Karina L. Walters

Measuring multiple minority stress: the LGBT People of Color Microaggressions Scale.

Lesbian, gay, and bisexual individuals who are also racial/ethnic minorities (LGBT-POC) are a multiply marginalized population subject to microaggressions associated with both racism and heterosexism. To date, research on this population has been hampered by the lack of a measurement tool to assess the unique experiences associated with the intersection of these oppressions. To address this gap in the literature, we conducted a three-phase, mixed method empirical study to assess microaggressions among LGBT-POC. The LGBT People of Color Microaggressions Scale is an 18-item self-report scale assessing the unique types of microaggressions experienced by ethnic minority LGBT adults. The measure includes three subscales: (a) Racism in LGBT communities, (b) Heterosexism in Racial/Ethnic Minority Communities, and (c) Racism in Dating and Close Relationships, that are theoretically consistent with prior literature on racial/ethnic minority LGBTs and have strong psychometric properties including internal consistency and construct validity in terms of correlations with measures of psychological distress and LGBT-identity variables. Men scored higher on the LGBT-PCMS than women, lesbians and gay men scored higher than bisexual women and men, and Asian Americans scored higher than African Americans and Latina/os.

Interpersonal Violence in the Lives of Urban American Indian and Alaska Native Women: Implications for Health, Mental Health, and Help-Seeking

OBJECTIVE We surveyed American Indian/Alaska Native (AIAN) women in New York City to determine the prevalence of 3 types of interpersonal violence among urban AIAN women and the behavioral health and mental health factors associated with this violence. METHODS Using a survey, we questioned 112 adult AIAN women in New York City about their experiences with interpersonal violence, mental health, HIV risk behaviors, and help-seeking. The sampling plan utilized a multiple-wave approach with modified respondent-driven sampling, chain referral, and target sampling. RESULTS Among respondents, over 65% had experienced some form of interpersonal violence, of which 28% reported childhood physical abuse, 48% reported rape, 40% reported a history of domestic violence, and 40% reported multiple victimization experiences. Overwhelmingly, women experienced high levels of emotional trauma related to these events. A history of interpersonal violence was associated with depression, dysphoria, help-seeking behaviors, and an increase in high-HIV risk sexual behaviors. CONCLUSIONS AIAN women experience high rates of interpersonal violence and trauma that are associated with a host of health problems and have important implications for health and mental health professionals.

Triangle of Risk: Urban American Indian Women's Sexual Trauma, Injection Drug Use, and HIV Sexual Risk Behaviors

A community-based mail survey of 155 urban American Indian women revealed 91% engaged in at least one lifetime HIV sexual or drug risk behavior, including 19% who had sex with an injection drug user and 7% who had traded sex. Sixty-eight percent of the respondents were sexually active in the last year, with more than half never using condoms. Six percent had ever injected nonprescription drugs; 62% drank alcohol in the last year, with 28% reporting at least one occasion of consuming six or more drinks containing alcohol. Respondents reported high rates of lifetime physical (37%) and sexual (39%) assault, which was generally associated with lifetime but not more recent indicators of sexual and drug risk behavior. Injection drug use mediated the relationship between nonpartner sexual (but not physical) trauma and high-risk sexual behaviors. Findings underscore the need for the integrated assessment and treatment of abuse and substance use as well as more research on the risk behaviors of this understudied and underserved population.

The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities.

National health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations. Yet, few studies have examined the range of health outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more inclusive research in the area, we present the Health Equity Promotion Model-a framework oriented toward LGBT people reaching their full mental and physical health potential that considers both positive and adverse health-related circumstances. The model highlights (a) heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and environmental context; and (c) both health-promoting and adverse pathways that encompass behavioral, social, psychological, and biological processes. It also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the health-promotion model. By explicating the important role of agency and resilience as well as the deleterious effect of social structures on health outcomes, it supports policy and social justice to advance health and well-being in these communities. Important directions for future research as well as implications for health-promotion interventions and policies are offered.

Decolonizing Strategies for Mentoring American Indians and Alaska Natives in HIV and Mental Health Research

American Indian and Alaska Native (AIAN) scholars in the fields of mental health and HIV face formidable barriers to scientific success. These include justifiable mistrust of historically oppressive educational systems, educational disparities, role burdens within academe, the devaluation and marginalization of their research interests, and outright discrimination. Research partners can work to dismantle these barriers by embracing indigenous worldviews, engaging in collaborative research partnerships, building research capacity within universities and tribal communities, changing reward systems, and developing mentoring programs. At the individual level, aspiring AIAN scholars must build coalitions, reject internalized colonial messages, and utilize indigenous ethical frames. The creation of a cadre of AIAN researchers is crucial to improving the health of AIAN peoples.

Buffering Effects of General and Medication-Specific Social Support on the Association Between Substance Use and HIV Medication Adherence

The success of highly active antiretroviral therapy (HAART) among persons living with HIV is largely dependent on strict medication adherence. Recent research suggests that alcohol and other drug use (AOD) may be an important barrier to HAART adherence. In this study, we examined the impact of AOD on HAART adherence as well as the moderating effects of general and medication-specific social support. The data were collected as part of a longitudinal randomized control trial with 224 HIV-positive patients at an HIV primary care clinic in the northwestern United States. Findings indicated that AOD use was negatively associated with HAART adherence and that medication-specific (but not general) social support moderated the AOD-adherence association at 3 (but not at 6 or 9) months. Results indicate the importance of medication-specific social support to treat comorbid AOD use and HIV; implications for future research and intervention programs for HIV-positive AOD users are discussed.

