting other people ‑‑ other people thinking your good people can go and definitely thinking that.  I know the last question I have is about compensation, but that really does let people know you value their time, right?  I'm like, we're getting paid for it.  So, to expect people to continually volunteer their time without being compensated is just not an equitable model.

So, I want to move on to the second question before we open it up.  So, where we start, the folks we start with are not always the folks we end with.  Projects can be long.  So, I'd love to hear a little bit about how you handle transitions.  Like, are there specific off‑ramps or on‑ramps?  So, I think about young people.  When we work with young people, sometimes when they graduate high school, it's a little bit harder because they're going to college and so they may come back a little bit less.  So, I'd love for folks to talk a little bit about handling those transitions and maintaining continuity of the research project and the partnerships. 

ANNELIESE SINGH:  I think sometimes it's with a broken heart, and I only share that to say that ‑‑ when Sari was sharing Leelah Alcorn's quote, it just reminded me so much of a person, Scout, who was a nonbinary person with the Georgia Safe Schools Coalition, and we stayed in touch as they went to college and they were brutally, I believe, murdered by Georgia Tech's police.  So, I think that ‑‑ I know your question's positioned in a different way, but I wanted to say that because I think there's this thing that's happening in our work with young people where folks are identifying more and more, as Alessandra was sharing.  I think that was in John's research too.  I mean, just that is amazing, and the harm is still happening.  So how do you hold the beauty of ‑‑ because of social media and DMs and text ‑‑ I mean, all of our CAB stuff is happening and it's not happening via email.  We're texting, we're Slack'ing, we're doing some things like that, and you get to know one another's lives.  It's not just like COVID and the pandemic where we were in Zoom.  You know, we've been in people's DMs and texts for a minute now, and so we hear random stuff, "Hey, do you have this resource or that?"  And sometimes your kind of riding a line.  So, I know the questions are really about transitions.  I think when you have those long‑term relationships, people cycle on and off as they need to.  We do use community agreements to really make that clear what those on and off‑ramps are, but to invite folks to stay connected if they would like to.  But that piece about the broken heart, that ‑‑ I think because of our current environment, which is really a continuation of the past legislative environment, people do tend to stay connected and you are gonna ‑‑ you're gonna grieve together over time. 

SARI REISNER:  Yeah, I think similarly we try to meet people where they are, and we know that people's lives are dynamic, and they change.  So, we will sort of ‑‑ whatever engagement young people would like to make with us, we try to do.  So, we do have sort of a set of standard practices; we'd like people to attend.  If people can't and they need to provide us with feedback and work with us in some other way, we are flexible.  And we also want to make sure that if people feel like they need to move on, that's okay to do that too and to support that and lift that up for them.       I will say that there's been some sort of challenging things.  I'm thinking of a project called Light, which was a cohort that we had done actually with Andrea Wirtz at Hopkins that followed trans‑feminine people.  I think more than a third of the 1500 were in the 18‑to‑24 age range.  And we sought to look at each of the incidents, but throughout the course of the study and working with our CAB, we kept hearing about people passing away, and that was the big voice on the CAB was like, "People are dying and you're talking to us about HIV."  And so, our pivot was that we estimated mortality and incidents in the cohort as our primary outcomes, but we also kind of lost people along the way because it was intense work, and we also, like, respected that and brought that.  So, I think honoring those experiences and honoring when it is time, when people feel like they can engage and when they can't have sort of been equally as important for the work ‑‑ or for me and for our teams.

JOSÉ BAUERMEISTER:  I'll just say that I think there's this kneejerk reaction sometimes to be colonial.  Like, "Wait, I found this person from the community, and they understand what we're doing, and we can't lose them."  And you have to check yourself, right?  Because I think as Sari was saying, it's okay for people to have complex lives and they may be moving, you know, they may have decided the me search is not what they want to be doing for the next stage of their career.  They want to start looking at cis cancer disparities in the Black community.  So how do we also then affirm that?  Like, you came into science because you were interested in understanding how it works and this felt exciting, but now you're growing and we need to also let you go and launch you, as opposed to, like, hold you back.

So, the place that I think does it really well ‑‑ and Sari and I are involved in this network, it's the [indiscernible] Network.  They have both a national youth board and a more localized subject matter experts’ team, and they have co‑created what are the graduation principles that the network will abide, either because you're aging out or because you have found something else you want to do.  So, then it creates permission structures that are in writing about, hey, you have a seat at the table, and you also get to decide when you want to stand up and leave.  And so definitely check that resource at the ATN, if it would be helpful. 

JOHN SALERNO:  And then I'd just like to add ‑‑ for my project which was with LGBTQ+ college students, it became complicated to transition as well because some of those students were graduating in the leadership, and I was graduating as well.  So, what I told myself was that even if this group or this project comes to an end, we still had a positive impact for the time that we were running.  And I think that that's something that everyone really has to think about when you're in community‑engaged research.  Are you having a positive impact?  And if it comes to an end, then being okay with that, being okay with the positive impact that you've had and moving on to the next thing.  A lot of you talked about people's lives and how they've moved on to different things in life, and you, yourself, might move on to something different in life when this community‑engaged group comes to an end.  So ... 

TERRI POWELL: Yeah, I like all of this, especially ‑‑ like you were saying, like everybody's ‑‑ like, letting people know you have permission to start or stop, as it suits your life.  Like, we all have very complex, dynamic lives.  You know, our plates become different, like full of different things over time, and over the years, I've started to call some of the meetings when a project ends, like a sunsetting meeting.  The sun may rise again, who knows, we may work together again, but right now let's sunset this part, and here are all the other ways we may continue to work together.  Like a lot of us, we're situated in universities.  I'm always like, call me if you need a space, you need a room, you need somebody for your ‑‑ I work in schools a lot ‑‑ you need somebody for your career fair.  So, I think really also expand the ways in which the partnership or the relationship can continue, even if the research doesn't.

So, I did have a question about compensation, but folks have pretty much answered that.  So, I just want to open it up, because I know we'll end soon.  Are there questions from participants that haven't already been asked?  I'll turn it over to you, Chris. 

CHRISTOPHER BARNHART:  Sure.  There are a lot; I might put some of these in the chat, but one that I was hoping you could answer live is with regard to trust.  There's been a checkered history, sometimes catastrophic, that has given marginalized and minoritized communities reason to have mistrust and distrust in researchers.  So, like, do you have any thoughts on how you can overcome that legitimate mistrust and distrust to truly authentically engage the community?  Like, what has worked for you all.  

ANNELIESE SINGH:  I think owning it.  I mean, I think with the Georgia Safe Schools Coalition, just the hostile environments in a lot of places, and then I think owning adultism, just naming that on the part of a researcher, practitioner, advocate, "This is how I'm gonna mess up."  And I think from whatever age we're at, being able to own our own dreams.  You know, for many of us, this is our community.  So, I think naming what is true and then that deep listening ‑‑ it just sounds like, oh, deep listening, but as the Buddhists say, listen with nine ears, that type of listening, the listening you want to do for the rest of your life that makes it meaningful.  So, I definitely want to hear what other folks are saying, but I think just naming the truth of it all really helps. 

JOHN SALERNO:  I was just gonna add that I think a problem in community‑engaged research is this idea of helicopter researching, where the researcher comes in, does their work, and then they depart, and the community partners never hear from them again.  So, I think if you're going to get involved in community‑engaged research and lead community‑engaged research, then you need to be committed to making sure that you are not going to be a helicopter researcher and that you're going to stay involved and try to stay in relations with your community partners.  And then also the idea of mutual benefit.  So, if you're doing this project because you're interested in it, that's great, but how is this gonna benefit your community partners as well?  So constantly being in conversation with them to ensure that you have an agreement and that it's mutually beneficial as well. 

SARI REISNER:  I think sometimes it depends, like the strategies differ depending on the sort of environments.  And what I mean by that is, when I'm working coming out of the university context, like I do some work with Finley Health at Boston, which is an LGBT health center, or in the case of the project that I've described, a lot of it's based at Boston Children's Hospital.  So, it depends on, am I in an academic setting, am I in an educational setting, am I in a community setting, and, like, those strategies differ.  So, in the case of working with trans and nonbinary youth, there's so much in the way of stigma and histories of stigma around access to gender‑affirming care.  So, some of the history ‑‑ like although Children's had one of the first models in the U.S. to use the Dutch protocols for care, there's still a perception that there's gatekeeping.  So that's like a very unique kind of thing that's coming out of that academic medical center, which has been something that is a strategy we have to work on and address in that unique context.  So, I think going to the local kind of level and seeing, like, what are the specific barriers that the local community has in working ‑‑ or even national ‑‑ with the organization that you're a part of and sort of understanding those and, like, calling those out and being willing to work and do some reparative work, as others have said.

Also, that kind of relates to ‑‑ I do want to pick up on one thing about the compensation that we didn't talk about, and sometimes institutional structures are like a square peg in a round hole for getting people paid.  It's like the impossible red tape and it's like ‑‑ for example, we would love to do cash, like we want to just pay people cash; that's what they want, but we can't figure out how to make that work with the administrative structures.  So, then we're in a situation where we're either giving gift cards, which is less ideal, or we're issuing checks and sometimes people's legal names don’t match, you know, just all of those levels.  So, it’s very hard because ‑‑ something like "Oh, my check is delayed" is like interpreted through a lens of mistrust.  So, some of it is also just education and just conversation about, like, "The delay in the check is not related to anything about your meaningful participation in our co‑connection," but it's a hard one to uncouple, particularly when we have those kinds of barriers.  That's the biggest one for us, is like how we get people paid in a timely fashion. 

TERRI POWELL: Yeah, I just wanted to piggyback on these too.  I really liked, Annaliese ‑‑ or Dr. Singh, when you said just owning it.  Many of our institutions have done a ton of harm to the communities around them, and so owning it and then taking the steps to not continue it.  Right?  I think sometimes ‑‑ like, trust is built over time, and so the expectation ‑‑ I remember when I very first started doing community‑engaged work, one of my then mentors ‑‑ still, Dr. Gary Harper.  He was just like, "If you're going to somebody's house, take your shoes off.  If that's what they do, take your shoes off."  Like, the onus is on us as researchers to say, "Hey, I know that things have not always been the best and I want to be a different ‑‑ I want to play a different role in that relationship, in the relationship you've had with our institution, in the relationship you've had with previous investigators."  

And to your point, Sari, like getting people paid, being fully transparent ‑‑ I mean, I keep email chains.  "See, I am on accounts payable, and I have emailed the finance person, and you let me know when it's in your bank account."  Like, really showing that I am doing my very best to make sure that this happens for you, because I think one of the things that we also need to remember ‑‑ an institution, like, make sure checks are paid.  If we're working with community partners, this could very well be like the difference between payroll being made, and so our delays for administrative things could really have a detrimental effect.  So really being transparent about what's going on and working as hard as possible to make sure that those things are resolved quickly and that partners understand, like, hey, I'm working hard and please know ‑‑ to your point, Sari ‑‑ it has nothing to do with your involvement, like we're just working through this tape over here.

So, thank you for that.  Other questions?  

CHRISTOPHER BARNHART:  Unfortunately, we are on time, we're actually a little bit over, but I just wanted to thank you all so much.  It warms my heart to see all these fantastic minds in one place, and community‑engaged research is so important, and you all have given me hope, the community's given me hope.  And NIH, NIMH, thank you all so much for your work and your time and showing up.  It's hard work, but we appreciate the fact that you keep doing it.       We are going to go on break.  We will all be returning at 1:00 p.m. for the next talk on risk and resilience, and we look forward to seeing you in just a little bit.  So, thanks, everybody, one more time.
[Break until 1:00 p.m. Eastern Time]

Risk and resilience:  Individual, Interpersonal and Family‑Level Factors

EVENT PRODUCER:  And we are back from the break.  I will now turn it over to Dr. Laura Thomas.  
 

LAURA THOMAS:  Great.  Welcome back, everyone.  I'm really excited to be moderating this next session.  My name is Laura Thomas.  I am a Program Officer at the National Institute of Mental Health.  My pronouns are she/her. 

We have a really exciting session up next on Risk and Resilience:  Individual, Interpersonal and Family‑Level Factors.  We will hear from three outstanding speakers and then have a discussion period afterwards.  So, we're going to be hearing from Diane Chen at the Children's Hospital of Chicago, Jessica Fish at the University of Maryland, Ethan Mereish, also at the University of Maryland, Rachel Schmitz at Oklahoma State University, Jason Nagata at the University of California, San Francisco, and Myeshia Price at Indiana University, Bloomington.  And then after we will have a discussion that's going to be moderated by Erika Forbes at the University of Pittsburgh. 

So, I will turn it over to Dr. Chen for our first talk here.  Thank you.

DIANE CHEN:  Hi, everyone.  Can you see everything all right?

LAURA THOMAS:  Yep.  You look and sound great.

DIANE CHEN:  Good afternoon, everyone.  My name is Diane Chen, my pronouns are she/her, and it really is such an honor to be here today to present alongside these esteemed colleagues. 

And today I'll be sharing some of our findings from the Trans Youth Care United States Study on Psychosocial Functioning in Transgender Youth After Two Years of Hormone Treatment. 

These are my disclosures. 

And so just as a bit of background, transgender youth or youth who affirm a gender that differs from their designated sex at birth, many, but certainly not all, trans youth experience gender dysphoria, which really refers to the distress that stems from an incongruence or a mismatch between the ways one experiences their gender and their designated sex at birth. 

Recent estimates suggest that somewhere between 2.7 and 9.2% of high‑school‑age youth in the United States identify as transgender or nonbinary, and all over the country we're seeing increasing numbers of these youth presenting to gender health clinics seeking gender‑affirming medical care to address gender dysphoria. 

Now, between 2019 and 2022 there were four published studies that prospectively examined psychosocial outcomes of gender‑affirming hormone treatment among U.S.‑based youth, and these have studies have generally found that aspects of mental health functioning improve after initiating hormones, but there are also some important limitations of these studies to acknowledge. 

And so, first, all of these studies utilize relatively small samples, so sample sizes of, like, 130 and smaller.  And their follow‑up periods really extended out only to one year following treatment initiation. 

Three of these four studies looked at psychosocial outcomes, lumping together youth that were initiating puberty‑blocker treatment as well as those who were initiating gender‑affirming hormones, which really makes it difficult to parse the effects of each treatment. 

Also, these studies were based on standard of care clinical data, and the authors all acknowledge that trying to collect outcome data in a really busy clinical setting really led to a lot of missing data. 

The samples were largely white across these four studies.  Between 65 and 83% of participants were non‑LatinX/Latine White, and they are not representative of the diversity of trans youth that we see in the United States. 

And, last, none of these studies examine potential mechanisms by which gender‑affirming medical treatments might affect psychosocial functioning. 

And so, in an effort to address some of these gaps in the existing literature we drew on data from the NIH‑funded Trans Youth Care United States Study, a longitudinal observational study evaluating the physical and psychosocial outcomes of two cohorts of transgender youth, those that are starting pubertal suppression treatment and those who initiating gender‑affirming testosterone or estrogen. 

And in this study participants were enrolled after the primary study team at one of these four study sites had determined that a young person was ready to start medical treatment, and participants completed measures at baseline and 6‑, 12‑, 18‑ and 24‑month follow‑up following treatment initiation. 

I'm going to focus on outcomes from the gender‑affirming cohort. 

And so, we have three specific research questions.  We were interested in examining how appearance congruence, depression and anxiety symptoms, positive affect and life satisfaction, how these factors change over the course of two years on gender‑affirming hormones. 

Second, we were interested in seeing how access to early gender‑affirming medical care was associated with our outcomes of interest. 

And third, we wanted to explore whether change in appearance congruence over the course of two years of treatment was associated with concurrent changes in depression, anxiety, positive affect, and life satisfaction. 

So, in other words, we were really interested in exploring whether the hypothesized increases in appearance congruence would be related to hypothesized decreases in depression and anxiety symptoms and hypothesized increases in positive affect and life satisfaction. 

And we published our findings last year, which I'll walk everyone through next. 

And so, in terms of our cohort, we enrolled 315 youth into the hormone cohort.  They were 16 years old on average.  The majority were White and designated female at birth, and 80% of those youth had engaged in social transition at the point of study enrollment.  And about 7% of youth had received early gender‑affirming care, which we sort of thought of as compromising the sub cohort of youth who had either previously received pubertal suppression treatment in early puberty or youth who were started on gender‑affirming hormones in, like, early mid‑puberty in the absence of past blocker treatment. 

We modelled the trajectory of each of our five variables of interest using unconditional latent growth curve models which examined how mean or average scores of depressions and anxiety, positive affect, life satisfaction and appearance congruence changed as a function of time. 

Next, we ran a series of adjusted models that estimated the effects of baseline age, designated sex at birth, minoritized racial ethnic/identity and history of early gender‑affirming care on the intercept and slope of each outcome.  So, in other words, we controlled the effect of these covariates on baseline depression and anxiety, positive affect, life satisfaction and appearance congruence as well as change in these constructs over time. 

And then, third, we ran a series of four parallel process latent growth curve models in which the intercepts and the slopes of appearance congruence were allowed to correlate with those of our four psychosocial outcomes. 

So, in terms of our hypotheses, we first hypothesized that over two years of gender‑affirming hormone treatment we would see increasing appearance congruence, decreasing depression and anxiety symptoms and increasing positive affect and life satisfaction.  And so, these were all findings, and this is a busy slide, so I'm going to take a moment just to orient folks to what you're seeing here. 

And so, what this table presents is the parameter estimates with a 95% confidence interval for the unconditional latent growth curve models that only took into account the effect of time, and the significant effects are bolded.  And the intercept means, this represents where folks are starting out at baseline, and the slope mean represents change over time.  And the slope values are given as a change in score per year, and those can be interpreted on the original scales. 

And so really what we're primarily interested in seeing here is whether the slope or trajectory of our outcomes of interest, whether they changed significantly and in the expected direction over the two-year follow‑up period.  And they do. 

And so, what we see here is that our depression and anxiety symptoms in our sample are decreasing significantly over that two‑year period; and positive affect, life satisfaction and appearance congruence are all increasing significantly, consistent with our hypotheses. 

And these graphs are just another way to depict that data I just showed you all in the table, and these graphs show the mean trajectories over time for each of our five outcomes.  And the individual dots that you see represent individual variability around that mean change over time.  So really the take‑home of this figure here is that there's so much variability that we're seeing in our sample around that mean sort of improvement over time. 

Okay.  So, moving on to our second hypothesis, we expected that the subgroup of youth who had previously been treated with puberty blockers in early puberty or had started gender‑affirming hormones would report higher appearance congruence, lower depression, lower anxiety and higher positive affect and life satisfaction at baseline.  And we didn't actually have any specific hypotheses about how early gender‑affirming care might be associated with change in these outcomes over time. 

And so this even busier table shows the parameter estimates of our conditional models that accounted for covariate effects.  And so, the first thing I want to highlight here is that the trajectories of change in our five primary outcomes remained significant and in the expected directions after we introduced covariates into the model. 

And then, next, also consistent with our hypotheses, access to early gender‑affirming medical care was associated with significantly higher appearance congruence at baseline, significantly lower depression and anxiety symptoms at baseline, and significantly higher positive affect and life satisfaction at baseline. 

And these figures, what you see is the mean trajectories of change over time based on whether youth had access to early gender‑affirming medical care depicted by the orange line and youth who did not have access to early gender‑affirming medical care depicted in the blue line.  And so, in general what you're seeing here is that the trajectories look pretty similar across the two groups and the key differences where youth are starting out. 

And so, last, we tested this hypothesis that increasing appearance congruence due to gender‑affirming hormone treatment, that that would be the mechanism of action driving the observed decreases in depression and anxiety and the observed increases in positive affect and life satisfaction. 

And so, this is what we found.  We found that increasing appearance congruence over two years of hormone treatment was significantly associated with both concurrent decreasing depression and anxiety and increasing appearance congruence over that two‑year treatment period was also significantly associated with concurrent increasing positive affect and life satisfaction. 

So, in terms of our key findings, what we've found was that depression, anxiety, positive affect and life satisfaction, these constructs are all improving over two years of gender‑affirming hormone treatment.  And these findings really replicate reports from other longitudinal studies of youth receiving gender‑affirming hormones and sort of extend those findings to a larger sample of more racially and ethnically diverse youth from four geographic regions in the United States and finding that these improvements are sustained over a two‑year period. 

We also found that appearance congruence improved over two years of hormone treatment, and this is really important as improving appearance congruence really is a primary goal of gender‑affirming hormone treatment.  And this change in appearance congruence had a moderate effect.  It was the strongest effect observed across all of our outcomes, which is also consistent with what's been reported in the literature, noting sort of large effects of gender‑affirming hormones on body image and body satisfaction and small to moderate sort of downstream effects on mental health. 

In addition, increasing appearance congruence over the two‑year period was also significantly associated with concurrent decreases in depression and anxiety and concurrent increases in positive affect and life satisfaction.  And so, these findings do suggest that appearance congruence might be a candidate mechanism by which gender‑affirming hormones influence psychosocial functioning. 

And, lastly, the importance of appearance congruence on psychosocial well‑being is further highlighted by our findings of gender‑affirming medical care in early puberty is associated with significantly lower depression and anxiety and significantly higher appearance congruence, positive affect and life satisfaction at the point of starting hormones.  And these youth had not undergone substantial gender and congruent puberty, and they looked better across the various domains. 

There were also some unexpected findings that weren't mentioned, and in these figures, you can see the mean trajectories of change over time based on designated sex at birth.  Youth designated female at birth is depicted by the blue line and youth designated male are depicted by the orange line. 

And so, what we see is that for depression, for anxiety, and for life satisfaction youth designated female at birth are improving significantly, whereas youth designated male at birth do not appear to be.  And so, some of our hypotheses for why this might be the case is that some key estrogen‑mediated phenotypic changes like breast development really can take between two and five years    to reach their maximum effect, so it may be that we need a longer follow‑up period to see the downstream positive effects of hormones on depression, anxiety, and life satisfaction. 

And it's also possible that changes that are associated with endogenous testosterone‑mediated puberty like a deeper voice or facial hair may be more pronounced and observable than those associated with an estrogen‑mediated puberty, potentially leading to more gender minority stress experiences by our trans‑feminine versus trans‑masculine youth in our sample.  And there's a large body of literature on the negative impacts of gender minority stress on mental health outcomes. 

So, I know I'm running out of time, but very quickly, in terms of next steps, we are a couple years into renewal funding to keep these cohorts together and to follow them on an annual basis for another four years, which then translates to six years after starting blockers or hormones.  We also reopened recruitment to further diversify our sample by selectively enrolling youth of color and trans‑feminine youth, and this continuation funding will allow us to compare the effects of hormones both within and outside the context of prior pubertal suppression treatment as the vast majority of youth in our blocker cohort will have progressed on to hormone treatment. 

And, also, as an exploratory aim for the renewal grant, we're proposing to characterize emerging subgroups of youth.  So, there's a great need to understand the medical care needs of nonbinary youth and youth who may discontinue medical treatments. 

And so that's all I have.  Thank you so much for your attention, thank you to the NIMH for providing a platform for us to focus on the health of SGM youth, and now I will pass things off to 
Dr. Jessica Fish.  
 

JESSICA FISH:  Thanks so much, Dr. Chen. 

And good afternoon.  Thank you for the opportunity to be here.  It's truly humbling to join such an enriching conversation about LGBTQ youth development and thriving alongside such a fantastic group of colleagues. 

As we discussed for the last day and a half, LGBTQ youth mental remains an urgent public health issue.  The urgency to address LGBTQ health equity is emphasized when we consider that one in five youth now identify as LGBTQ, that LGBTQ youth come out earlier than in prior generations and are navigating complex school and family contexts at formative and critical developmental stages for self‑concept and well‑being.  And contemporary cohorts are currently navigating an incredibly volatile dynamic policy environment that has serious implications for their development, access to resources and mental health. 

We also know that the data show that LGBTQ continue to experience mental and behavioral health disparities, inequities, even starting at the age of 10 years old.  And as such, the family environment and the relationships therein are critical for development and health of youth during adolescence and spans across the life course. 

Yet even with advances in social and scientific understanding of sexual and gender minority adolescence in recent decades, research on their family environment remains underdeveloped.  To date, many of the LGBT family literature focuses on youth's disclosure of sexual identity and the health‑related associations when parents either accept or reject their youth's sexual and/or gender identity.

Less often conceptualized and studied is a broader array of parent‑child processes and parenting practices that may influence youth's positive development and health, particularly as it relates to youth's marginalized sexual and/or gender identity.  However, a more nuanced view of parenting practices and behaviors in the overall family environment may provide unique perspectives on how parents could support LGBTQ youth's positive development and health, thwart deleterious impacts of stigma, and offer distinct targets for parent‑ and family‑based intervention. 

Historically, LGBTQ Youth Family Scholarship has focused on the relationship between accepting or supportive family interactions or rejecting unsupportive family interactions with outcomes of mental behavioral health.  Most often these familial experiences are assessed independently of one another and consistently show that family acceptance is positively related to mental health, whereas rejecting familial behaviors compromise positive development of health for LGBTQ+ youth. 

Whether intentionally or unintentionally, this work has amassed ‑‑ the work that has amassed in the last 15 years has conjured acceptance and support as antithetical or polar to rejecting an unsupportive family environment; In essence, two ends of same continuum which emphasize these are potentially competing narratives where high support is akin to low rejection, that families are supportive or rejecting. 

However, more recent conceptual and measurement work in this area has found that items capturing family acceptance and family rejection actually load onto two distinct factors and these factors are weakly or even unrelated; in other words, that youths' reports of parental acceptance is not necessarily correlated with youth reports of parental rejection.  Studies that assess these two factors in tandem demonstrate that although family acceptance is related to better mental health, the inclusion of family rejection in these models wash away any gains that result from family acceptance, suggesting that in the presence of negative or unsupportive behaviors, accepting behaviors don't have the same positive effects for youths' health. 

So, in essence what we see is that acceptance and rejection are actually two distinct and unrelated constructs, each of which may be present or absent regardless of the other.  And in fact, I would argue these continuums actually more readily reflect quadrants that characterize unique profiles or experiences of acceptance and rejection in a way that has not been traditionally conceptualized or studied in the context of LGBTQ youth family environment.  And recent studies force us to acknowledge that youth can and do experience both accepting and unsupportive behaviors within family contexts, sometimes from different family members or sometimes the same person in different contexts. 

Although most LGBTQ folks can attest to this experience in their day‑to‑day lives, this nuance is not necessarily conceptualized or tested in LGBTQ youth family research. 

It is also important to note that trends indicate that parents' reactions to LGBTQ youth identity have changed since research started examining these interactions 30 years ago, suggesting more tolerance and acceptance from parents but also greater nuance in the discourse surrounding parental reactions to LGBTQ youths' disclosures. 

Recent national samples show that 71% of contemporary LGBTQ youth report having disclosed their sexual orientation and 52% their gender identity to parents and caregivers.  And with the shift in social acceptance, many of these youth are coming out to parents who genuinely reassure youth of their love and support, which requires that we evolve our thinking about LGBTQ youth family environments to consider the nuance of what support is, how it is operationalized and in what ways it might benefit youths' development and mental health in various forms. 

The need for this shift in thinking is well illustrated in the current literature.  Many studies note that positive effects of family support for youth mental health, and really that is consistent for all young people.  Support is a baseline expectation we have for all parents.  And, yes, many parents of LGBTQ youth need to ‑‑ need help and support to get to this baseline, and it is an important requisite and correlate for youth health. 

I've observed, however, that many people who write about LGBTQ youth and family often conflate this positive association as a protective association, insinuating that parent support buffers the harmful effects of stigma on LGBTQ youth mental health and behavioral health.  However, most published studies do not support this hypothesis.  Most currently published work that assess this association do not observe family support as a moderator and effect modifier of the relationship between minority stress and LGBTQ health, the findings of which collectively tell us that support alone is a requisite but not enough, in and of itself, to offset harms of stigmatizing experiences. 

And so, this begs the question:  In the face of ongoing and intractable stigma, what can parents do to minimize the harms of minority stress for LGBTQ youth. 

For youth with stigmatized social identities, family plays a crucial role in imparting adaptive processes to help youth thrive in the face of oppression and discrimination.  These adaptive processes and strategies, also referred to as developmental competencies, are unique to youth who must learn to navigate unique social environmental stimuli that result from their marginalized identities, such as discrimination and devaluation.  The role of family support in promoting adaptive strategies is well illustrated in the racial/ethnic socialization literature.  Racial/ethnic socialization theory articulates how parents use specific tactics to communicate messages about race and/or ethnicity to children, several of which promote adaptive strategies that bolster positive identity development and well‑being even in the face of discrimination. 

Emerging research also provides valuable insights into these processes among LGBTQ‑headed households, parents who enhance their children's consciousness of and strategies to circumvent stigma and discrimination that stem from cis and heteronormative perspectives.  For example, gay and lesbian parents actively educate their children about LGBTQ history and culture and prepare them to navigate potential instances of stigma in their day‑to‑day lives. 

Notably, unlike racially and ethnically minoritized parents raising youth with similar racial or ethnic identities, cisgender heterosexual parents do not have a schema for navigating the world of an LGBTQ+ person.  Thus, they cannot rely on their own experiences when socializing with their child around having a marginalized sexual orientation or gender identity. 

Research on trans‑racially adopted children, so White parents raising adopted children with minoritized identities, show that parents can and do elect to self‑educate and engage in racial/ethnic socialization strategies that support the development and adaptive strategies and resources among their children.  Trans‑racially adopted children whose parents engage in these strategies like preparation for bias and cultural integration do show psychosocial benefits from these parenting practices, and so it stands to reason that heterosexual and cisgender parents could elect to parent in ways that impart adaptive strategies for LGBTQ+ children to help them navigate anti‑LGBTQ stigma and engage with community and resources in an effort to remain resilient in the face of ongoing minority stress. 

And this idea was the impetus for development of the LGBTQ Youth and Family Study which was specifically designed to explore how cisgender heterosexual parents interact with their LGBTQ+ adolescents and engage in practices specific to their child's sexual orientation or gender identity.

The families from the Mid‑Atlantic region of the U.S. were eligible if they had a child between the ages of 15 and 19 who identified as LGBTQ.  Parents who were cisgender and heterosexual, youth who disclosed their sexual orientation or gender identity at least to one parent six months prior to the interview, and both youth and parents had to be willing to participate in separate but simultaneous 90‑minute interviews.  The full sample is 27 families and includes 61 90‑minute semi‑structured interviews with 29 youth and 32 parents. 

Today I just want to briefly share the landscape of our first pass at the data which was focused specifically on sexual orientation parenting strategies.  We identified seven overarching categories that captured a multitude of parental processes, interactions and dynamics specific to their child's sexual minority identity.  In most categories, parents and youth identified processes that supported youths' growth and development as a sexual minority person but also behaviors that diminished or prohibited acceptance of their child's sexual identity.  This was present both within and across families. 

Regarding these practices, some actions were intentional, whereas others were not, and yet all served to socialize their child to understand their world and how to navigate it as a sexual minority young person. 

It's also important to note that these categories also represent the presence absence of these behaviors.  So, for example, encouraging exploration includes parents whose behaviors that supported and scaffolded exploration but also behaviors that thwarted or pushed or encouraged concealment. 

While I don't have time to delve into each of these categories, so stay tuned for hopefully our upcoming publication, I wanted to share some of the high‑level takeaways from this work and what it might afford us for future research and practice. 

So, our initial findings identified myriad parenting practices related to youth sexual orientation.  These included efforts to support sexual minority identity exploration and development and prepare youth to navigate a world that continues to stigmatize non‑heterosexual sexuality but also interactions that often inadvertently communicate discomfort, doubt of youth's identity, and that youth were to blame sometimes for their experiences of stigma. 

These interactions also unfolded over time.  They were an ongoing and iterative conversation that spanned months and years that communicate parents' values, either explicit or implicitly, and attitudes towards LGBTQ youth's identity and the development of adaptive skills to navigate various contexts and experiences related to their identity.  Some of these concepts mapped well 
onto parenting practices for racial/ethnic socialization, such as preparation for bias and instilling pride, whereas others were unique to sexual orientation experiences, such as managing identity disclosure and challenging and dismissing identity. 

For many, these interactions are present within the same family, suggesting that youth can and do receive mixed messages about affirmation alongside undermining interactions that devalue their identity. 

What was clear throughout our interviews is that parents deeply love and care for their children and are desperate for information on how to support them and help them navigate a world as a sexual minority person, and that youth need more active, intentional and consistent messaging from parents so as to not doubt their genuine love and concern for their well‑being. 

Regarding research advancement, I'm arguing that it's time for a radical revisioning of how we conceptualize LGBTQ youths' family environment.  Data emphasize the complicated and dynamic nature of LGBTQ youths' family experiences and how they both simultaneously support and undermine their positive development and health. 

We also need to move beyond support and consider how parents socialize their children around identity and build developmental competencies related to navigating hetero and cisnormative contexts in a way to equip youth with the tools to mitigate the harm of stigma, a shift away from family acceptance and rejection and to family environment and processes will provide a much needed expansion of how we talk about LGBTQ as family and will ultimately provide new opportunities to develop and advance measures, methods, and interventions. 

With that I say thank you, and I turn it over to my colleague 
Dr. Ethan Mereish.  
 

LAURA THOMAS:  Oh, we can't hear you.  I think you're muted, Ethan. 

ETHAN MEREISH:  Oh, Sorry.  You'd think I'd learned that by now.  Thank you. 

Hello, everyone.  My name is Ethan Mereish.  Thank you so much, NIH, for hosting this wonderful workshop as well as inviting me to participate along with many great presenters. 

I'll be presenting on oppression and mental health and substance use among QTBIPC adolescents.  I just wanted to acknowledge I have no conflict of interest to report, as well as my funding source, NIAAA. 

I'll be using the term "QTBIPC" throughout the presentation, which refers to Queer, Trans, Black, Indigenous, People of Color, or SGM people of color, but QTBIPC is what I'll be using.

As you have learned over the past few days, there are lot of ways that health inequities that SGM adolescents experience.  QTBIPC adolescents also experience these disparities.  So, for example, QTBIPC adolescents report poorer mental health and greater substance use compared to their same‑race heterosexual and cisgender peers.  So, for example, black SGM adolescents report poorer mental health and greater substance use compared to Black heterosexual and cisgender individuals. 

Sometimes there's some ‑‑ some of the findings also show that QTBIPC adolescents may be at greater risk for some of these outcomes compared to their White SGM adolescent peers.  However, there are some mixed findings in the literature around that.  These health inequities often are rooted in oppression and oftentimes stigma models help us understand that; for example, the Minority Stress Model or SGM literature or racism‑based stress models or BIPOC literature or stigma models more broadly.  And that stigma or oppression is a stressful process that leads to poor health outcomes. 

While these models are really helpful and informative, their application and sometimes their focus can be one axis of oppression, such as racism or heterosexism, and oftentimes an over‑focus on the individual and their other interpersonal processes, like experiencing discrimination, with little attention to the structures that QTBIPC adolescents live in, the oppressive racist, heterosexist and sexist oppression that they live in.  
So that's why we're using oppression language throughout the presentation given that it's more consistent with intersectionality frameworks, as well as it centers oppression, structures of oppression that purposely harm and inflict harm on marginalized communities and further create and reinforce health inequities as a way to create and maintain current power structures. 

As we know, consistent with oppression models and stigma models, oppression exists at multiple levels, including the structural, interpersonal and individual levels. 

Now, for QTBIPC adolescents specifically and people more broadly, they experience also intersectional oppressions.  So, all experiences of oppression are intersectional, and there are also unique types of intersectional oppression that QTBIPC adolescents experience.  So prior scholars have documented, for example, experiencing racism and intersectional invisibility within SGM communities given that oftentimes SGM communities have been centered through a white supremacist lens, and so whiteness has been seen as the norm of the SGM communities, so it creates a lot of intersectional invisibility for BIPOC individuals within SGM communities. 

QTBIPC individuals also experience heterosexism and cis sexism within their own racial and ethnic communities as well as broader communities and society in general, and they also experience racism in dating and close relationships. 

While most of this ‑‑ while these intersectional stressors have been documented in prior work by other scholars, most of this work has been often applied with adult samples, and only a few studies have examined these stressors and how they may relate to health outcomes among adolescents specifically.  And so, I'll be talking about that in a second. 

I also just really want to highlight a quote that really perfectly captures intersectional oppression that I came across recently by Sonia, who's a queer Palestinian author, and they write, "As a queer Palestinian, I have to tell you that nothing brings racists to my sphere faster than asserting my existence as a queer Palestinian." 

So, I think this quote perfectly highlights intersectional invisibility but also how by making oneself visible both in terms of queer and their Palestinian identity brings interacting and increasing forces of oppression, including racism for this person. 

So now I'm going to walk you through a few studies that I've done with colleagues, including Dr. Fish, looking at how intersectional oppression relates to different health outcomes among QTBIPOC adolescents. 

So, the first study is a sample of over 3,000 QTBIPOC adolescents from across the country who are between the ages of 13 and 17.  This was using Dr. Ryan Watson's 2017 LGBTQ and national teen survey. 

One thing I want to highlight is that almost the entire sample reported experiencing at least one intersectional stressor over their lifetime, just highlighting the pervasiveness of these stressors.  Now, in terms of their associations ‑‑ this is a cross‑sectional study with health outcomes ‑‑ we found that intersectional microaggressions were associated with greater depressive symptoms, poorer self‑esteem and lower sense of mastery, and self‑esteem and mastery also mediated the associations between intersectional microaggressions and depressive symptoms. 

Building on this study, we wanted to also see how intersectional stressors and microagressions are related to substance use and what factors could moderate or protect against those.  So, using the same sample, we found that intersectional microaggressions were associated with greater alcohol use, hazardous use, as well as other substances like cannabis and nicotine. 

As Dr. Fish has just highlighted, while finding support is important, it wasn't enough to buffer the impacts of microagressions on substance use. 

Lastly, in a more study using a more recent iteration of the National Teen Survey, the 2021 version, we looked at QTBIPOC adolescents and sampled 1300 adolescents across the country who reported drinking in the past year.  We wanted to see how ‑‑ we wanted to replicate the prior finding I just showed as well as to look at some of the other mediating factors. 

So, what we found in this study is that intersectional microaggressions were associated with greater alcohol use and greater hazardous use among ‑‑ in the sample and drinking to cope motives actually mediated this association.  So, more experiences of intersectional microaggressions were related to greater drinking to cope motives, so wanting to drink to cope with distress, and that was associated with greater alcohol use. 

So the implications of these three studies is that intersectional oppression‑based stressors are a unique risk factor for depressive symptoms and substance use among QTBIPOC adolescents, and while a limitation of the studies that I presented are all cross‑sectional, as well as the broader literature, we need to understand how these factors unfold over time, over adolescents, and in their daily lives, as well as for us to examine mechanisms, mediating mechanisms as well as resistance factors, that can help inform interventions. 

And, lastly, given that most studies in the field don't look at structural oppression, we really need to understand where someone lives and their experiences with oppressive structures that they interact with and how that impacts their mental health especially, as prior presenters have mentioned, increasing rates of cissexism heterosexism across the states in terms of state laws and policies, as well as increasingly racist policies and laws across the country. 

So that takes me to my current study, which is a longitudinal and daily diary study looking at how intersectional oppression is related to substance use among QTBIPOC adolescents as well as how structural oppression might interact with those associations. 

This study is still ongoing.  We're very much in the middle of data collection so I won't be able to present the longitudinal associations, but I just want to give some preliminary findings from our baseline survey. 

So, so far, we've recruited about 1700 participants, just to take out a baseline survey, who are between 13 and 17 years old and reported past‑year drinking.  And I just wanted to highlight some findings in relation to intersectional stress and oppression as well as structural oppression specifically. 

So first I just want to highlight that we asked participants about their concern, worry and stress regarding increasing hostility and discrimination in society.  83% of our sample reported actually seeing that as a concern for themselves, as well as 75% of the sample reported being concerned about police brutality, experiencing police brutality themselves or other people within their communities just to, again, highlight how pervasive these stressors are for their daily lives. 