Indian Boarding School Experience, Substance Use, and Mental Health among Urban Two-Spirit American Indian/Alaska Natives

Background: Systematic efforts of assimilation removed many Native children from their tribal communities and placed in non-Indian-run residential schools. Objectives: To explore substance use and mental health concerns among a community-based sample of 447 urban two-spirit American Indian/Alaska Native adults who had attended boarding school as children and/or who were raised by someone who attended boarding school. Method: Eighty-two respondents who had attended Indian boarding school as children were compared to respondents with no history of boarding school with respect to mental health and substance use. Results: Former boarding school attendees reported higher rates of current illicit drug use and living with alcohol use disorder, and were significantly more likely to have attempted suicide and experienced suicidal thoughts in their lifetime compared to non-attendees. About 39% of the sample had been raised by someone who attended boarding school. People raised by boarding school attendees were significantly more likely to have a general anxiety disorder, experience posttraumatic stress disorder symptoms, and have suicidal thoughts in their lifetime compared to others.

Who, and what, causes health inequities? Reflections on emerging debates from an exploratory Latin American/North American workshop

Rapidly rising interest - from national and international health organisations, governments, civil society, the private sector and myriad academic disciplines - in what has become known as the ‘social determinants of health’1 2 is welcome to the many, in and outside of public health, who have long held that issues of social justice and the publics health are inextricably linked (box 1).2 3 As inevitably happens, however, when an issue gets ‘mainstreamed’, a multiplicity of disparate voices enter the discussion, informed by not only different disciplinary vantages, but also divergent values, priorities and politics. ### Box 1 Political, historical, intellectual and economic context of a Latin American/North American discussion about societal determinants of between-country and within-country health inequities 1. Political, historical, and intellectual context 1. Explicit efforts to develop theories articulating the causal connections between political economy, social injustice and health inequities can readily be traced back to the mid-19th century.2–8 Examples include the European writings of Rudolf Virchow (1821–1902) and Friedrich Engels (1820–1895) in the 1840s, as linked to societal upheavals spurred by the rise of industrial capitalism, along with their subsequent elaborations in the early 20th century by European, North American and Latin American analysts and politicians, such as Chilean president Salvador Allende (1908–1973), variously concerned with the health impact of political and economic systems, and political and economic injustice, both within and across nations and regions.2–6 More recent antecedents include: A. the rise of critical science frameworks during the 1960s and 1970s, including within the health fields, as spurred by post-World War II national liberation and anti-imperialist movements along with the emergence of worldwide social movements regarding racism, indigenous rights, gender, sexuality, human rights and the environment (ecology), and B. since the mid-1990s, a …

Sexual Orientation Bias Experiences and Service Needs of Gay, Lesbian, Bisexual, Transgendered, and Two-Spirited American Indians

Summary Employing both quantitative and qualitative methodologies, this study examined: sexual orientation bias experiences among American Indians (AIs) who were gay, lesbian, bisexual, transgend-ered, or two-spirited (GLBTT-S); service provider attitudes toward AI GLBTT-S; and service barriers and needs with respect to AI GLBTT-S at one AI community-based organization. Among the 14 AI GLBTT-S surveyed, the percentages reporting various bias-related experiences were comparable or greater to those reported for non-AI GLBTT-S in other studies (e.g., 36% had been physically assaulted because of their sexual orientation). The 22 service providers surveyed revealed generally low levels of heterosexism, which was inversely related to contact and comfort with AI GLBTT-S as well as understanding of AI GLBTT-S terms. Data from 8 focus groups (7 with service providers and 1 with AI two-spirited men) yielded four main themes related to problems and barriers to service utilization for AI GLBTT-S (i.e., invisibility, discrimination, trauma, and identity) as well as ideas for community-based program planning with this population.

Determinants of Health Among Two-Spirit American Indians and Alaska Natives

In comparison to other racial/ethnic groups, American Indians and Alaska Natives (AIANs or “Natives”) suffer from glaring disparities in health-related resources and outcomes. Specifically, morbidity due to violence and substance use is higher and overall mortality is greater [IHS]. AIANs who identify as gay, lesbian, bisexual, or transgender (GLBT) or with the modern roughly equivalent Native term “two-spirit” (hereafter collectively referred to as “twospirits”) face additional stressors associated with negotiating their dual oppressed statuses. They often confront heterosexism from Natives and racism from GLBTs. Not surprisingly, two-spirits are thought to be at even greater risk for adverse health outcomes than other Natives (Walters, 1997; Walters et al., 2001). Preliminary empirical evidence supports the notion that two-spirits experience disproportionately greater anti-gay as well as anti-Native violence, including sexual and physical assault during childhood and adulthood (Walters et al., 2001; Simoni et al., 2004a) and historical trauma (Balsam et al., 2004)-experiences that are typically linked to adverse health and psychosocial functioning. Despite the considerable heterogeneity both within and across the more than 562 federally recognized tribes in the United States, the universal experience of colonization has created a shared history for two-spirit people, shaping distinctive conditions of health risk and resilience.