We also looked at baseline, just how and if these are ‑‑ these concerns are associated with poor mental health outcomes, and we found that they were associated with greater depressive and anxiety symptoms as well as past‑year suicide ideation. 

Now, connecting back to structural oppression, we're also curious about their perceptions of structural oppression.  So, for example, how they perceive their current cities, towns and states in terms of what kind of racist policies and laws are being passed as well as what kind of cissexist and heterosexist laws and policies are being passed, so their perception of those laws. 

And what we've found is that greater perception of structural racism and structural cis‑heterosexism was also associated with greater depressive and anxiety symptoms and suicide ideation. 

Now, a limitation of this work ‑‑ this is their subjective perception of where they live in terms of how oppressive it is, and so what we will be doing in the study is also looking at state‑level laws and policies to look at how structural oppression, examined more objectively, relates to these different health outcomes.  I don't have that data to present yet, but maybe in a couple more years. 

Lastly, I just want to leave us with a more positive finding which is while QTBIPOC adolescents navigate these oppressive structures, it's not their responsibility to change them.  It's our responsibility as adults to change these oppressive structures. 

However, QTBIPC adolescents are motivated for social change and social justice, and so we asked participants about their perceptions of that, and 85% of the sample reported that it's their responsibility to get involved and make things better for society.  About 85% reported "people like me should participate in political activity and decision‑making in our country." 

And so, while they are highly motivated to participate, less so had the opportunity to do so, so being engaged in protests or joining political organizations or contacting their public officials.  So just something to think about in terms of advocacy efforts, how we can include QTBIPOC adolescent voices in the conversation and in social change movements. 

So, I'll wrap up here.  I just want to acknowledge the participants in this study, our wonderful Lavender Lab Team as well as our amazing QTBIPOC advisory board and collaborators. 

And just thank you all, and wishing everyone a happy Pride Month, and a reminder that Pride is a riot, so no Pride for some without liberation for all of us.  Thank you. 

And I'll pass it on to Dr. Rachel Schmitz.

RACHEL SCHMITZ:  Thank you so much, Dr. Mereish.  I'll go ahead and share my screen.  

Okay.  Hopefully that looks good for everybody.  Let me know if anything isn't clear, if you all can't hear me.  But I did want to send a quick thank you to everybody, the organizers, everybody at NIMH and everybody putting this together as well as all the contributors, attendees.  This certainly takes all of us to be supporting really equitable social change for queer‑identifying young people. 

So, my research today that I'm going to be sharing with you is really focused on a couple of different projects that I had ongoing, but they share the common thread of really emphasizing LBGTQ2S young people, really navigating residential instability, economic precarity in a variety of ways, particularly while they are experiencing homelessness.  They may have been kicked out of their family‑of‑origin homes, some may have felt like it was their last resort, something that they felt they had no other alternative because of challenges at home, and other experiences of just more instability in terms of their residence. 

But I did want to highlight I'll be focusing on identity, family, religion, as well as resilience, because these topics have really emerged in my research that is primarily qualitative that I'll be talking about today. 

They all factor really powerfully into young people's understanding of how they grow up, how they develop, how they emerge into young adulthood, which we know can really be a lifelong experience when you're also navigating various oppressions, marginalizations, and just figuring out who you are with all these structural constraints.  There's a lot of work and labor that these young people are putting into this experience of traversing the liminality of young adulthood, is how I've termed it. 

So, a quick note on language.  I know a lot of us here are already doing this in our work, but really centering on the person in our research and the individual.  So, there's been some shifts in language. 

When I first started with this research working with youth experiencing residential instability and homelessness, it was more so homeless youth, so that homelessness, more of that really kind of master status; but now moving into this more equitable, compassionate and, therefore, human‑centered approach where we are emphasizing the young people specifically and the noting that they are having these experiences of homelessness, but it's not the defining factor of their lives. 

And I utilize LGBTQ2S and the "plus" in my research to really denote how people ‑‑ how young people are identifying across diverse and expansive gender and sexual identities, also recognizing Two Spirit because that's a growing identity we see for Native and Indigenous‑identifying folks ‑‑ and in Oklahoma, that's been even more prevalent in my research ‑‑ but the "plus" I also like to include in there for broader inclusion and recognizing that these expansive categories are continually growing and changing, and being very affirming of that. 

So, the scope of my work I'll be sharing with you is, again, emphasizing LGBTQ2S+ young people who are experiencing homelessness, because we know that the numbers of queer youth and homelessness or residential instability is over ‑‑ or that they are overrepresented, so it's disproportionately high that we see queer youth accessing services or resources or youth experiencing homelessness. 

We know from a lot of the research already shared in this workshop that young people are navigating a lot of challenges in general within society, but when it's also these structural, interpersonal and even individual oppressions related to their more marginalized gender and sexual identities, we know that those experiences of homelessness only compound what they are already navigating in their lives.  So, we know that there can be a lot of challenges within their families of origin, how they may be experiencing trauma and other types of conflict in their lives that may shape a lot of those very diverse and complex pathways into and out of homelessness. 

So really the question driving my research projects is how we can better support youth living on the margins of society, because we know that they're navigating so many things all at once, and we obviously want to support them and provide resources.  And so the best way that I really decided to do that in my research was emphasizing that transitional period of emerging adulthood, more so the 19‑to‑26 age range, though I have been expanding that further as I've been conducting research with young adults because we know that adulthood is not something, you just turn 18, you wake up one day and you're an adult, but it's really this continual process of how young people are navigating that. 

And so really want to sit down with youth and ask them what we can do better, how we can do it, getting feedback from their lived experiences for how services, policies, and programming can be improved based on their lived experiences. 

And so that's what I set out to do with these different research projects that are grounded in young people's lived experiences, so they are all drawing from in‑depth qualitative interviews, and I really highlight it as a strength that we're emphasizing young people's subjective lived experiences and perspectives. 

So rather than saying, you know, this isn't objective, this can't be considered necessarily validated or generalizable data, argue instead that it's really critical to have these very nuanced and diverse individualized perspectives that young people can share because they're never going to be the same.  And the more we're learning from different young people from a variety of backgrounds, then the more comprehensive our toolkit can be for how we're able to apply research and also wanting to really elevate marginalized voices, which ties into the regions in which these different studies were conducted in more underrepresented predominantly rural and socially conservative states. 

So, from a qualitative methodology, these two studies were conducted ‑‑ oh, and between 18 to 26 years old for young adults.  That actually varied because in Nebraska, where I'm from and got my Ph.D., the age of adulthood is legally defined as 19, whereas in Oklahoma it is 18. 

But specifically living and working in these two regions, these two studies, one comes out of my dissertation work at University of Nebraska‑Lincoln and the other comes in where I am currently as a professor in Oklahoma.  But they're really highlighting young people's experiences across, whether it's identity development, how to navigate family relationships, and then in Oklahoma I moved into this emphasis on relationships with companion animals because there is that emerging area of research and just policy work in different services and resources aimed at supporting people experiencing homelessness so that they can remain with all of their loved ones, including their companion animals. 

But there was of a lot of overlap in these studies because of the regions.  We know there is emerging anti‑LGBTQ2S legislation and policy‑making that's continually affecting all LGBTQ people, but specifically when we think about young people without resources, maybe reliable sources of support like youth living in homelessness ‑‑ again, really expansively defined ‑‑ then we also have to think about how those ‑‑ that structural oppression can significantly shape their ability to meet their basic needs, to broaden into those more higher levels of personal development when we think about identity development. 

So, I did work with service providers both in Nebraska and Oklahoma, and it really was a powerful process for me in my own reflexivity and positionality.  There were things that I was thinking, oh, I could just talk about companion animals with youth experiencing homelessness, but providers told me, well, you don't want to mislead young people thinking they might get a therapy or a service or an emotional support animal out of this project because of its focus.  They really helped me conceptualize, think about what's going to be helpful for them and the youth, and also think about language.  So, I was really challenging my own personal assumptions as well as my own personal privilege in coming from academia, entering into these spaces, and recognizing that the youth themselves are the experts in this ‑‑ in this research process. 

So, getting into some my key findings here, identifying identity was really powerful for the young people across both studies.  And they talked about, of course, not having a stable residence or residential stability was one of the biggest challenges.  They didn't have anything.  They weren't able to meet their basic needs.  They were struggling on a daily basis.  So, Sawyer saying, "I've never felt so alone before in my life." 

And, additionally, family relationships, like people have shared quite a bit, can be really fraught, adding that layer of economic instability that's affecting the entire family system, but then we know youth and young adults are certainly more ‑‑ potentially more precarious because of their age range. 

So young people talking about maybe they've always felt like they didn't fit in, or Melanie saying, "I've always been like a black sheep in the family," drawing from her identity but also just how she didn't ever really mesh with her family, potentially shaping some of her experiences of homelessness. 

Similarly, Lily experiencing a much more abrupt transition because of this explicit removal and being kicked out of her house when she turned 18, recognizing that though this, in her perspective, supported her mental health because she didn't have to then constantly deal with family conflict and challenges. 

Religion also played a powerful role, especially from the data out of Nebraska.  I actually didn't ask about religion, but it emerged as a primary factor and source of influence in young people's lives.  Oftentimes it was choosing their own religion and spirituality, like Elliot saying, "I became Wiccan because Wiccans don't judge," and this helped Elliot be not afraid of going someplace and other people judging, knowing they have that support.    

Finally, resilience really emerged for these young people, that they weren't just passive recipients of oppression and marginalization but that they were oftentimes taking agentic steps to say, well, I'm going to really focus on myself, like for Abby, saying, "Life has actually become clearer," when she was able to really center herself and her identity. 

And then this is where pets really emerged in the focus from the Oklahoma study.  Avery, for example, saying, "My pets are my grounding rod.  I really thrive on that furry, four‑legged unconditional love." 

So, this leads into some of my contributions, recommendations for especially more LGBTQS2 inclusive services for mental health and housing, but also pet‑centered support.  This is something that's really difficult for housing especially, but then thinking about for young people in even more precarious housing positions. 

So, any questions or comments or publications from this work I'm happy to share and thank you all for having me.  
 

LAURA THOMAS:  Great.  And next up we have Jason Nagata.  
 

JASON NAGATA:  Thank you so much for the opportunity to speak today about eating disorders in sexual and gender minority adolescents. 

I'm a pediatrician by training specializing in the care of adolescents with eating disorders, and I wanted to start with a case. 

Sam, who uses him/him pronouns, is a 16‑year‑old transgender boy who was assigned female sex at birth and was teased and bullied at school for being the only transgender student in his class.  He internally felt that his body was too feminine, and he wanted to be able to defend himself from bullies, so he started watching muscle‑building influencers on social media and turned to weight‑lifting in order to bulk up. 

He would often work out compulsively at the gym for four or more hours a day.  Although he felt insufficiently muscular, he simultaneously felt too fat.  Furthermore, getting menstrual periods was distressing for him, and he learned that he could suppress his periods by eating less, so he counted his calories obsessively and restricted his caloric intake to less than 1,000 calories a day.  If he consumed more than that amount, he would vomit or exercise more.

Sam's story highlights the complex relationships among gender identity, body image and eating disorders in today's adolescents.  Eating disorders are a serious mental health condition, significantly impairing health and functioning due to persistent disturbances in eating behaviors.  Some examples include anorexia, bulimia, binge‑eating disorder and avoidant restricted food intake disorder, and these can have significant physical, psychological and behavioral consequences. 

Some examples of disordered eating behaviors can be fasting, skipping meals, severe restriction of food intake, vomiting, laxatives, diuretics, and binge eating. 

Muscle dysmorphia, also known as bigorexia or reverse anorexia, is a subtype of body dysmorphic disorder, and it's characterized by a preoccupation or obsession with insufficient muscularity, so in most cases an individual's build is normal or muscular, and this is associated with distress or impairment in functioning. 

In order to achieve these goals, people may engage in muscle‑building behaviors like protein overconsumption while restricting carbohydrates and fats, use of appearance‑ and performance‑enhancing drugs and substances like anabolic steroids ‑‑ androstenedione or creatine ‑‑ and compulsive or excessive exercise. 

Now, adolescence is a really important period for the emergence of gender identity, sexual identity, and increased sensitivity to body image, which may put adolescents at risk for eating disorders, and the literature shows that sexual minority adolescents have two to four times greater odds of having an eating disorder diagnosis and 1.5 higher odds of engaging in disordered eating behaviors than their heterosexual peers. 

And there's less data on gender minority adolescents, but some studies have found that over 40% of transgender adolescents reported at least one disordered eating behavior and 17% reported at least three disordered eating behaviors. 

These high rates of eating disorder symptoms and behaviors are reflected in data from the PRIDE study, which showed 14 to 24% of sexual minorities, and an even higher rate, 23 to 28%, of gender minorities reported dietary restraints in the past month, 9 to 15% reported binge eating, and 4 to 10% reported excessive exercise in the past month. 

This is the conceptual framework of some of the influences on eating disorder risk among sexual and gender minority adolescents.  While there are a lot of contributors ‑‑ the media, peers and parent influences, societal stigma, discrimination and bullying, gender norms, objectification ‑‑ identity concealment can all lead to internalized homophobia or transphobia, self‑objectification, low self‑esteem and body dissatisfaction, which can always lead to eating disorder vulnerability.  And, as mentioned, this is all heightened during the adolescent period. 

I wanted to highlight three theoretical models that could impact eating disorders and body image in sexual and gender minority adolescents. 

First, gender norms may reinforce feminine body ideals that promote thinness and weight‑loss behaviors, while masculine body ideals promote muscularity and muscle‑building behaviors.  The tripartite influence model highlights the three largest social influences on body image:  the media, peers, and parents and family. 

And, finally, minority stress theory explains how discrimination, stigma and bullying can contribute to poor body image and heightened eating disorder vulnerability. 

First, when talking about gender norms, transgender individuals in particular may have heightened risk for eating disorders if their sex assigned at birth does not match the gender norms assigned with their gender identity.  We found from the PRIDE study that the gender and body‑image norms were more associated with gender identity than sex assigned at birth in transgender people. 

So here when we look at the traditional eating disorder symptoms that are associated with thinness and weight loss, a transgender woman, who would have been male sex assigned at birth, reported highest eating disorder symptoms, including restraints, weight concerns and shape concerns and overall symptoms of eating disorders, whereas these were lower in transgender men, who would have been female sex assigned at birth. 

Conversely, when looking at muscle dysmorphia symptoms in gender identity, the drive for size is the highest in transgender men who would have been female sex assigned at birth and lowest in transgender women who would have been male sex assigned at birth and somewhere in the middle for gender expansive or nonbinary people, and this is also reflected in overall muscle dysmorphia symptoms. 

Moving on to the tripartite influence model, as mentioned, traditionally the media, parents and families and peers were thought to be the three biggest social influences on body image and eating disorders, and I wanted to highlight that social media, which is a relatively new exposure, somewhat uniquely combines all of these with the media and peers and, to a lesser extent, families and parents. 

And so, comparisons to unattainable body ideals, perhaps through filters, editing, curation, and publication bias ‑‑ meaning only publishing or posting the most glamorous photos ‑‑ pressure to display one's own body in order to gain likes and followers, and even overt exposure to eating disorder content may lead to an increased risk of eating disorders through social media. 

I wanted to next present some data from the Adolescent Brain Cognitive Development Study, which is one of the largest long‑term studies of brain development in adolescent health in the United States, following nearly 12,000 adolescents from ages 9 through 14 currently, so this data will be mostly an early adolescent. 

First, I wanted to note that we did find that sexual minority adolescents had significantly more overall screen time per day.  Sexual minority adolescents reported almost four more hours of daily screen time than their heterosexual peers, and even those who are questioning their sexual identity had about 1.5 more hours.  And this was also associated with greater problematic social media use, which includes elements of addiction like inability to stop despite trying, withdrawal, tolerance, conflict and relapse. 

We found similar trends in gender minority adolescents in that four and a half more hours of screen time were reported by transgender adolescents compared to their cisgender peers and 3.4 more hours in gender‑questioning adolescents, and this was also associated with greater problematic social media use. 

We also looked at data on binge‑eating disorder, which actually is the most common eating disorder in adolescents, characterized by eating a large amount of food in a short amount of time, loss of control in eating, and associated guilt, and also found that sexual minority adolescents had a threefold higher odd of both binge‑eating disorder and binge‑eating behaviors. 

Now, when looking at social media to potential binge‑eating disorder, this prospective cohort study, we did find that every additional hour of social media that was used was associated with 62% higher odds of binge‑eating disorder one year later and then, to a lesser extent, texting, watching TV, and total screen time also associated with higher odds of binge‑eating disorder one year later. 

When thinking about other specific symptoms of eating disorders, this cohort study, we were also able to link screen time and social media time with higher symptoms of fear of obesity, self‑worth tied to weight, compensatory behaviors to prevent weight gain, binge eating and distress with binge eating two years later. 

And one, I think, unique area of exposure in social media that kind of integrates the minority stress theory is cyberbullying.  We already know that bullying or in‑person bullying has been shown to be a risk factor for eating disorders, but online cyberbullying, about 10% of adolescents in the ABCD Study had reported cyberbullying victimization, and this was almost three times higher in gay, lesbian, and bisexual adolescents and 2.2 times higher in transgender adolescents.  And we similarly found that cyberbullying was associated with eating disorder symptoms like worry about weight gain, self‑worth tied to weight, compensatory behavior to prevent weight gain, and binge eating. 

41% of gay, lesbian, or bisexual young adolescents 11 to 12 years old reported experiencing sexual orientation discrimination, and this was associated with higher odds of binge eating and binge‑eating disorder one year later. 

Now, I've mostly focused on risk factors, and I wanted to highlight a few protective factors that were identified in the recent literature review that we conducted, including positive identity feelings, family and social support, safe school environments, and access to gender‑affirming care, particularly with lowering eating disorder symptoms and body dissatisfaction. 

I also wanted to note that social media and some of these exposures that I've mentioned are not inherently good or bad.  There may be some risks and some benefits, and I think our goal in supporting our youth are to maximize the benefits while minimizing the associated health risks, including poor body image and eating disorders. 

So, with that, I would like to thank our lab team members, funders like National Institute on Mental Health and the cohort studies, the Adolescent Brain Cognitive Development Study and the PRIDE study, participants, and investigators. 

And all of these findings are summarized in a review article that was actually published this week on eating disorders in sexual and gender minority adolescents. 

So, thank you so much, and I'm happy to pass it to our next speaker, Dr. Myeshia Price.  
 

MYESHIA PRICE:  Hello.  Thank you, as others have said, for the invitation, and for even putting this together.  It's always great to be among people who are like‑minded and saying a lot of the same things that you're saying. 

And so ‑‑ Myeshia Price.  I use she/they pronouns.  I'm currently at Indiana University, Bloomington. 

I like to start any sort of research talks I give with the understanding that research is biased from the start to the finish.  So, with that being said, I share that I'm queer in both my sexual orientation and gender identity.  I am a single parent to now six‑year‑old who is ‑‑ who identifies as being neither a boy nor a girl, both a boy and a girl depending on the day but is somewhere in that sort of nonbinary state of being without the label because they're six.  And so, yeah, those are sort of the things that I bring. 

I'm also a developmental psychologist, so I approach research with that lens.  And prior to this I was Director of Research Science at The Trevor Project, so a lot of that data is going to come from there.  A lot of what I talk about will come from my experience there. 

I have these stats up here in this information, but I'll kind of zoom through it because we've all been together two days at this point, and I won't be talking about anything unique or special other than to say I'll be talking about suicide, and it is the second leading cause of death among young people age 10 to 24, and LGBTQ youth are at increased risk for that.  CDC finds them to be four times ‑‑ sorry, more than four times as likely to attempt suicide as compared to their peers. 

And obviously looking at this from an intersectional perspective, which others before me have done a really eloquent job at talking about so I won't go into too many details about that, but I will say that we find over and over again that young people ‑‑ young LGBTQ people with more than one stigmatized identity are even more susceptible to some of these poor mental health outcomes we find.  Largely that's because you have this stressor of being a young person anyway, right, or going about being a young person today or any time in history has been very difficult and complicated, and you have stressors that anybody would be experiencing.  But then, on top of that, you have specific LGBTQ stressors that you may be experiencing, and then when you have more than one stigmatized identity ‑‑ it might be racism, anti‑immigration policies from previous speakers we've heard today, it could be gender‑based discrimination on top of sexual orientation‑based discrimination ‑‑ if you have a lot of that, that could increase their risk. 

More importantly, and one of the reasons I'm really glad to be talking about it today, is that protective measures have been found and are known to sort of interrupt that stress. 

And so all of these negative outcomes, when you think about it, it's sort of like there's a middle person.  If the reason why we see this increase in LGBTQ suicide risk is because of how they're treated, then obviously if we put in their better treatment and affirmation and things like that, we can see more positive outcomes. 

So, as I mentioned, I was previously Director of Research Science at The Trevor Project, so I will be presenting some of these overall findings from that study ‑‑ from the study in 2023.  They have a new study, and Derrick yesterday went over a lot of those findings from 2024, so there's probably some similarities there, but this will be looking at the 2023 national findings as well as some other things in there. 

Just a quick overview in case you weren't there or want me to talk about what happened in 2023, this is sort of the timeframe from that.  We stayed over COVID between September and December.  These data were between September and December.  A lot of unique IP addresses went in there, but it got sort of ‑‑ after all the data cleaning and everything like that, it ended up being about 28,000 LGBTQ young people between the ages of 13 to 24. 

And the suicide risk questions were specifically taken from CDC, and that's been the YRBS, which has been the case for ‑‑ again, I won't speak to 2024, but it has been the case since the beginning of a lot of these surveys, and that was because the idea is to sort of norm it against what the government is able to collect and to ‑‑ in a sense, so that this data is also somewhat representative of what we're seeing in the population. 

This is just a quick breakdown of the demographics, and I like to use this to point out that a lot of the research in this space is predominantly White, and we purposefully tried to avoid that by putting quotas and things like that, capping things so that we ended up with 50% White, and a lot of this allowed us to go into more specific analyses.  And so, when half ‑‑ when only half of them is White, we were able to look at very specific findings within the cross‑section of race and sexual orientation and/or gender identity. 

So, when we talk about anxiety and depression, we see that the majority of young people, LGBT young people, have symptoms of anxiety, and those rates are even higher when we're looking at ‑‑ when we're comparing transgender and nonbinary to their cisgender LGBTQ peers.  Now, that's important because this is a fully LGBTQ sample.  So, whenever the rates are higher for trans and nonbinary youth within the sample, it's hard not to compare to other ‑‑ within groups or compare to LGBTQ young people. 

We also see that more than half of them reported symptoms of depression.  And, again, those rates were higher when they were trans and nonbinary. 

And then we're thinking about rates of suicide.  We saw 14% overall of young LGBTQ young people in the sample attempted suicide in the past year ‑‑ again, that was one in five when we're talking about trans and nonbinary youth ‑‑ and 41% overall for LGBTQ young people seriously attempted suicide in the past year.  And I keep saying "overall" because I'm going to get into more of a nuanced view of these data in the sense that we see that younger LGBTQ young people report higher rates of both of these ‑‑ of both of these measures of suicide.  And, again, I could get into ‑‑ I don't want to go over my time too much, but it does suggest, and I've seen over and over in research, that younger people are not necessarily having a lot of support. 

So, when you look at parental support, you look at peers and things like that, the younger people are missing that in schools, at home, and all these other places; whereas, when people are older, they have a little bit more flexibility to figure that out for themselves. 

And then you can look at rates of suicide.  We see that trans men report higher ‑‑ and, again, I just point this out because a lot of money and funds go ‑‑ a lot of ‑‑ I can't speak about them all, but I know historically a lot of funds have gone towards trans women, and a lot of that was because it was attached to HIV AIDS funding. 

And then we can see that young people who are multi‑sexual in the sense that they're attracted to one or more genders are reporting higher rates.  Again, we're probably looking at where they're able to ‑‑ the fact that they're likely experiencing stigma even within the LGBTQ population, and then we have the race, which was covered by a few people who have spoken before, and I can appreciate that, but obviously you would be more likely to be experiencing more than one stressor as a result of this.  And, specifically, I think multiracial youth are often forgotten about in most research, but their findings are higher than or equal to a lot of other BIPOC young people. 

And then, of course, there's regional differences.  And something that is important to remember is that suicide is very complex, and so I think people would expect this to be even more dramatic based on where the policies are and what's happening politically, but there's a lot of protective factors in there also that are not necessarily related to LGBTQ status but other things that might be supporting young people.  It's very nuanced. 

So specifically looking at risk factors, we find that LGBTQ young people are reporting victimization.  This is just at school.  So more than half of them have been verbally harassed because people thought that they were LGBTQ at school. 

And you can see that even ‑‑ almost 1 in 10 were physically attacked at school.  These are findings from school.  So, these are some of the things that could be associated with their increased risk. 

And then we're looking here at having been physically harmed or threatened in the past year.  24% of young people reported that.  And then here you also have a graph illustrating how that ‑‑ this is the chi‑squared.  There's nothing predictive here, but we can see that young people who experience this reported higher rates of attempting suicide in the past year. 

And we see the same thing as discrimination.  You can see that the majority of LGBTQ young people report having felt discriminated against in the past year due to either their sexual orientation or gender identity, and, again, that experience ‑‑ those who experienced that report higher rates of attempting suicide in the past year. 

There's also bullying experiences, which is important, because I think ‑‑ I like to illustrate this for a couple reasons.  First of all, middle school young people are experiencing this a little bit more compared to high school, and then you have trans and nonbinary youth reporting higher rates of it compared to their cisgender LGBTQ peers, but then you also have this instance where I think a lot of people forget that some of this stuff still happens in person.  There's a lot of attention, warranted attention, on cyberbullying, but it's also the case that sometimes this is happening in these face‑to‑face interactions which allows for the potential for some sort of intervention or bystander intervention a little bit more so than the cyber ‑‑ the electronic bullying.  And then you also have the rates of suicide for those who have been bullied or ‑‑ those who have experienced bullying and those who have not.  You can see this is just ‑‑ you know, the difference in those rates is pretty extreme. 

Most importantly, something that's near to dear to me is looking at protective factors.  Right?  So, one of the things we asked young people on the survey in 2023 were what are some topics that you want people in your life to know more about that could benefit you, that would be helpful and supportive of you. 

The most common thing that young people reported was support and acceptance.  And I like to talk about that in the sense that a lot of people think I have to understand all of these identities; I have to know everything.  But you don't really.  You just have to be supportive and accepting. 

An example I like to use with folks is a lot of times ‑‑ if my kid started playing a sport, I wouldn't have a lot of knowledge about that.  I know bare minimum when it comes to sports.  But I would still be very supportive and accepting and be there cheering.  And so maybe along the way I would learn all the rules about football or soccer, but right now I don't know them, but I would still go to those games, drop my kid off, and cheer.  I think that's the important part young people are looking for is just that support acceptance, and then perhaps later you can ‑‑ you know, we see they would like people in their lives to know about gender identity and sexual orientation, but, number one, they just want to be accepted and supported. 

And then we also asked about common ways that LGBTQ youth report things that are happening with their parents that make them feel supported, and that's being welcoming to their friends and partners and things like this.  These are specific tasks that our separate papers illustrated how they are associated with protectiveness. 

These are affirming spaces ‑‑ I'm going to start speeding through some of this.  I see you came on the screen ‑‑ so supportive spaces, as you can see, what happens with home and school and community events. 

Something I also think is important is if they're not getting at home and they only get it at school and we take the school away, young people don't have an affirming place to be, and for a lot of them, they just don't have that.  And you could just see what social support in and of itself is doing. 

Finally, respecting pronouns.  This is the easiest lift.  If you ask me if there's anything that's really simple that I can do tomorrow when I leave here or I can start doing today, pronouns 
is ‑‑ respecting young people's pronouns and chosen names is quite literally life‑saving for a lot of them.  And you can see that half of them do not have that with the people they live with.  So not just in their lives, these are people with whom they live that do not respect their pronouns. 

In conclusion, LGBTQ young people are at increased risk for suicidality, but it's because of the way they are treated for the most part, among the many other things. 

And multiple marginalized identities can help them survive, which I think is an important part if you can lean on one identity and feel a sense of pride and support in that space, but it may also be associated with increased risk.  Supportive people and places are incredibly protective. 

That's it.  
 

LAURA THOMAS:  Great.  Thank you so much.  That was a really outstanding set of talks there, hearing both about some risk factors and resilience or mental‑health‑promoting factors. 

I'm now going to turn things over to Dr. Erika Forbes, who is our discussant, who's going to lead us and moderate the discussion.

Dr. Forbes?  
 

ERIKA FORBES:  Hi, everyone.  Sorry.  Just making sure I'm sharing properly.  Is that working?  
 

LAURA THOMAS:  Yes.  We can see and hear from you.  You're not in presentation mode yet.  
 

ERIKA FORBES:  That's the problem.  Okay.  Let me try again.  
 

LAURA THOMAS:  There you go.  
 

ERIKA FORBES:  Thank you.  Great. 

Okay, everyone.  Thank you so much for hosting this exciting event and organizing it.  It's been really impressive.  And thanks for including me, and, of course, happy Pride Month to all. 

I'm Erika Forbes, and my work focuses on neural mechanisms of depression and related problems, and it includes investigation of mental health disparities in sexual or gender minority youth. 

As you can see from this impressive lineup, we have quite an impressive lineup and a compelling set of presentations to discuss, and, furthermore, I think we have one more than some of the other panels.  So, we really have a lot of great material to feed our discussion today. 

Briefly, I wanted to just kind of put things in context a bit by stretching into a topic that wasn't covered in depth in the topics so far but to think about social and affected processing tendencies and how those contribute to the intensity of mental health difficulties, in this case suicidal thoughts, and also providing information on individual differences and vulnerability mechanisms or even in understanding group‑level disparities in mental health. 

So, from this work I wanted to mention two findings from recent studies.  One is some work from Dr. Stanley Seah in our lab on the study that was focused on the development of Anhedonia in which he asked whether sexual minority identity interacts with neural response to social reward and how that's associated with higher suicidal ideation intensity. 

So, in this study people are recruited for vulnerability to Anhedonia, and he found that that group had higher suicidality, higher depression and higher victimization but that, furthermore, sexual minority youth who had lower response in the temporoparietal junction, shown in this solid line here ‑‑ and the brain region is shown in this red cluster here in the figure ‑‑ had higher intensity of suicidal ideation. 

And this is a brain region that's involved in processing social and kind of relevant social affective information.  And we see that these differences might increase risk for some people.  So, again, if sexual minorities are at particular risk and, in addition, if they have this characteristic of social processing, this might be potentially meaningful. 

And this could reflect things like greater disengagement or diminished interest in social feedback that could then create a risk that might reject things like ‑‑ or reflect things like their experience with victimization in the past.  It could be protective in some ways.  Perhaps if they've found that it's safer not to be trusting and engage with people who are new to them and who are providing some social reward, it's valuable for you to be able to be a little bit cautious, but on the flip side, there could be risk for social isolation and other concerning mental health outcomes. 

The second example is from work by Dr. Kristen Eckstrand from our DYADS study which focuses specifically on suicidality in social and gender minority young adults.  And here the finding was that higher left caudate response to a friend in a videotape from a social support interaction interacted with having higher negative response to real life social threats, as people reported in real‑life surveys, that was associated with higher intensity suicidal ideation.  So, people who had more response to this reward region plus higher negative responses like feeling guilt or humiliation or shame after experiencing a daily threat like victimization or exclusion or rejection tended to have higher suicidal ideation. 

And, again, this makes us think that processing social information or attunement to others has its kind of good and bad points and can also tell us something about who is at particular risk.  So, people who are maybe potentially sensitive to social information and, in addition, experience social threats and have a strong response to those might be particularly liable, so just to give a little bit of thought to what kind of mechanisms we can be thinking of to understand individual pathways and then in group‑level issues. 

So on to the more important thing, which is the questions for our discussion today.  There have been so many great points and really, really strong data raised in these talks, and they prompt a few different questions that I think could hopefully fuel a little bit of discussion among us right now and then also lead to some Q&A with the audience. 

So, first, how can we understand varying risk factors and protective factors and outcomes either in our conceptual stance towards generating hypotheses, understanding what we need to test, or formulating our research or interpreting findings or translating that into policies or interventions?  Intersectionality and the way that intersectional oppression can apply is really important to consider.  The varieties of sexual orientation and gender identity identities need to be considered.  So often people are just grouped into a sexual and gender minority population or group, which can be useful in some ways in a small study or even in an epidemiologic study, but that doesn't really capture the full extent of people's experiences or their risks or their protective factors.  And socioeconomic contexts are important. 

Another is the critical need to address nuances and complexities; that, for example, support is not support is not support, that mere parental acceptance doesn't mean effective or helpful buffering from unpleasant outcomes, or social media use per se is not good or bad.  Thankfully we've moved away from the idea that social media use is causing depression and suicidality. 

By the way, what we need to understand is the problematic levels of social media or game or phone as Dr. Nagata just described. 

Another is how we incorporate developmental factors into our models, into our research.  This is appealing to me because I'm a developmental and clinical psychologist, and it does seem so important to understand the timing not just of gender‑affirming care ‑‑ that's an important one for sure ‑‑ but also of other interventions, of understanding risks, of understanding resilience.  What do we need to know about when things happen and how ‑‑ when it's helpful and when it's not. 

And then, finally, how do we interventions build on findings about processes and mechanisms?  We're making so much progress with understanding these, and then I can't resist asking how we translate them to the next step. 

So, I'm looking forward to hearing everybody's thoughts on those.  
 

LAURA THOMAS:  Great.  Thank you. 

And I invite the panelists from the last session to turn on your cameras to participate in this discussion.  Do any of the panelists have any responses to some of the ‑‑ to any of the questions that Dr. Forbes just presented, expand on any of those?  

Erika Forbes:  You can look for your name if you wonder what applies to your talk or whose talk inspired which question.  
 

DIANE CHEN:  I'm happy to start.  And I'm actually going to ‑‑ it's not actually the question you targeted at me but actually the first question around, like, individual factors and whatnot. 

And so obviously my presentation was regarding sort of mental health outcomes secondary to treatment with gender‑affirming hormones. 

And one thing that has I think been really kind of salient when we're looking at our data is the amount of variability around those sorts of mean trajectories of change over time. 

And so, when I think about studying outcomes of some type of medical care intervention, I think that we need to start thinking about kind of individual risk profiles for mental health conditions because there's so much variability.  There were young people that looked great from a mental health standpoint before treatment and they looked great throughout treatment, right, and there's a subgroup of youth that don't look great at the start of treatment and they continue to experience high levels of sort of, like, mental health concerns despite receiving gender‑affirming medical treatments.  We're looking at some of our four‑year data and taking sort of, like, a mixture‑modeling sort of approach when we're thinking about distinct subgroups and distinct trajectories.

And I think that really is the sort of next step for some of the work that our team is doing is identifying the young people for whom gender‑affirming medical care really is not sufficient to addressing a lot of these contextual risk factors that a lot of my co‑presenters talked about from sort of a minority stress standpoint, from a family support, or lack thereof, standpoint that supporting sort of gender congruence, addressing the physical gender dysphoria is not going to be sufficient in addressing sort of the more holistic mental health and wellness needs of trans youth.  
 

ERIKA FORBES:  It's a good point.  Of course, there are lots of other visibility factors combined with stress and with structural issues and all of the different vulnerabilities that gender minority youth might experience. 

Yeah, we probably need to broaden to more of like a multilevel ecologically valid view of what happens.

RACHEL SCHMITZ:  Yeah, and I can expand on that.  Cause Dr. Chen, when you mentioned that holistic perspective and approach, that's really been guiding my research as well.  It's moving more into just thinking about companion animals as family, especially among marginalized groups, and thinking about how they can be these critical sources of support, especially for mental health, coping, resilience.  But yet our pets and companion animals ‑‑ while, yes, it's oftentimes a very privileged experience, because they can be very expensive and thinking about housing, but I think expanding that scope for people who may not have that economic stability but still finding ways, as a society through services and programming, to support all of their holistic needs, getting even beyond those basic needs being met, which we know are fundamentally critical, but then also considering, well, things can look different for different people, for how they're finding supports, whether it's through their pets, companion animals, through different hobbies that they're hoping to maintain or just things that they are most comfortable with in those housing environments. 

So I think it is further complicating what we know and what we can continue to work with, and knowing that there's not a one‑size‑fits‑all for either mental health supports, residential, economic stability, but really working as much as we can within the constraints of our own structures and resources, but working to make it a more individualized experience for finding out what people need from a very personalized sense and then doing our best to try and meet those needs where people are, versus a more top‑down approach. 

JASON NAGATA:  I can go next, and I want to thank all the speakers for their really insightful comments.  And I particularly wanted to follow up on Dr. Chen's really interesting data in sort of answering the question, what are the next steps for interventions or guidance?  As a pediatrician, I do think that there's a lot that can be done in general pediatrics and specialty pediatrics, particularly for the care of gender minority adolescents.  I think while many people are very well‑intentioned, actually our current guidelines and standards are very binarized.  We use CDC growth charts that only have male and female sex assigned at birth.  There's no nuance.  A lot of our guidelines right now are binary, and they're based on older data, and I do think that at the national level, when all we have‑‑ like even 
The most well‑intentioned pediatricians who want to provide gender‑affirming care, there just aren't data to provide, like, what are normal growth rates and trajectories for somebody who's nonbinary.  The same goes for even blood pressure percentiles or any kind of percentiles, they're all based on sex assigned at birth.  So, I do think that more guidance and data, really for all transgender youth across general health, could really be a big protective factor in the future. 

ERIKA FORBES:  What about in our conceptual models?  Does anybody have ideas about how to incorporate many different factors, intersexual identities, other risk factors, other contextual factors.  

JESSICA FISH:  I can jump in here, because I think this also dovetails with the complexity and nuanced point that you were raising.  I think that's what I'm bringing to the fore, is this idea that we have kind of talked about family in this kind of broad stroke, like family support is important ‑‑ and absolutely family support is important and absolutely family acceptance, which I would say is a different feature of support that acknowledges youth's sexual orientation or gender identity is important, but even within those features, even within those interactions, there are unique processes at play that may be more helpful than others.  And I think that as someone who's a family scientist, who has a background in couple and family therapy, we are just starting to scratch the surface around what those parenting practices look like, the way youth perceive those parenting practices, the way they internalize those parenting practices, the degree to which parents feel comfortable engaging in those parenting practices, and the degree to which they are consistent with those parenting practices.  For those of us who are parents, we know consistency is key with children.  And so, to say something that is affirming while also your nonverbals are potentially unaffirming sends mixed messages to young people as children, as adolescents and even as young adults when they're engaging with family, and those mixed messages have impact, at least we're finding that they have impact in specific ways.  

So when we think about our conceptual models, I want us to think more deeply, more concretely about how we think about family process, about how we think about child interactions, so that we might actually be able to identify instances where parents can make small but substantial shifts in the way that they engage with their children around their sexual orientation or gender identity that may have net benefits, as we wait for the world to catch up and affirm queer and trans young people.  And so, I'm just thinking about this as a protective feature that we have not tapped into, into its full potential.  And this also includes, for example, for folks who are racially and ethnically minoritized to be able to adapt processes ‑‑ for example, racial and ethnic socialization or cultural pride ‑‑ to be able to understand that those messages actually have application broader than just race and ethnicity.  They have application for sexual orientation and gender identity.  That's an inherent point of resilience and strength for those communities, right?  So, we have not really even tapped into that.  

So, I guess I'm inviting folks into that conversation, because I think it's something worthwhile that we can look into and potentially leverage to help support young people as they navigate these systems and policies that are, like I said, still trying to catch up to support their thriving. 

MYESHIA PRICE:  Yeah, I was actually gonna talk about that a little bit.  I was like, yes, when you had that slide up there, because that's something that I'm gonna start looking into, sort of thinking about how particularly ‑‑ I could speak to at least the Black experience.  There's a lot of socialization that goes in there that's very protective and how do we take that and, first of all, let parents know they already know how to do that.  I think that's the hard part, they're like "I don't know what to do."  And we're like, "You're already doing it."  If your kid comes home and some kids are making fun of their last name or whatever, you probably have the tools to support them in that way, and you probably got that from your parents.  Having the last name Price, like I got things from my parents who told me what to tell people.  I just told my kid this week the same exact thing, "Tell them you're priceless or whatever."  So, it's sort of like we have these things, and so how do we take those and literally just apply them to supporting the LGBTQ youth in our lives, because that's already existing.  

And something else I wanted to point out is socioeconomic, things that I think often get ‑‑ they get included sometimes as we'll control for this or things like that, but I think they deserve a little bit more attention, particularly when we talk about resilience, because we're seeing that strength and resilience comes with being able to have something to eat on a regular basis or having ‑‑ even parents, it's hard to be there and be, I guess, in the moment when you're struggling to support your basic needs, and I think that's something ‑‑ particularly for young people, sort of looking at their own but also their families, are they getting their basic needs met, I think, is such an important discussion. 

ERIKA FORBES:  Great point.  

I think we're supposed to ‑‑ should we open the floor to questions from the audience?  I'll defer to Dr. Thomas. 

LAURA THOMAS:  Yeah, we have had some questions come in the Q&A, which our presenters can head over and look at maybe during the next break or after this.  You don't have to try to multitask right now.  

I have a question.  So, a lot of you have used the word youth and adolescents, and that encompasses a really broad age range.  You know, a 12‑year‑old is quite different from a 17 or 18‑year‑old.  So, I kind of wanted to hear from you about how you tailor your research or your research questions to the age and developmental stage of the participants, of the kids that you're focusing on, or how you're taking that into account. 

JASON NAGATA:  I can maybe start, and I think that's a really great point.  I think even with our intersectionality discussion, when we're talking about adolescents or youth, another aspect of their identity is really their age and their developmental stage and pubertal status and level of parent support.  'Cause I heard Dr. Thomas mention for a 10‑year‑old that's technically the start of adolescence, that's gonna be very different than an 18‑year‑old, than a 24‑year‑old regardless of their sexual orientation or gender identity, but obviously these intersectional lenses can add a lot to it.  

I will just share that there is a lot of ‑‑ I think there's a lot of overlap in these terms and I just wanted to share there's this nice article that summarizes some of these terms.  It was published in the Lancet Child and Adolescent Health, which kind of shows different definitions of adolescence.  So, the World Health Organization, technically the definition is 10 to 19; youth is technically 15 to 24, and emerging adulthood kind of goes into the 20s and 30s.  And I think in this article they actually argued that the new adolescence should really extend into the 20s, because there still are a lot of developmental changes that are happening ‑‑ growth, brain development ‑‑ even into the 20s.  So even though in the U.S. 18‑year‑olds are technically adults, there still are a lot of ways that they can benefit from family and parental supports.  

And I will say in the area of eating disorders where this comes out in terms of treatments, we do typically ‑‑ for adolescent minors, there's a lot more ‑‑ like the primary treatment is family‑based therapy, family‑based treatments.  Whereas once somebody's 18 or older, if they're living on their own, if they're more independent, then the primary treatment modality becomes individual cognitive behavioral therapy.  So, it does kind of reflect how much independence there is and what support, whether financial or medical or whatever, goes on.  So, I do think that we need to ‑‑ because this adolescent, young adult range is really wide spanning, that is a really important aspect of intersectionality for all of these studies. 

ETHAN MEREISH:  I can't agree more.  Our current studies have been focusing on teens who are 13 to 17 years old, and that's still a pretty wide age range.  One thing that we've tried in terms of our work is we have a teen advisory board.  So, we run all our measures, all our surveys, all our materials through them to get their feedback, and our teen advisory board reflects the studies that we do; so, they're all 13‑ to 17‑year‑olds.  So, we've been finding that is a pretty helpful and really important piece of research, to get their feedback, to get their input.  A lot of times they identify language, and they name it as not helpful, or they could ‑‑ they often sort of snip out language that is written by adults or framed by adults to be more friendly to teens.  So, we've even had them write some questions or revise our informed assent.  So, I can't emphasize enough the importance of including teens in the research process. 

LAURA THOMAS:  That's a great point.  Do any of the other presenters have experience with involving youth themselves in the work that you're doing or helping to inform the questions you're asking, how you're asking them and how you're interpreting data and dissemination, kind of all along the spectrum there?  If anybody has any other comments, I think that's a great thing to emphasize. 

RACHEL SCHMITZ:  I have actually incorporated this into all of my qualitative‑interview-based studies, but especially with youth and young adults, you know, getting that feedback with the advisory board is, as Dr. Mereish mentioned, always critical.  I've worked with different service providers, like I mentioned, the language on pets versus companion animals.  "Companion animals" oftentimes comes from more professional academic circles and not wanting to objectify the non‑human animals we live with, but they informed me, "No, these kids, they're not really gonna understand what you mean, or they might conflate it with a service animal."  So, we understood that pets were just the appropriate language to use for working with youth.  

And then getting feedback in real‑time.  So, after every interview, I conclude it by "How did you find the interview?" To get feedback for myself as an interviewer, and then also asking them, "What would you like the study to do?  How would you like the findings applied, what do you want me to do with it?"  And they're like, "Well, just make things better, actually utilize the findings in different programming."  Like I was conducting a lot of these interviews at a drop‑in shelter in Oklahoma, so it was specifically having the findings readily available to you.  They could pick it up maybe as a one‑pager while they're at the drop‑in shelter, but it was a lot of actually applying it to the things that would benefit the youth.  So, I think asking the measure, collecting the data, whether it's a survey or interview, and then having that feedback as a source of data that you can concretely pull from as well and even revise your methods as you're collecting data is really critical too.  

LAURA THOMAS:  Great.  Thank you.  

Well, it looks like we are up against our time limit.  I want to thank all of our speakers from the session, as well as 
Dr. Forbes, our discussant.  That was really ‑‑ I learned so much, and that was a great way to end it, kind of tying it back with the former panel.  We have 13 minutes now of break and then we'll come back at 3:00 p.m. for our final session.  Thank you. 
[Break until 3:00 p.m. Eastern time]

RESEARCH ON SERVICES, INTERVENTION, AND PREVENTION

IRENE AVILA:  Okay, welcome back from the break.  I will now turn it over to Dr. Mary Acri. 

MARY ACRI:  Good afternoon.  My name is Mary Acri, pronouns she/her, and I am chief of the child and adolescent mental health services research program within the Division of Services and Interventions Research at NIMH.  I have the pleasure of introducing our next set of presenters, who will be speaking about research on services, intervention, and prevention. 
Dr. John Pachankis from Yale University School of Public Health and the LGBTQ Mental Health Initiative; Dr. Maggi Price from the School of Social Work at Boston College; Dr. Robert Rosales from the Center for Alcohol and Addiction Studies, School of Public Health at Brown University; Dr. Katie Edwards from the University of Nebraska‑Lincoln; Dr. Jessica Schleider from the Feinberg School of Medicine, Northwestern University; and Dr. Cathleen Willging from the Pacific Institute for Research and Evaluation.  Our discussant for the Q&A is Dr. Dorothy Espelage from the School of Education at the University of North Carolina at Chapel Hill.  

I will now turn it over to Dr. Pachankis. 

JOHN PACHANKIS:  Great.  Thank you for the introduction and for the opportunity to speak today. 

So, I'm going to be presenting a brief overview of the state of evidence‑based mental health treatments specifically for SGM individuals; first justifying why such treatments are needed, then discussing how we should go about developing them, whether these treatments work, and how we can implement them.  So, it's true that the mental health field doesn't possess sufficient resources to adapt every treatment for every distinct population and that waiting for such research could prevent people from getting efficacious treatments now.  It's also true that good treatment should already be guided by an idiographic case conceptualization that addresses each client's needs presented at intake.  It's also possible that SGM people might be able to benefit from existing evidence‑based treatments, and we certainly need more research into this question.  

At the same time, there are three reasons why we should develop mental health treatments specifically for LGBTQ people.  The first is that as evidence‑based ‑‑ these treatments serve as an evidence‑based alternative to conversion therapies, so‑called conversion therapies.  Most minority populations don't have such a clearly harmful alternative that has been promulgated to them throughout history and still today.  Second, professional bodies such as the APA has explicitly called for treatments to assess and address minority stress among SGM people but hasn't provided concrete guidance for how to do this.  And third, because RCTs of SGM‑specific treatments are themselves experiments, it can answer scientifically important questions such as the causal role of minority stress and its reduction in the mental health of SGM people, such clinical trials have great utility. 

So, what would a treatment specifically adapted to SGM's distinct concerns look like?  So, minority stress, theories of social safety and related theories, which we're familiar, specify exactly what such a treatment might look like.  They specifically spell out how SGM people's experience of stigma and social disadvantage lead LGBT people to hide their true selves, feel ashamed, expect and poorly adapt to rejection, and so forth.  Because all of these reactions represent cognitive, affective and behavioral reactions within the person, these reactions can theoretically be affirmatively addressed through mental health treatments/psychotherapies.  Yet, until recently no empirically supported mental health treatment had addressed these reactions and been tested in RCTs specifically for LGBTQ individuals.  

So, to create such a treatment, we interviewed numerous mental health professionals around the country who had spent their entire careers working with LGBTQ people.  We asked them how we should adapt CBT to best support LGBTQ people's mental health.  We also met with dozens of LGBTQ people themselves who were experiencing depression, anxiety, suicidality, and substance use.  The mental health professionals told us about the ways they'd seen LGBTQ people grow past stigma by first acknowledging the pain of stigma and the impact it has on mental health, standing up to stigma, especially as it manifests in oneself ‑‑ for example, an internalized homophobia, bi‑phobia, trans‑phobia ‑‑ learning new empowered ways of thinking and behaving, and finding support, meaning and purpose within the LGBTQ community and beyond as they do so.  

So, we packaged all these research findings, professional wisdom and lived experience into a CBT treatment manual that provides LGBTQ people with the tools to understand and challenge the ways that minority stress manifests in their lives and impacts their mental health.  We then trained therapists to use this manual and tested the treatment success in an initial randomized control trial.  To my knowledge, this was among the first mental health treatments to target LGBTQ people's minority stress to see if it could exert a positive impact on their mental health.  I unfortunately don't have time to go into the content of the treatment, but, in short, it's guided by a personally tailored minority stress informed case conceptualization that specifies techniques for addressing various minority stressors that SGM individuals might be facing.  And it does this by, for example, raising awareness of the existence of early and ongoing minority stress and the impact that has on mental health, reducing characteristic ways of avoiding the emotional consequences of minority stress, such as through drinking, drugs, self‑harm, and other forms of emotional numbing.  The clinicians we spoke to, many of them noted that their LGBTQ clients exhibited kind of characteristic unassertiveness, and so we added a specific set of modules on asserting oneself against the emotional consequences of minority stress to break social withdrawal tendencies.  The treatment also has a focus on reworking internalized stigma as it manifests within oneself; importantly, not challenging the reality of minority stress experiences but, rather, the veracity of their internalization and the negative direction towards oneself, thinking that one is inferior or unworthy of love and acceptance.  And finally, the treatment intentionally builds and draws on cues of social safety and community support to promote mental health.   So, this treatment teaches people these cognitive, affective and behavioral skills that help them start overcoming the painful patterns of thinking and behaving that they've often held onto their entire lives because of stigma and have set them up for mental health risks.  

So, we first delivered this treatment across ten sessions to 63 young gay and bisexual men in New York City.  Looking at the lines in blue, which represent the trend for before to after receiving treatment, compared to the lines in gray, which are the parallel trend for people assigned to the waitlist, we found that this treatment helped the participants in the study feel less depressed, less anxious, drink less, have safer sex.  We did a parallel study with young sexual minority women in New York City who were recruited because they are at risk of depression, suicide and alcohol use.  And, similarly, we found that the treatment ‑‑ the line in blue here compared to the waitlist, the line in red ‑‑ helped these individuals feel less depressed, less anxious, and experienced less hazardous alcohol use.  Importantly, much of the sample in the study identified as gender‑diverse or transgender.  

We then asked whether this treatment might be more efficacious than existing interventions for LGBTQ people.  So, in a trial with 254 young gay and bisexual men in Miami and New York City, we compared this LGBTQ‑affirmative CBT to LGBTQ‑affirmative supportive counseling, as typically delivered in the community, and single‑session HIV testing and referral, with the justification for HIV testing and referral being that it's one of the most common ways that young gay and bisexual men have contact with social services.  We found that LGBTQ‑affirmative CBT was associated with small to moderate relative benefit, compared to these other two treatments.  For substance use we found the largest effect sizes, with LGBTQ‑affirmative CBT yielding significantly greater impact on substance use problems than the other two treatment conditions.  Also consistent with the transdiagnostic basis of the treatment that targets the minority stress mechanisms theorized to underlie the multiple co‑occurring outcomes that disproportionately affect LGBTQ people, we found that the treatment was associated with significantly stronger reduction in the comorbidity count that we looked at compared to those other two conditions.  That comorbidity count was composed of the presence of depression, anxiety, hazardous substance use, and HIV risk behavior.  

We then looked to see for whom the treatment was most efficacious.  We interviewed the therapists both quantitatively and qualitatively at the end of the study ‑‑ there were about 12, 13 therapists on this trial ‑‑ and asked them what factors they thought might moderate the efficacy of the treatment.  We inputted their top 20 nominations into a machine learning analysis and found that only one moderator emerged as significant and that was race/ethnicity, such that Black and Latinx participants, who composed the majority of this treatment sample, experienced significantly more reductions in our preregistered comorbidity count from LGBTQ‑affirmative CBT compared to the other conditions.  We're still trying to empirically establish reasons for this moderation, but clinically we noted that Black and Latinx participants perhaps may have been more amenable to the minority stress focus of the treatment, perhaps because they were able to draw on their racial socialization experiences to incorporate the minority stress lessons of LGBTQ‑affirmative CBT.  

So now that we have evidence for the efficacy of this LGBTQ‑affirmative and other mental health interventions, we can turn our attention to studying how to ensure that this evidence‑based practice for LGBTQ people reaches those who are most in need.  So, the U.S. has this amazing national network of LGBTQ community centers, about 60% of which provide mental health services to over 50,000 LGBTQ people each year, especially those who might not otherwise receive care or feel comfortable in general mental health care settings.  So, we partnered with Center Link, which is the coordinating hub of the U.S.'s 320 or so LGBTQ community centers, to survey the directors and CEOs of these centers to assess their capacity to implement LGBTQ‑affirmative CBT.  So, most of these center directors and CEOs reported room to improve the mental health services they offered to their LGBTQ community.  Most also reported that their staff could benefit from training in LGBTQ‑affirmative CBT, after we described the treatment for them, and a hundred percent of them said that they would devote the staff and administrative time and resources necessary for their mental health staff to be trained in this LGBTQ‑affirmative CBT.  

So, we trained them, but we also used implementation science to determine whether the training was efficacious, namely in a waitlist-controlled trial of an 11‑week, one‑hour‑a‑week training in LGBTQ‑affirmative CBT to about 130 mental health providers working in LGBTQ community centers across 21 states.  We found that ‑‑ looking at the lines in blue, which is the effect from pre‑ to a three‑month follow‑up from having received the training versus the line in red, which is the trend for waitlist, we found that the training was associated with significantly greater increases in providers' cultural confidence, minority stress knowledge, knowledge about CBT, their familiarity with LGBTQ‑affirmative CBT skills.  And in a demonstrated simulated practice assessment that we created with videotaped vignettes, we also found that providers showed significantly greater uptake of LGBTQ‑affirmative CBT, as they naturally described how they would treat the LGBTQ actors in those vignettes.  

So, we're now in the process of training over 700 mental health providers in LGBTQ‑affirmative CBT, who are working at 90 LGBTQ community centers across the U.S.  Ninety of these centers have signed up; they've signed up over 700 of their providers.  And we randomized the centers to receive one of three types of training, with the lightest touch version being an online course consisting of instructional lectures, instructional animations, case‑based video demonstrations, and interactive practice exercises for the providers, and the highest touch version being ongoing supervision from our team.  And the goal is to identify the types of training that are best suited to the types of centers, according to the center's environment, staff, budget, and so forth.  

So in conclusion, future research directions, I think, would importantly involve continuing to be curious and open about whether and how to adapt existing treatments for LGBTQ populations, while at the same time moving beyond only our CTs to speed up the dissemination of these treatments that we already have, including those for the general population that can be readily adapted to using evidence‑based LGBT tailored case conceptualization.  And finally, we can use the tools of implementation science, including from global mental health contexts where such interventions are being scaled up using technology and task‑shifting, to ensure that providers are trained in this treatment in high‑needs settings in the U.S., and identifying other ways to encourage uptake of LGBTQ‑affirmative mental health treatment in the highest need context.  

So, I'll end there and just thank the funders, primarily NIH, the collaborators and the research team behind this work.  Thank you, and I'll pass it on to Dr. Maggi Price. 

MAGGI PRICE:  Thank you so much.  My name's Maggi Price: I use she/her pronouns, and today I'm gonna home in on one very specific study, a study that focuses on targeting multilevel transphobia through a multilevel intervention.  Now, this quick presentation will have two parts ‑‑ and a brief shout‑out and thank you to my research team, the Affirm Lab.  None of this work would have been possible without their great help.  Okay.  So, this presentation has two parts.  The first part is, I'm gonna present to you a multilevel stigma framework that I think really builds well on Dr. Pachankis's amazing work.  So conceptually it shouldn't be much of a jump.  And then the second part of the presentation, we'll dive into that specific study example that I mentioned where I'll talk about developing and testing a multilevel intervention that targets multilevel stigma, specifically multilevel transphobia. 

All right.  So, the first part, let's talk about the stigma framework.  We're going to begin by covering some key terms.  So, stigma.  Stigma can be defined as societally deemed inferiority based on a circumstance, identity or behavior.  Conceptually, it's very much related to minority stress.  Stigma can be considered an umbrella term that encompasses specific types of stigmata, like sexism, racism, transphobia.  Stigma is also multilevel; it exists across three levels.  At the most proximal level ‑‑ we're gonna kind of go proximal and work our way out.  At the individual level, we can think of stigma as existing as internalized stigma.  In other words, the adoption of stigma‑related beliefs.  An example of internalized stigma is a Black child believing that they are inherently inferior.  Now, a Black child isn't born having this belief.  They are taught this by interactions that they have with other people.  So that brings us to our next level, interpersonal stigma.  That is, stigma between people.  Often, we use terms like discrimination and identity‑based bullying to refer to this construct.  An example of this happening is a peer saying, "No homo."  Now, the frequency with which this slur is used is dependent on context or the society that the peer is in.  That leads us to our last level of stigma, that is structural stigma, which can be defined as community characteristics, like attitudes and laws or policies that inhibit the well‑being of stigmatized people.  An example of structural stigma is the dominant belief in a state that a fetus's life is more important than a pregnant person's.  

Now, very briefly I'm gonna tell you what research has shown so far.  Lots of research has shown that interpersonal and internalized stigma is associated with mental health inequities.  For example, higher levels of depression, anxiety, suicidality, et cetera, for groups of stigmatized identities, including LGBTQ youth.  There is a little less research on structural stigma, but it is a growing area of work.  And similarly, research on structural stigma shows that it's also associated with mental health inequities, so worse mental health problems and worse treatment outcomes for youth with stigmatized identities.   

So, in sum, stigma is a multilevel problem, and a multilevel problem needs a multilevel solution.  So that gets us to part two, multilevel interventions that address stigma.  So, to illustrate this piece, this type of research, I'm gonna talk about this specific example, and this multilevel intervention that I developed was focused on improving mental health care for transgender youth.  The transgender youth as a population I became really passionate about as a clinical psychologist in training.  So, I'm a cisgender person myself, and though I'm part of the queer community, I had very limited experience understanding transgender folks' needs and mental health care.  So, when I was a clinician, I had a lot of learning and skill development to do, and I learned through reading books, talking to my friends who identified as transgender and learning from my clients that ‑‑ my clients were experiencing internalized and interpersonal stigma in the community and that was often getting worse in mental health care.  So, they would start to access care and then get discriminated against even further in mental health care.  So, I realized that we really needed systems‑level change or multilevel change to address mental health services for transgender youth.  So that's how I got into multilevel intervention work.  

Before we dig into the nitty‑gritty of the study, I want to apply that multilevel framework that we just talked about to understanding mental health care with transgender youth.  So internalized stigma might manifest, for example, as a transgender woman believing that she is defective because of her gender.  And in mental health care, interpersonal stigma might look like discrimination from a provider.  So, for example, a therapist saying something like, "Are you sure you're transgender?  You look like a normal man to me."  And then structural stigma, we might think of it as existing in the clinic setting.  An example ‑‑ a few examples actually of how it might manifest are intake forms that only have binary options ‑‑ same with bathrooms ‑‑ or a culture of co‑workers and providers who generally endorse transphobic beliefs. 

So, I'm gonna tell you more about this intervention.  We're gonna start by thinking through how we can target each level.  So, when we think about internalized stigma, we're really thinking about internalized stigma at the client level.  And we can target this type of stigma through therapy, right, providing clients with the skills that they need to tackle that internalized stigma, just like Dr. Pachankis mentioned in his intervention work.  At the next level we're gonna target interpersonal stigma, and when it comes to mental health care, we might do that with a therapist.  So really trying to reduce instances of micro‑aggressions and give therapists the skills that they need to provide affirming care, and we'll often do that through training.  And lastly, when we think about the structural level ‑‑ in this case, a clinic level ‑‑ we'll target policy change, practice change, and changing the physical space.  

Okay.  So, in this study, several community members ‑‑ community stakeholders and groups were involved.  So, who created the multilevel intervention?  This work was orchestrated by my research team, the Affirm Lab, and we worked really closely with transgender and nonbinary youth as well as their parents to create the therapy.  We also worked with providers who had been working with transgender youth for decades and who were real experts in best practices, as well as providers who didn't know much and could tell us exactly what we needed to teach them.  Together, they helped us create the training and figure out what to do to change the clinic.  

Okay.  So, I'm gonna tell you what resulted from all of that work.  So at the therapy level, we created essentially a compilation of key principles and skills that any therapist can use to augment the treatment that they're already doing regardless of orientation, modality, et cetera.  And of course, this was according to the community, particularly clients and their parents, as well as empirical research and professionally endorsed best practices; for example, from the American Psychological Association.  And we packaged all of these principles and skills into something called "gender‑affirming psychotherapy."  More concretely, gender‑affirming psychotherapy includes 38 skills and 27 principles, and principles are simply key pieces of knowledge that guide practice.  To give you some examples, a skill might be to ask about gender during intake, so something relatively simple that everyone does at intake, and a key principle is understanding that family support is a key protective factor for transgender youth especially.  

So that's what the training looked like.  Let's move on to that second level, tackling therapist‑level stigma via training.  So, again, we worked with providers, and we created something called the gender‑affirming psychotherapy training.  And as I'm sure you all know, mental health providers are very busy and they have little time to sit down for a long training that covers all of those principles, all of those skills.  So, they asked for the training to be online.  They wanted it to be self‑paced.  They also wanted it to be really interactive and to provide some sort of incentive beyond the incentive, of course, of knowledge, acquiring new knowledge.  So, we did exactly that and the primary incentive that we included with the training is providing continuing education units.  

Now, importantly, we do a lot of ‑‑ there's a million training courses out there, right, on affirming practices, and it was really important that we make this a training intervention of sorts.  But what really makes training an intervention?  Well, what we did is we used behavioral science to design our training, in addition to community‑engaged methods.  And as you all know, any good NIH‑funded researcher wants to target mechanisms, wants to engage those mechanisms to change whatever outcome.  In this case, our primary outcome was changing therapists' behaviors.  So, we looked at the literature, identified some hypothesized mechanisms known to be associated with provider behavior change and targeted those.  So, for this study it was attitudes, confidence, and knowledge, and we used evidence‑based strategies to target each of these mechanisms.  So, examples include we had provider stories in the training to improve attitudes.  We had opportunities for practice activities to increase confidence, so rehearsal; and we also had engaging didactics to ensure knowledge acquisition.  

So that was the training.  Lastly, the third level, clinic‑level change in policy, practices, and space.  An important question that I had to ask myself several times throughout the study is how to change a clinic with a limited research study budget.  Most of this study was funded by an Early Career Award, which is an amazing mechanism, and it is modest in terms of research funds.  So, we had to be pretty creative, and what was key to creating change at the clinic level was community engagement.  So, we worked really closely, and we continue to work really closely with a particular multi‑clinic agency in Boston, and we met with providers weekly for years and we still have these meetings.  And we partnered with them to identify what they needed to change in their clinic to ensure that they could use gender‑affirming psychotherapy, and then we made those changes before the training happened.  So, we did things like we changed the electronic health record to be more inclusive, we changed intake forms.  And the agency really wanted everyone to be trained, because they suspected that true clinic‑level change would not happen unless everyone did it.  So, they helped convince leadership to mandate training.  

We were also pretty creative.  So, therapists asked us to pay them for their time in training.  We certainly could not afford that, and so instead we asked how long you need to take eight hours of training and we made itself‑paced so they could do it over a long period of time, and they asked for two months.  We also certainly didn't have the budget to make bathrooms more inclusive.  So instead, we provided didactics on how a provider could advocate for change or do something as simple as change the signage in a bathroom, which is a pretty low‑cost intervention for bathroom inclusivity. 

MARY ACRI:  Dr. Price, you have one minute remaining. 

MAGGI PRICE:  Okay, thank you.  

So, I did multilevel intervention work.  This is the final result.  So, we only have preliminary results at the moment.  We're collecting follow‑up data right now, but for our sample, therapists showed significant two‑month improvements in all the key mechanistic outcomes ‑‑ so attitudes, bias, knowledge, and confidence ‑‑ and we showed behavioral change, most importantly.  More concretely, the pilot clinic has since begun gender‑affirming groups for kids and parents.  

Thank you so much.  If you're interested in the training, it is available online at this URL.  And I'm passing it off to Dr. Rosales.

ROBERT ROSALES:  So hi, everyone.  I'm really excited today to be presenting for NIMH.  My name is Robert Rosales, and my pronouns are he/him and [indiscernible].  Today I'll be presenting on a topic I have been working on for a few years now.  Specifically, I'll tell you about a qualitative study I just completed.  It's a little bit more preliminary than the interventions that we've talked about here, but I think it'll be very informative, and I'm calling it ‑‑ you kind of forget about it ‑‑ Latinx and non‑Latinx White sexual minority drinker experiences with discrimination, affect, and drinking.  

As most probably already know, underaged drinking is a significant issue that can have serious negative effects on brain growth as well as mental health, like increasing depression and anxiety symptoms.  Research has shown that there is a reciprocal effect of alcohol on mental health among youth, where greater alcohol use can increase mental health issues and, inversely, some youth may use alcohol to help cope with mental health issues.  Alcohol use is the most widely used substance among teenagers, with NIAAA showing that 15% of teenagers reported drinking in the past month.  Meanwhile, Moderating the Future data shows that nearly 62% of youth report drinking one spiked [indiscernible].  We know from research that sexual minority youth are significantly more likely to use, be willing to use, and have earlier initiation of alcohol use than the general youth population.  Research has put the risk of alcohol use among sexual minority youth at nearly double the general youth population, with some variables.  One of the reasons proposed for this greater risk of alcohol use comes from the minority stress model, which says that sexual minority people may have worse outcomes because of the increased stress they face through being marginalized in the U.S.  

In addition, we are at a turning point right now in substance use among Latinx adolescents.  Prior national rates of alcohol use showed that Latinx adolescents reported lower alcohol use compared to their White counterparts on almost all measurements. 

However, the most recent Monitoring the Future data shows that those numbers have flipped.  Adolescents of color now report even greater alcohol use than their White counterparts.  The graphic created here on the right side shows the national rates of alcohol use, intoxication, and heavy drinking between LatinX and non‑LatinX White adolescents. 

As you can see with blue bar here, LatinX now exceed the number by White youth. 

With these two groups meeting greater risks for alcohol use, it's imperative that we understand the experiences of the LatinX sexual minority youth who may be facing stress from being marginalized for both their sexual and ethnic status, as well as many other potential marginalizations. 

In fact, Dr. Meyer created double jeopardy hypothesis to say that there may be a greater risk for mental health issues among sexual minority youth of color because of racism and heterosexism. 

I conducted a literature review on this topic and found that LatinX sexual minority youth overall reported greater substance use, including drinking frequency and heavy episodic drinking, than their heterosexual LatinX adolescent counterparts.  However, they reported lower substance use, including alcohol use, than the general sexual minority youth population. 

The literature presented only two risk factors, of which one was school‑based victimization but no protective factors.  So LatinX sexual minority youth are a unique group that may face various risks but also present with unique protective factors that can be leveraged in treatment.  Therefore, I conducted a qualitative interview with LatinX and non‑LatinX sexual minority youth to understand the similarities and differences but also to understand what should be targeted or leveraged in treatment. 

For these qualitative interviews I had two aims.  The first aim was to refine and adapt measures for an EMA study that I was going to do later on that we're actually working on now, which I won't talk much about in this presentation.  What I will talk about is our second aim, which was to explore the experiences of stress, substance use, and understand differences by ethnicity. 

In terms of the methods, I set out to recruit 20 15‑to‑19‑year‑old sexual minority youth who had drunk once in the last 30 days and experienced any racial or sexual discrimination in that time period.  I aimed to get about a 50/50 sample of LatinX and White youth to understand the differences in their experiences, and these are some of the flyers we used in the community and online in Spanish and in English. 

The entire interview was conducted over Zoom.  We gave an option for in‑person, but no one chose it ‑‑ I don't think I would choose it either ‑‑ and participants were asked to take some questions aloud and then answer open‑ended questions. 

I won't speak too much about the analytic plan because we don't have much time, but I will say that there were three coders who used thematic analysis to find similar themes in the conversations, and then my colleague Dr. Sarah Chavez at Brown University led this coding for me. 

In terms of the results, we ended up getting nearly 50/50 LatinX and White participants.  Most participants were assigned female at birth, were in college, and we able to get a diverse group of people from different gender identities. 

So, I'll talk about two themes from these (inaudible) just because of the limited amount of time. 

First, we saw differences in the reasons why people drank alcohol that were related to their ethnicity.  For example, a LatinX participant talked about how drinking looks different in Latin America.  They specifically said, "Well, sometimes when I'm in the Dominican Republic, the main reason I drink is because, well, everybody else is drinking." 

Meanwhile, most participants talked about drinking because they enjoyed it.  Almost everybody said, "I was going to a party" ‑‑ said something to the effect, "I was going to a party with friends on Saturday.  I was like, guys, let's drink together for a bit.  I have this one friend that we drink together with because we really enjoy it." 

We also saw differences in the reasons why people abstained from alcohol use sometimes.  For example, one 19‑year‑old LatinX woman ‑‑ and I'm using the term that they provided to us ‑‑ said that she decided not to use substances because of the potential for losing her student visa.  "I feel like there's an added level of stress with the idea of possibly losing your visa.  A lot of my friends go around smoking a lot of time and I'm, like, I could never.  I abide by federal law." 

This talk about fearing law came up often in the interviews with LatinX participants but not with White participants.  On the other side, a general reason why somebody would not drink in our study, a 15‑year‑old LatinX White nonbinary participant said, "Because I had a really good day that day, so, I don't know, I don't want 
to ‑‑ I guess, like, I don't need the alcohol nor want it, you know." 

So, a lot of participants said similar things, both LatinX and non‑LatinX White, that they did not drink just because they didn't feel like it in those days. 

Possibly more related to NIMH, sexual minority youth feels that they use substances to cope with stress and negative effects from racism and heterosexism.  I'd like to point you to alcohol to cope with stress comment here on the right side which we heard from a few participants. 

Specifically, this participant said, "It's like you kind of forget about it, but at the same time it kind of amplifies the thoughts.  Like if you do think about it, it just helped me get it off my mind." 

This is specific to LatinX participants that had said this, and they were pretty much saying that it either sometimes makes them feel better or sometimes amplifies the negative emotions that they get from experiencing racism or heterosexism. 

What does this all mean?  Well, social stress, specifically racism and heterosexism, happen to a lot of sexual minority youth and should be addressed in treatment. 

In addition, there are other unique cultural reasons why LatinX sexual minority youth may use alcohol.  In fact, there's some treatments that have been shown to address these stressors.  For example, I have one of the studies that we published that helped analyze data from a randomized control trial that showed that the culturally adapted motivational interview treatment developed by Christina Lee showed the ability to reduce alcohol use and mental health symptoms when compared to non‑adapted motivational interviewing.            The intervention aimed to address the social context of drinking and acculturation stresses that influence drinking behavior among LatinX adults heavy‑drinking adults. 

Meanwhile, a colleague of mine, Dr. David Zelaya, has a K23 to further adapt this intervention to LatinX sexual minority adults using an LGBTQ+ affirmative model of adaptation. 

However, from my interviews I found that the interventions need to be adapted to youth developmental stages.  

For example, the CAMI currently provides information about drunk driving with children in the car because of the high rates of drunk driving among LatinX adults.  This and other experiences like substance use due to dating will need to be adapted for adolescents because dating looks so different for adolescents as well.  So, there is potential to create an intervention that specifically works for LatinX sexual minority youth and addresses the needs that they have for interventions. 

Quickly, no study has no limitations.  So, first off, most of our participants are 18 to 19 years old.  In the future we would love to get participants who are much younger than us, 15 to 17, to understand their experiences and how that might be different.  We also can't generalize to a larger sexual minority youth population due to a small sample using qualitative data and we can't make any causal inferences. 

And then I also thank NIH for all their funding, recognize my lab members, my collaborators, and some of my mentors on my (inaudible).  Thank you. 

And from here I'll pass it off to Dr. Katie Edwards.  
 

KATIE EDWARDS:  Thank you.  Okay. 

Thank you all so much for the opportunity to speak here today.  I'm really grateful to talk about the prevention and treatment of intimate partner violence for sexual and gender minority youth. 

So, we know from a growing body of literature that sexual and gender minority youth experience intimate partner violence or teen dating violence at rates higher than heterosexual cisgender youth.  So, this is data from the CDC's YRBS, which I'm sure many of you are familiar with. 

Sexual minority youth experience significantly higher rates of past‑year teen dating violence victimization compared to heterosexual youth, and we see the rates especially high for bisexual youth. 

In our own work we have examined the rates of teen dating violence across the number of different types of perpetrations and victimization.  In a study of a little over 300 sexual and gender minority youth, we've found that nearly half reported past three months' perpetration, and over half reported experiences of teen dating violence victimization in the past three months. 

And this is a largely diverse sample.  Over half, queer youth of color, over half were trans and gender diverse, and the majority of the sample, or a little over half, was plurisexual. 

Although there's less research on intimate partner violence, there's a growing body of literature suggesting that youth of color, particularly Black, Indigenous, and multiracial queer youth, may be at increased risk compared to other racial and ethnic groups, and there's also some research showing that trans and gender diverse youth experience higher rates of intimate partner violence than cisgender sexual minority youth.  And this is a really important consideration for future research to really think more about this from an intersectional framework. 

Similar to heterosexual cisgender youth, we know there's numerous short‑ and long‑term negative outcomes associated with intimate partner violence. 

Some of our work has also highlighted that sexual and gender minority youth survivors actually have worse outcomes than heterosexual cisgender youth who have experienced intimate partner violence stemming from minority stressors, which I'm going to talk about here in a minute. 

So, again, because of these high rates, because of the numerous short‑ and long‑term deleterious outcomes, primary prevention of teen dating violence is really, really important.  So, when we're thinking about prevention, we think about risk and protective factors across the social ecological model.  And we know that there are what we call universal risk and protective factors that appear to be relevant to all youth and experiences of dating violence.  So, for example, alcohol use across populations is a risk factor for dating violence or intimate partner violence, whereas emotion regulation is a protective factor. 

We also know that sexual and gender minority youth have population‑specific risk and protective factors for intimate partner violence, and this really comes from theories of minority stress and resiliency. 

So, what we know is that internalized homophobia, biphobia, transphobia, as well as identity concealment, those are risk factors, and those stem from larger systems of oppression and more distal stressors, including identity‑based victimization. 

A protective factor for IPV that we have seen in some of our work is LGBTQ+ sense of community. 

So, what do we know about prevention of IPV?  We've learned more about rates, there's more research on risk and protective factors, but we really know very little about how we prevent intimate partner violence amongst sexual and gender minority youth. 

What we do know is that universal prevention programs either don't work or we don't know if they work.  So, when you see researchers doing subgroup analyses or moderation analyses looking at SOGI status as a function of program outcomes, either that's not happening, or the few studies that have, with the exception of one, finding that the program does not work as well for sexual and gender minority youth. 

Why is this the case?  Existing universal primary prevention programs for IPV have been criticized for being heteronormative, lacking representation and relevance to sexual and gender minority youths' lived experiences, and not being rooted in theories of minority stress and resiliency, so really trying to build upon the existing literature. 

We have a number of different projects right now funded to really try to understand what types of initiatives work to help reduce intimate partner violence and related issues such as problem drinking, mental health, so really trying to de‑silo prevention, and also to promote more positive youth development.  So, we have projects that are focusing on the role of mentors, some other projects focusing on the role of caregivers and families. 

And also, a program that I'm going to just highlight some findings really quickly, Promoting Resilient Youth with Strong Hearts and Minds, PRYSHM, which was named by our queer youth advisory board, and this is an online program to prevent intimate partner violence and alcohol use.  So, I'm going to just highlight this one right now since it's the one that's furthest along. 

So PRYSHM is an online group‑facilitated program to prevent alcohol use and teen dating violence among sexual and gender minority youth aged 15 to 18 who are also dating.  It's nine 45‑minute sessions targeting risk and protective factors for both intimate partner violence and alcohol use.  It's delivered online to sexual and gender minority youth across the U.S.  We had a waiver of guardian consent, and it's live‑facilitated on Zoom by two sexual and gender minority adults, two groups of about 10 to 12 youth. 

There's a number of intervention components that can really be kind of bucketed into three.  First is minority stress and positive identity development components and then teen dating, violence, and alcohol use prevention components, which are more universal approaches, but we really, really deeply adapted these to be relevant in the lives of queer youth; a number of intermediary outcomes, with our ultimate outcomes being to decrease teen dating violence and alcohol use. 

In terms of developing this, this is participatory research like most of the other work in my lab, extensive literature reviews, but really, really work closely with sexual and gender minority or queer youth advisory board of youth across the U.S. who really, really co‑wrote this program with us ‑‑ which was a really beautiful experience ‑‑ expert review, open pilot trial, and pilot RCT. 

The pilot RCT, we had 304 youth 15 to 18.  This came from the ‑‑ some of the data I showed you earlier.  We recruited largely through social media, boosted ads, we screened for eligibility and then fraudulent responders, which was in the thousands, baseline surveys and randomized to condition, immediate post‑test and a three‑month follow‑up. 

What we found is that relative to the wait list control conditions, participants in the PRYSHM condition had reduced alcohol use in teen dating violence, perpetration and victimization, as well as negative alcohol consequences.  And these were at the three‑month follow‑up. 

Participants in the PRYSHM condition had increased sense of LGBTQ+ community, sexual communication, self‑efficacy and accurate perceptions of alcohol use norms.  So essentially what that latter finding means is that perceptions of other queer youth drinking, that those perceptions of the frequency of that went down with the intervention. 

And our social norms data.  We collected social norms data prior to this study, again, so that we could really root everything, social norms scenarios, everything, in queer youth lived experiences. 

Some additional findings.  The program worked equally well for sexual and gender minority youth of color, high fidelity, and we collected a lot of process data, exit interviews, post‑session surveys, and it was found to be acceptable and perceived by youth as impactful. 

One youth said, "I think you might have had this effect for me because I was able to be myself and everybody else and just be my, like, most authentic version without facing judgment or criticism." 

Another youth said, "They" ‑‑ "they" are meaning the queer adults who taught the program ‑‑ "They made it to adulthood and they're thriving with their job, their partner, and I'm like, oh, yeah, they're okay, they're perfectly fine.  Like, this is something to look forward to." 

So, before I wrap up, I'm going to just do a quick comment more on kind of the intervention.  We talked a lot about prevention of intimate partner violence among sexual and gender minority youth, and I want to comment a little on the response piece. 

We know that sexual minority youth have unique barriers to help‑seeking and disclosure.  What we have found in our work is that they fear being outed.  They're worried about the responses they may get.  They're also worried about further stigmatizing a community that is already highly, highly stigmatized and facing a lot of hate and discrimination. 

Sexual and gender minority youth are also more likely to disclose to informal supports, which is consistent with the broader literature with other populations as well, so much more likely to tell a friend, for example, as opposed to, like, law enforcement or a doctor or psychologist. 

And what we know from our research is that it's so critical to respond in affirming, trauma‑informed and supportive ways, that those positive responses really, really help promote healing and recovery and, of course, needing trainings for these types of initiatives as well. 

So, in terms of final thoughts, yes, there are high rates and negative consequences of intimate partner violence, but prevention is possible.  We see that in our work.  Prevention and treatment efforts should be rooted in theories of minority stress and resiliency, use anti‑oppressive approaches, center the voices of sexual and gender minority youth in their leadership and program development and evaluation, focus on positive identity development, including critical consciousness and skill acquisition, moving beyond individual‑only approaches, and using innovative strategies to reach sexual and gender minority youth who are not out and in rural, remote areas of the country where they may be limited to no affirming prevention or intervention services. 

And, finally, we must continue to focus our efforts on dismantling systems of oppression that perpetuate high rates of IPV and other deleterious outcomes among sexual and gender minority youth. 

Thank you again so much for your time and for your attention. 

And I will now turn it over to our next speaker, Dr. Schleider.  
 

JESSICA SCHLEIDER:  Thank you so much.  I'm going to share my screen and we'll get started. 

So, I'm really excited to be able to share with you all today at this really important event, ‑‑ I'm truly thrilled with this taking place ‑‑ some of our lab's work on single‑session interventions to promote mental health specifically and sexual and gender minority youth. 

We've already discussed at length the really upsetting disparities that sexual and gender minority youth face in both rates of mental health difficulties and access to care, and reckoning with that real disparity is going to require us to reckon with really difficult realities about the mental health system we have at this point. 

The first is the vast majority of sexual and gender minority youth with mental health needs are not going to access any form of formal support.

The second reality is that the supports that do exist are often structurally incompatible or purely inaccessible with how and where sexual and gender minority youth want to engage with care or, if they are accessible, often they're insufficiently affirming to meet the needs that sexual and gender minority youth are going to have in the course of their mental health treatment, making them less likely to be effective. 

The third reality is that despite the fact that we've dedicated so much time and effort over the years to creating interventions that are, while evidence‑based, multi‑session and take quite a while for people to engage with and are quite high intensity, we know from national insurance reimbursement data that the most common number of interactions that any individual is likely to have with the mental health care system is one.  So, we've not done the best job at aligning how people are able to engage with treatment on a regular basis with the design of our interventions. 

Of course, it would be ideal for everyone to be able to access full‑length interventions, but that's going to require structural change that is unlikely to happen in the short term, so we need some solutions in the meantime. 

One possible solution to this problem is by expanding the workforce in mental health, but unfortunately this solution alone is not going to do the trick because provider shortages are just too severe to fix access to care problems through just workforce expansion. 

This is a map from HRSA data showing in medium and dark blue the mental health provider shortage areas in the United States.  It's not an error.  The entire map really is medium or dark blue, and this isn't even accounting for the number of providers who are trained to serve the unique needs of SGM youth who are going to be providing affirmative practices.  So, we're really facing an extreme situation that's going to require creative solutions right now.  And the solution that our lab tries to investigate and understand how it can be applied to this population are single‑session interventions. 

And I'd like to just share a quick definition of what SSIs are before we continue. 

What I mean by a single‑session intervention is a specific structured program that is intentionally ‑‑ and that's key ‑‑ involves just one visit or encounter with a clinic, program, or provider.  I say "intentionally" because showing up for an assessment and not being able to continue with treatment wouldn't be considered an SSI.  Rather, there's a shared understanding between the provider and the recipient of the intervention that we're going to make the most of the time we have now whether or not we're able to continue together our work. 

Single‑session interventions can be accessed on one or many occasions.  There's no assumption that one session is going to solve everyone's problems.  This is a one‑at‑a‑time mode of support whereby each encounter is optimized for the likelihood of change rather than a one‑and‑done form of support. 

SSIs can be self‑guided, or human facilitated and can exist within or outside of formal healthcare settings, making them a unique opportunity to scale. 

But in all cases, SSIs drop this often false assumption that people will always be able to return for session 2 while instill the belief that meaningful change is possible at any moment, even if that moment is brief, and this aligns with how when we speak to youth in our qual study, we learn that youth want to access care which is as‑needed when and where needs arise in a fluid manner.    

And this isn't just a nice theoretical idea.  Decades of research actually tell us that SSIs do help.  This is the first time I'm presenting this slide.  
So, we're just getting through right now an umbrella review of all the systematic reviews of single‑session interventions that have ever been conducted, and there are 24 of those in total.  And what we've found in this meta review is that, overall, SSI benefits reported in 20 out of 24 reviews were significant across both mental health and service use outcomes in youth and adults. 

Moreover, when we directly compared single‑session intervention meta‑analytical effects to multi‑session therapy, multi‑sessions only outperformed single‑session interventions in one of four cases. 

This is a forest plot of all the meta‑analytic estimates of single‑session intervention effects across multiple problem types with an overall effect size of about .25, which is small, but at the population level, that has an opportunity to make a real dent. 

I want to emphasize that SSIs are not going to ever replace other forms of multilevel mental health treatment that we already have and that we're already creating, but I do think these interventions can bridge otherwise unfillable gaps in mental health care ecosystems, especially for SGM youth. 

And the reason for that is as follows.  We've been doing research on this topic for several years now, almost 10 years for me, and our evidence‑based interventions through NIH‑funded and other trials and pragmatic evaluations have actually already reached more than 30,000 sexual and gender minority youth. 

The reason for that is, one, because we co‑design these interventions with youth least likely to access care, which includes SGM youth, and we set up our interventions so that anyone with an internet connection can access them whether or not they have parental involvement in their mental health care.  That is, our SSIs are accessible as needed.  And I'm happy to talk more about that with anyone who's interested in securing consent waivers.  But securing those waivers from the IRB for both anonymous evaluations and non‑anonymous evaluations has led to samples that are majority sexual and gender minority across almost all of our trials. 

We have a variety of interventions that we've built.  What they have in common is they all target a short ‑‑ a modifiable short‑term belief or behavior, whether that's autonomy, hope, resource uptake or internalized stigma, in the case of SGM youth, whereby short‑term improvements can spur meaningful improvements and longer‑term change. 

In our RCTs we see significant clinical outcomes across three‑ to nine‑month follow‑up periods which is consistent across the rest of the literature. 

We've shown in our intervention trials of non‑adaptive single‑session interventions for youth mental health problems focusing on depression and anxiety that actually the unadapted SSIs targeting things like behavioral activation or the idea that change is possible because of how things work, they're equally acceptable and effective in cisgender and transgender youth and sexual minority youth and heterosexual youth across multiple trials, including thousands of teens. 

However, we were really fortunate to get a grant ‑‑ myself and my collaborator Catherine Fox at the University of Denver ‑‑ to co‑design and adapt some of our interventions for SGM youth specifically since that was so disproportionately who was accessing our interventions, and the feedback they gave us made it really clear that they want interventions, even if these are effective at reducing depression, that can validate the stigmas and the oppression they experience and perceive and to help them process that experience in the world that's unique to having specific marginalized identities. 

And, of course, this makes perfect sense because as we've all been talking about over the past day and a half, minority stressors at multiple levels directly impact the experiences of mental health that trans and sexual minority youth experience, and, as a result, it's important to have brief interventions that not only target general psychological processes, but they can also target minority stress‑specific reactions like to internalized stigma. 

And that is why we worked with these young people to co‑design Project RISE, a digital single‑session online self‑guided intervention that takes about 20 minutes that's designed to help teach about minority stress theory to teens and help them make an action plan to cope with minority stress and identify it for when it comes up in their life even though it's unfair and they shouldn't have to, so giving them tools to cope successfully in an unfair world. 

We ran a pilot RCT with 538 adolescents, all recruited by Instagram, across 43 states.  We obtained an IRB waiver for parental consent requirement to ensure equitable access.  These are just some stats on the demographics, which I won't run through.  We had a decently diverse sample, which we were excited about. 

Project RISE includes psychoeducation, stories, and interactive exercises to help people understand how systems of privilege and oppression work across multiple intersecting identities and what minority stress is and how to spot it in your everyday life.  Teens can select from various stories that we built out with our teen advisory board to understand how people have coped with minority stress in their own life.  And then teens can create a personalized minority stress coping card, guided by John Pachankis' LGBQ affirmative CBT model, to help them cope with minority stressors when and where they come up in their own life. 

In this pilot RCT, which included LGBTQ+ youth ages 13 to 17, we found that 90% of youth in the RISE condition who began the intervention completed it.  If you do digital mental health research, this is a remarkably high completion rate. 

Youth rated both the active and the control conditions as helpful and acceptable.  For reference, we didn't feel good about randomizing people to a no treatment control, so we offered a one‑page explainer on minority stress theory if they were randomized to that condition.  So, they liked learning about minority stress theory regardless of the condition, but what the active intervention condition was, was all of the interactive elements that we embedded into the single‑session online program. 

Post‑SSI using RISE showed greater decreases in internalized stigma, increases in identity pride and declines in self‑hatred, and those internalized stigma improvements persisted two weeks later. 

Folks from our lab have been leading the way in understanding for whom are these interventions effective, but we've actually found ‑‑ and this is work recently led by Ian Sotomayor, an incoming Ph.D. student in my lab ‑‑ Project RISE is equally acceptable and effective for White SGM youth and racially and ethnically minoritized SGM youth, and work led by Ya‑Wen Chang and Ian and others in our lab found that Project RISE showed no differential effects as a function of internalized or structural stigma that youth were facing across the country, which is promising because this is an intervention that can be accessed by youth regardless of their circumstances. 

Where we're going next with this work involves implementation, so implementing within and outside healthcare systems to more sustainably ensure access to these kinds of supports and also addressing structural access barriers that may uniquely affect SGM youth like parent consent policies and structural stigma. 

Our interventions are all publicly available, including Project RISE, so if you'd like to go through it yourself or use it, please feel free to go to our Project YES, Youth Empowerment and Support, website and try it out.  We've tested Project YES as a platform in a whole bunch of different partnerships at this point both within and outside the United States and found that it's acceptable and effective for youth in a variety of circumstances. 

And I'll just skip to the end because I'm coming up on my time, but I just want to highlight an important element of all of this, which is that no matter how scaleable we create interventions to be, it will not matter if structural factors are getting in the way of SGM youth accessing them. 

In our mixed‑methods work with youth who participated in our trials, we have asked them what gets in the way of mental health care if you haven't been able to access it.  And 32 to 42% of teens who we've asked this question identify parents as the primary barrier, with especially high rates of that barrier among SGM youth.  This is because SGM youth don't feel they can necessarily go to their parents if they live in unaffirming households, or they don't have trusted adults that they can trust with the issues that they're experiencing. 

So I'm really excited that right now, through grants from the NIH Office of Science Policy and through Hopelab, we're actually collaborating with teens, primarily SGM teens, to understand teens' use on parental consent policies and to work with them to build a dashboard for therapist teams and administrators to use to hopefully streamline efforts to advocate for policy change to allow youth across the U.S. to self‑refer to mental health care given that the laws are very inconsistent and spotty across the country at present. 

Thank you so much, and I really appreciate the opportunity to share this today. 

Oh, and I'll introduce our next speaker, Dr. Willging.  
 

CATHLEEN WILLGING:  Can everybody see my screen? 

So, my name is Cathleen Willging.  I am from the Pacific Institute for Research and Evaluation in Albuquerque, New Mexico, and ‑‑ come on, video. 

Okay.  Sorry about that. 

And today I'm going to talk to you about one of my favorite implementation science studies which centers on making schools safer and more supportive of LGBTQ youth. 

Okay.  Why aren't you advancing? 

Sorry, I don't know why it's not advancing.  There had to be at least one presentation. 

Okay.  I'm going to ‑‑ this is embarrassing.  I'm going to pause my share and start all over again.  Okay.  
 

EVENT PRODUCER:  Hi.  Would you like me to share your slides with you?  You can just tell me to advance.  
 

CATHLEEN WILLGING:  Let's do that.  
 

EVENT PRODUCER:  Okay.  
 

CATHLEEN WILLGING:  I have to stop the share first.  
 

EVENT PRODUCER:  No, it's okay.  I got it. 

CATHLEEN WILLGING:  Okay.  Now I can't find you on my screen.  Hold on. 

All right.  There we go. 

So today we're going to talk about one of my favorite implementation science studies. 

Next slide. 

So, as we all know, there are things that schools can do to reduce social marginalization among LGBTQ youth to enhance their well‑being.  Six evidence‑informed practices are establishing safe spaces like GSAs, prohibiting harassment and bullying, implementing inclusive health education, staff development, and enabling access to medical and behavioral health providers with experience serving LGBTQ youth. 

Very few schools nationwide implement all six practices.  In 2018 almost 21% of schools in our study state of New Mexico implemented all six. 

Next slide. 

Our statewide community engaged study is called Reducing LGBTQ Adolescent Suicide, and it aims to support schools in adopting the full suite of practices to prevent adverse outcomes among LGBTQ high schoolers using implementation science frameworks and methods. 

The setting is New Mexico, a rural state where LatinX and Indigenous people compromise most residents.  Here almost 15% of high schoolers identify as sexual minorities and a little over 3% as gender minorities. 

We randomized 42 high schools in implementation and delayed implementation conditions.  Schools in the first condition used the dynamic adaptation process, which is a multifaceted implementation strategy with discrete components like assessment, mobilizing champions, coaching and monitoring, and for those who might be new to implementation science, implementing strategies are methods to get folks to do things they might not do on their own. 

Next slide. 

The two research questions I'll address today are how the dynamic adaptation process was applied to address health disparities for LGBTQ youth by implementing the six evidence‑informed practices and how successful were school using this process in achieving adoption outcomes. 

Next slide. 

To answer the questions, I'll draw from several qualitative data sources, including semi‑structured interviews and focus groups conducted annually with administrators and staff in implementation condition schools and monthly periodic reflections with our implementation coaches and technical assistance experts. 

We also used mixed‑method structured collaborative assessments to document practice implementation and fidelity at baseline and over time.  These assessments provided data for action planning in the dynamic adaptation process. 

Next slide. 

Guided by the exploration, preparation, implementation, sustainment framework, the dynamic adaptation process calls for convening implementation resource teams in schools in the preparation phase.  In the implementation phase it allows for intentionally adapting practices rather than doing so spontaneously without consideration of context and fidelity.  And this diagram depicts the process's iterative nature where planning leads to action which leads to assessing outcomes, more planning and action, and every step of the way entails reviewing data and feedback. 

Next slide. 

A community academic partnership that took root during the exploration phase supported the use of the dynamic adaptation process.  It included state officials, school professionals, and local LGBTQ organizations, and these partners and our implementation coaches made training and technical assistance possible for schools and consulted with the implementation resource teams to set up GSAs, establish supportive policies, and respond to crisis events.  And while this image might suggest a top‑down hierarchy, the structure was actually a lot more organic in its configuration. 

Next slide. 

And so, a quick overview of results.  So, assessment data used in an action planning included YRBS findings and qualitative data from the academic partners.  In the exploration phase, we conducted readiness interviews with school personnel to identify factors potentially impacting future implementation of the six practices.  These and other data were then shared with the team for planning purposes. 

First, these data clarify the influence of political climates and local contexts on a school community's ability or motivation to support LGBTQ students better. 

Second, the data pointed to deficits in knowledge in access to training on LGBTQ student needs. 

Finally, the data brought attention to pragmatic concerns like time, workload and turnover to the fore.  And I should also mention that there was a very powerful narrative of treating all students the same that many, particularly administrators, offered as explanations for how their schools dealt with LGBTQ students. 

And so, these findings confirmed our choice of the dynamic adaptation process for supporting implementation. 

Each factor is something that the process addresses:  Responsiveness and adaptiveness to context, integrated training both in implementation and topic‑specific coaching the problem solved, identification of champions to push back on dominant narratives that can thwart implementation efforts, as well as a flexible dynamic team‑based approach to alleviating pressure on any one individual. 

Next slide. 

Underpinning the dynamic adaptation process were the implementation resource teams of school nurses, counselors, social workers, teachers, health educators, librarians, other school personal and sometimes students and parents based on what the schools would allow. 

The teams were charged with completing the structured collaborative assessments, taking part in implementation coaching and training to build capacity and confidence in action planning in designing and carrying out implementation strategies and facilitating buy‑in and collaboration amongst school professionals.  The camaraderie that developed reduced isolation and stigma concerns among members, and this was decisive in schools in socially conservative communities where team members risked being gossiped about and ostracized but found support from one another. 

Next slide. 

Given the dynamic nature of our overarching implementation strategy, the makeup of teams would shift over time to tackle emergent needs.  And here's an example of one school team over a couple of years.  The school nurse was its first lead, pulling in a small group of folks to meet.  The principal was passively supportive but not involved with the team. 

For the first year the team created posters with resource information for students.  You can see here how the team evolved by the implementation phase's third year.  Here a social worker took on the lead position and more folks joined, including other social workers, counselors, a health teacher, a local health clinic representative and school security personnel. 

Critically, the principal became actively engaged, reserving meeting spaces, asking the team to organize staff training and fielding pushback from parents and other school community members.  The team also set up subcommittees to accomplish tasks like creating a resource website, integrating LGBTQ inclusive materials and health education classes and doing a student needs assessment to guide their work.  And this was one of our strongest teams, achieving fidelity for four practices and making a lot of progress on the others.  And even during the pandemic, this team sustained most of their work. 

Next slide. 

During the implementation phase, the teams and their coaches did the structured collaborative assessment, which included a checklist outlining the elements of each practice, and this work was instrumental in action planning.  If a school had an element, teams checked yes, but not without the coach prompting discussion about what it really looked like and if it fulfilled the function delineated in the assessment or needed a lot of work. 

If an element was absent, it was flagged as no for consideration during action planning.  If elements were unknown, the team would talk with others in the school community and determine their status, and these conversations really helped the team identify who else they might want to include in the team because of their specialized expertise.  And the give‑and‑take that transpired during this assessment socialized team members into implementation efforts, allowing members to get a clearer picture of what was going on in their schools, and it also prompted them to challenge beliefs that sufficient support was already in place and that some practices were unnecessary or impossible. 

For example, many teams in rural or smaller communities initially wrote off GSAs as something they cannot get going, yet through discussions with team members, students, coaches and local organizations, most schools had GSAs by the end of the implementation phase.  The teams really could not create useful action plans without the assessments. 

Next slide.  
 

MARY ACRI:  Dr. Willging, you have one minute left.  
 

CATHLEEN WILLGING:  Are you kidding me?  I had this all ‑‑ okay.  
 

MARY ACRI:  I'm sorry.  
 

CATHLEEN WILLGING:  Now, let's just say community academic partnership and the coaching support really helped broaden the sense of community within the teams, plugged the teams into local organizations with expertise in the practices.  We were able to facilitate training of over 2,000 people because of the structure with the community academic partnership in practices related to suicide prevention and in LGBTQ and trans 101.  We really were able to get people to think differently and critically about school communities.  We were able to nurture greater buy‑in and implementation of leadership and alignment in the schools.  And I'm just going to say we were also able to adapt practices in a very thoughtful way and make changes to school environments. 

Next slide.  I just want to jump to the punch line. 

So how did everything work out in our studies?  Start schools had about 43% of the practice elements outlined in the structured collaborative assessment in place.  By the end of their period they had, on average, implemented roughly 80% of the practice elements, and these were statistically significant findings, meaning that the schools really did make major strides in increasingly the adoption of the entire suite of practices. 

Next slide. 

Just really quickly, I think the dynamic adaptation process has a lot of value from not just impacting LGBTQ health equity but for also enabling other innovations that can help other populations that are impacted by health disparities.  We're now using this process to help school‑based health centers implement structurally competent practices to improve well‑being for LGBTQ youth. 

And I apologize for taking too much time, and I'd like to hand it over to Dr. Dorothy Espelage.  
We thank our partners too.  
 

DOROTHY ESPELAGE:  Great.  Thank you very much. 

Well, I'm Dorothy Espelage.  As I said, I'm here at UNC‑Chapel Hill, and I use pronouns she/her.  I'm quite honored to reflect and discuss these six papers. 

I think it's important to understand where I'm coming from.  For 30 years I've studied bullying and sexual violence in school‑based settings largely, K‑12 and, more recently, higher education.  About 20 years ago (inaudible) who's a professor at Boston College, we started to interview young middle schoolers, and that's when we started to look at homophobia and developed a measure for this. 

You can imagine in the 30 years, at least the last 20 years specifically, trying to do this work in schools has become an ebbs and flows challenge.  So much like the mom that said that she's feeling hopeful, I'm feeling hopeful given the structural stigma that's showing up all over the place in many states. 

So, I needed that hope as I continue to figure out ways in which to support gender and sexual minority youth, especially in the context that Dr. Edwards talked about where there's either no services or there's not affirming families, and so it's helpful to see that things are happening. 

So, I have cited much of ‑‑ many of your work, and I'm just glad that there are future generations of folks that are really getting in there and NIH is funding this work.  I think across the papers we see very clear, strong, rigorous program development intervention development, very systematic, not just to focus on the RCTs but really looking at implementation science, which many of us live in that implementation science space. 

As a school‑based research person that did RCTs for many, many years, some of which failed because of implementation, I love that we're actually talking about who it is that this works for in which context.  So (inaudible) work of adapting the CBT treatment manual focusing on minority stress ‑‑ and I have a few questions that if we don't have questions, that I'll pick your brain a little bit on just the work that you've done. 

But, again, this just shows ‑‑ answering that question, too, of where you meet and how you implement this program in community centers that look very different in culture and context is great. 

Yay to Dr. Price.  Loved seeing multilevel stigma framework.  I'd love to see what you might propose ‑‑ and maybe have written in this space as well ‑‑ of moving from that clinical work to the schools, because a lot of what I was seeing ‑‑ I'm like, this is what they do in schools, and what teachers say to gender, and sexual minority youth is unbelievable.  And, of course, we have the structural stigma states like Florida and my state, North Carolina, where you can't say gay, you can't even put your pronouns out there; otherwise, they might call home and out you.  How can we do this work?  So just brilliant, looking at the multilevel stigma framework.  I will go and read more of your work. 

Dr. Rosales, yes, understudied population.  We were just writing revise and resubmit, and I ran across some of your work that we'll now be citing to look at those ‑‑ intersectionality of LatinX and non‑LatinX sexual minority and the drinking behavior and minority stress.  It's brilliant, brilliant, and shows the complexity for the reasons for using substances and for not using substances.  Right?  And so that's where the qualitative work really helps inform a lot of the quantitative work. 

It also points out that we have got to continue ‑‑ NIH, CDC ‑‑ to track these trends because you showed that increase, right, in that if we had not been monitoring the future, we would not have seen that uptake in the LatinX population.  And it would be important, as the structural stigma increases in so many of our states and in our school buildings, to see how that tracks over time. 

I'm a groupie of Dr. Edwards, and so when she came into the field, I was very happy to know that when I do leave this career, that there's going to be folks like Dr. Edwards and all of you on this panel here to do this work, doing some brilliant work, of course, really always community engaged.  Her training was that way.  I know that.  Always youth voice, going into some really, I will say, places of opportunity ‑‑ don't like to say challenges because challenges are always successes for Dr. Edwards ‑‑ but also recognizing that the disclosure ‑‑ and I hope that you'll continue to publish in this area of disclosing of IPV and teen dating violence and sexual violence ‑‑ is really, really a challenge, and we need to continue to look at who do they disclose to, when do they disclose, under what context.  That disclosure literature is limited beyond basic help‑seeking behaviors, so how can we support them. 

The single‑session interventions made me think, Dr. Schleider, of the great psychotherapy debate back in the day ‑‑ I'm now totally dating myself when I say Bruce Wampold in the great psychotherapy debate, right?  There was this idea that you needed these long sessions, you know, and then you have Carol Dweck and David Yeager in our space of bullying prevention really showing that longer isn't always better. 

So, I'm so excited to see your work, and I know that you're out there in the popular press, too, getting the word out about these single sessions, so that's great.  I appreciated that it's not the one‑and‑done, because I think people can construe it that way.  That was wonderful. 

Please publish what both of you and Dr. Edwards reminded us ‐‐ and this is hopeful ‑‑ this waiver of parent consent and the waiver of guardian consent, please publish.  Publish that.  Get it out to us ‑‑ it sounds like you're working with the youth to figure out this ‑‑ because the IRBs are pushing back against that in many of the states, we're in.  It's just not going to be possible in my state of North Carolina. 

Which, saying that, the other part of hope that I have is that I believe that ‑‑ I mean, it depends on the administration and what's happened next, but if we look at the number of bills that the ACLU is tracking ‑‑ I think it's 550 right now ‑‑ that are anti‑gay, anti‑LGBTQ, all kinds of anti, I think we're going to see a continual increase in doing this work and reaching youth at least within school‑based settings. 

And so, I'm now hopeful that there's Florida adolescents that actually can get online and get single session or go through some of these technology‑based applications.  I think that's what's going to happen. 

I think it also highlights how it is that social media is really helping gender and sexual minority youth.  I hope you guys continue to publish that and get the narrative out there that it's not all bad in these spaces.  And then, certainly, as on the task force of the American Psychological Association advising the Surgeon General on the legislation that would get rid of some these social media contexts that are protective, I'm hopeful that we can highlight some of this work. 

And then the last study, Dr. Willging, on implementation science just reminded me so much of so many of my challenges in school‑based work.  I really would like to have a cup of coffee and figure out how you got so many high schools on board during this climate, so that's great.  It looks like ‑‑ but it also just shows this is ‑‑ implementation science is an iterative process that takes a lot of commitment, and I loved how you showed how the nurse was at the center and the principal was, you know, kind of not in it, and then over those three years it built.  Very, very powerful. 

So taken together, I think we see really strategic, rigorous research that's systematic.  Strong theoretical frameworks.  Loved all the theories of change and the logical models.  All very important. 

Thinking about the proximal to the distal, I think that we need to continue to think about how we're going to change some of the structural stigma.  Many of the papers are still focused on that individual level, then moving out to those layers of the (inaudible) I think is important.  We were just finishing a paper that showed just even policies at a state level and a district level, municipalities that are queer‑friendly actually right down to the teachers that are LGBTQ in our national sample are less likely to be bullied and harassed or experience violence in the classroom, but also the kids report less youth violence as well.  So, I think we need to continue to do some of that work that Mark Hatzenbuehler has done over the years to show that policies do not solve the problems, but they're certainly a first step in understanding how it is that even who we elect at a district level for superintendents can have an impact on gender and sexual minority youth as well. 

I could go on and on, but I know that we have questions.  So, thank you.  It was quite an honor to meet many of you and to look at your work, and I'll continue to follow your work.  And congratulations on all of the great outcomes.  
 

MARY ACRI:  Wonderful.  Thank you so much for an enriching set of presentations. 

There's a couple of questions that are not specific to any individual, so would love to have multiple perspectives on this. 

First is, in your work developing gender‑affirming interventions or prevention programs, have you experienced any barriers related to coverage of services by private or public health insurance?  
 

JESSICA SCHLEIDER:  I'm happy to address that. 

Speaking specifically to more atypical models like single‑session approaches, there are no insurance infrastructures to reimburse for these interventions.  It's largely because ‑‑ and I think this is an issue that disproportionately will end up affecting SGM youth and other groups with limited access to care ‑‑ without that initial intake session with a therapist where somebody receives a diagnosis, there's not much insurance can do.  And if you take into account that that first session is often the last session, that's a huge, missed opportunity. 

So, what we've done so far is work with a couple of state mental health agencies to figure out opportunities to get waivers for Medicaid reimbursement avenues to single‑session therapies to do pilot studies to show cost effectiveness.  But a state‑by‑state solution with the pilot program in every state across five different Medicaid‑funded clinics is going to be quite a haul. 

So, I do think collaborating with youth to figure out what kinds of pathways are going to be necessary to allow them to access support easily, seamlessly and as and when they need it is going to be crucial because otherwise it's unlikely that any of these programs are going to stick.  
 

MAGGI PRICE:  I can add that in the training intervention, we have a whole module on helping transgender youth access services, including really concrete resources and steps to take and for, you know, how to provide a supportive letter, what needs to be included in that letter, giving letter templates, walking people through the process of providing referrals for gender‑affirming services when available. 

So that is ‑‑ those measures can be used to overcome barriers to care in places where you can access gender‑affirming medical services, which are, of course, fewer and fewer. 

That's all I've got.  
 

JOHN PACHANKIS:  I think LGBTQ community centers are doing amazing work.  They're also really worth studying, and there's increasing focus on studying them.  But they are particularly likely to offer services to people who are under‑ or uninsured, people who otherwise wouldn't be able to receive care. 

And how they do that is probably worth careful study, including probably ‑‑ well, we know they provide a lot of support groups, a lot of peer counseling.  They're really filling a void; not just a void of insurance, but the historical roles of those centers are to fill a void in the face of government neglect during the Gay Rights Movement, the AIDS epidemic, et cetera. 

And how they are now really filling the void of mental health care, including adult care for people who otherwise wouldn't be able to get them, is not only worth studying but also worth a lot of credit because these are people on the front lines who are ‑‑ who are doing what much larger systems with many more resources should probably be doing for the whole population, including LGBTQ youth and others.  
 

MARY ACRI:  Excellent. 

Something that, Dr. Willging, you said that I thought was quite interesting is the implementation.  And taking it a step further, how do we sustain ‑‑ adopt, sustain, and scale up mental health interventions for these populations in such a contentious political climate?  
 

CATHLEEN WILLGING:  I will say that I am fortunate to live in New Mexico where we do tend to have a more progressive climate and legislation that's specifically put in place to support students and create expectations within schools that they're going to support LGBTQ youth in particular. 

In terms of sustaining the interventions, what we've been exploring is how do we develop an implementation support infrastructure at district and at state levels so that we can kind of maintain this progress. 

One of the biggest challenges we encountered that I didn't get to speak about today was turnover.  In one of our schools, for example, they had turnover in the board of education and in most of their school personnel.  So, when you're trying to really maintain these local teams, that's a challenge.  But if we do have that capacity at that higher level and those expectations, we can continue to support this work.  So that's really where we're trying to focus our future work.  
 

JESSICA SCHLEIDER:  I would add to that, in addition to focusing specifically on, you know, increasing access to support for SGM youth, I really do believe that increasing access and onramps for all youth to access mental health support ‑‑ because this is not an access issue that's specific to any one population ‑‑ will in turn allow for more individualization of those supports once people access them depending on people's needs.  Right? 

So if nationally, in collaboration with nonprofits, et cetera, some of the programs that we're developing and deploying are deployed at scale and anybody can access them, there's the opportunity, as in currently available options, for youth to select activities based on what problem are they experiencing right now, which could include SGM‑affirming support specifically or more domain‑general supports depending on what's coming up. 

So, I do think taking a more ‑‑ a broader approach and creating opportunities for precision support within that broader approach would be an easier way in.  
 

CATHLEEN WILLGING:  Can I just add to that?  I mean, just even building capacity and implementation facilitation, so if it's a practice for SGM populations or for other groups, like just having that coaching and consultation kind of model in place I think would really help us come a long way in terms of improving access as well as quality of programming.  
 

MARY ACRI:  Yeah.  And Dr. Schleider, something you mentioned ‑‑ and correct me if I misheard this ‑‑ that you had sought a waiver of parental consent, and that's fascinating.  All the help‑seeking models for children and adolescents really focus on the caregiver as the pivotal entry point into care, and so that is just a fascinating way to optimally facilitate service use by overcoming what might be, you know, on the parent's side, a stigma or mistrust or these other factors that interfere with help‑seeking.  
 

JESSICA SCHLEIDER:  Absolutely.  And that will ultimately require policy change at the state level because there's so much inconsistency from one state to the next about whether that's allowed and whether those policies are implemented properly.  So, clinics have no incentive to enforce policies like that if they perceive a legal liability, for example, that they don't want to address. 

So, there are lots of layers of challenges to that path, but teens are seeking support online whether we want them to or not, and so they're already doing it.  Whether or not they tell their parents is a different issue, but if we create more formal onramps and opportunities for us to embed evidence‑based tools in the spaces where teens are already seeking care and not telling anybody, that is a win for everybody.  
 

KATIE EDWARDS:  Yeah, and I'll add to that.

In our studies we have waivers of guardian consent.  I mean, of course, youth can tell anyone they want to that they're doing this.  But over in the PRYSHM study that I presented, over half of youth weren't out to their families, and they really needed, and they wanted this, and I think that's why we got the effects that we did. 

And, of course, we want to include caregivers.  Right?  I mean, we have a couple of grants where we're doing a family acceptance project with caregivers.  But the reality is for some youth, that's not an option, and they're absolutely going into online spaces, and so how can we create spaces that are safe for them. 

And so, yeah, that's something that we're doing in a lot of our work, and I know it can be controversial.  I think we're just really trying to help youth thrive in the face of myriad adversities, especially who are in the parts of country where 
they ‑‑ they have nothing, you know, in terms of affirming‑care services.  It's really hard. 

For some of youth it was the first ‑‑ like when they logged on, it's the first time they've ever been out in a space with queer people.  And we had youth, like, crying.  It was so powerful. 

Anyway, I'll stop talking.  
 

MARY ACRI:  Well, rather than ‑‑ you said controversial, and what I just hear is hope, that even finding ‑‑ you know, within a sidewalk, there's a flower growing between the cracks, that we're finding a way for folks to get the support that they need. 

And so, for all of you, it's just pioneering work that ‑‑ I'm just so grateful for all of your research in this area. 

I'm going to turn it over to Dr. Friedman‑Hill for some closing remarks.  
 

STACIA FRIEDMAN-HILL:  Thank you. 

So, I'm actually not making the closing remarks, but it's my pleasure to introduce Christina Borba, who will be providing final remarks to close out our meeting. 

Dr. Borba is the director of the NIMH Office for Disparities Research and Workforce Diversity.  In her role as director of ODWD, Dr. Borba leads the development and implementation of scientific policies and research initiatives aimed at reducing mental health disparities and advancing equity in mental health interventions, services and outcomes.  Her work also focuses on increasing workforce diversity and scientific attention to mental health disparities experienced by women and people living in rural areas. 

Dr. Borba received her doctorate in public health from Emory University and her master's degree in public health from Boston University.  In her previous position she served as the vice‑chair of research in the Department of Psychiatry at Boston Medical Center and director of the Boston Med Center Global and Local Center for Mental Health Disparities. 

Since her arrival at NIMH in the fall of 2022, Dr. Borba has hired new subject matter experts for the Office of Disparities Research and Workforce Diversity, expanding the capacity of the office to focus on the needs of the wide umbrella of populations that experience mental health disparities, including LGBTQIA people. 

I've had the privilege of working with Dr. Borba as co‑lead of the NIMH Mental Health Disparities Team, and I want to share that 
Dr. Borba has a special knack for building coalitions, making all people feel welcome and valued, and is a fantastic mentor. 

Christina, I'm looking forward to your thoughts on some of the highlights of this meeting and areas that NIH needs to focus on going forward.  Thank you.  

CHRISTINA BORBA:  Thank you, Stacia.  That might go down in history as one of the best bios I have received, so thank you so much. 

Good afternoon, everyone.  I'm Christina Borba, my pronouns are she and her, and like Stacia said, I am the NIMH director for the Office for Disparities Research and Workforce Diversity.  I've had the pleasure of serving in this office since September of 2022, and I am just absolutely thrilled of the two days that we have spent together, and it is truly my pleasure to close us out on this remarkable time that we've spent. 

I want to thank everyone, first, for participating, including all of our speakers, our moderators, or NIH and HHS staff as well.  It really does take a village to put this two‑day workshop together. 

I've been so impressed by the different presentations.  It's been such an opportunity for me as the director of the Disparities Office to really think about where NIMH should really be thinking about in terms of next steps. 

But some of the key themes that I really picked out ‑‑ and there's a lot of themes ‑‑ but some of the key themes from the past couple of days kind of centered around some different buckets. 

One was measurement.  We spoke quite a bit about measurement of gender identity and sexual orientation and really came away with the feeling about how the field is progressing with more accurate questions and measures.  We talked little bit about the YRBS question response of that "not sure," which was really expanded in 2021 to reduce confusion.  There seemed to be a feeling that the quality of our data is better, the type of data that we're collecting is better, but much, much more work is needed in this space. 

The other theme that really came out of the past couple of days was really about taking on an intersectionality lens, and that also includes an intersectionality lens in our data analysis as well.  And I'll get more around intersectionality in a bit. 

Stigma seemed to be a very common theme in the past couple of days, really focused on stigma at multiple levels.  There seems to be a lot of research at the interpersonal level but major gaps in really thinking about stigma at the structural level. 

What I really appreciated was yesterday's closing session from our youth panel and really talking about what are the strengths of our youth and where can those strengths be used in thinking about intervention development, more community engagement, and we talked about youth being peer mentors as well, and it was really great to focus more on strengths and what our youth bring to the table both on research and practice as well. 

I very much appreciated the conversation we've had over the past couple of days on the role of social media.  Our youth panel talked quite a bit yesterday about the queer media and the impact that that has had, the positive impact that has had on them.  And there is a lot of controversy in the field right now regarding the role of social media and the fact that there is research that really shows how really evidence‑based interventions can be delivered through a social media platform was really great to see. 

We talked about the role of community and having a community and the solidarity between communities, even taking on that intersectional approach within our communities and creating safe spaces in the world for our youth to be part of and to thrive.

And then, lastly, another theme that came up, and we talked about it this afternoon, was really the importance of implementation science in the role of scalability and sustainability of our evidence‑based treatments. 

So, what I took away from the past two days is really thinking about what are the future directions for NIMH?  NIMH is committed to the mental health of our LGBTQ+ youth, and it's clear from our two days together that more work is needed, and we are committed for more research on the structural factors that are associated with poor mental health for our LGBTQ youth, including structural stigma. 

It's clear that more research is needed on more structural interventions as well, suicide prevention interventions for our youth, and really the theme of community engaged research, the true community engaged research that really involve our LGBTQ youth specifically looking ‑‑ working within an intersectionality framework, getting more youth involved, taking the time to listen, and really involving them in the research process from beginning to end, and that youth can be role models for themselves as well.  

And then, lastly, for future directions, I also heard about the importance of dissemination and how we as scholars don't do a great job when thinking about disseminating research back to our communities, so really thinking about that role of dissemination in all the work that we do. 

                         So, in summary, I would like to say I would like NIH to aspire to center equity in all the science that we support.  I'd like us to change the way research is conducted by really thinking about who is involved, how they are involved, and when are they involved in the research process.  I'd like NIH to take on an intersectional lens.  Research is needed to explore the intersectionality of understudied social identities, but also research is needed to investigate the mechanisms of how intersecting systems of oppression interact to impact mental health outcomes. 

Incorporating intersectionality frameworks into our research, while complex, and it's due to the challenges of conducting structural level research, it is vital at improving the health equity of LGBTQ youth.  Addressing the negative health impacts of social systems of oppression and isolation from each other is not enough.  Intersectionality must become a central framework for our public health research. 

So, our Day 1 yesterday started with saying "has it gotten any better" from Dr. Meyer, and I would say we still have a lot of work to do, and NIMH and NIH are committed to funding research to support the health of our LGBTQ+ youth.  And although we do have a lot of work to do, I am very hopeful for the future, given everyone's commitment these past two days, to further the health of our LGBTQ+ youth. 

I want to thank you all for participating, I hope you all have a wonderful rest of the day and week, and a very happy Pride Month to everyone.  Thank you.

(Adjourned)