Mark L. Hatzenbuehler

The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth

OBJECTIVE: To determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors. METHODS: A total of 31 852 11th grade students (1413 [4.4%] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006–2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and antibullying) that specifically protected lesbian, gay, and bisexual students. RESULTS: Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96–0.99]). CONCLUSIONS: This study documents an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation–related disparities in suicide attempts.

Emotion dysregulation and adolescent psychopathology: A prospective study

BACKGROUND Emotion regulation deficits have been consistently linked to psychopathology in cross-sectional studies. However, the direction of the relationship between emotion regulation and psychopathology is unclear. This study examined the longitudinal and reciprocal relationships between emotion regulation deficits and psychopathology in adolescents. METHODS Emotion dysregulation and symptomatology (depression, anxiety, aggressive behavior, and eating pathology) were assessed in a large, diverse sample of adolescents (N=1065) at two time points separated by seven months. Structural equation modeling was used to examine the longitudinal and reciprocal relationships between emotion dysregulation and symptoms of psychopathology. RESULTS The three distinct emotion processes examined here (emotional understanding, dysregulated expression of sadness and anger, and ruminative responses to distress) formed a unitary latent emotion dysregulation factor. Emotion dysregulation predicted increases in anxiety symptoms, aggressive behavior, and eating pathology after controlling for baseline symptoms but did not predict depressive symptoms. In contrast, none of the four types of psychopathology predicted increases in emotion dysregulation after controlling for baseline emotion dysregulation. CONCLUSIONS Emotion dysregulation appears to be an important transdiagnostic factor that increases risk for a wide range of psychopathology outcomes in adolescence. These results suggest targets for preventive interventions during this developmental period of risk.

Stressful life experiences, alcohol consumption, and alcohol use disorders: the epidemiologic evidence for four main types of stressors.

BackgroundExposure to stress is potentially important in the pathway to alcohol use and alcohol use disorders. Stressors occur at multiple time points across the life course, with varying degrees of chronicity and severity.MethodWe review evidence from epidemiologic studies on the relationship between four different stressors (fateful/catastrophic events, child maltreatment, common adult stressful life events in interpersonal, occupational, financial, and legal domains, and minority stress) and alcohol consumption and alcohol use disorders.ResultsStudies generally demonstrate an increase in alcohol consumption in response to exposure to terrorism or other disasters. Research has demonstrated little increase in incident alcohol use disorders, but individuals with a history of alcohol use disorders are more likely to report drinking to cope with the traumatic event. Childhood maltreatment is a consistent risk factor for early onset of drinking in adolescence and adult alcohol use disorders, and accumulating evidence suggests that specific polymorphisms may interact with child maltreatment to increase risk for alcohol consumption and disorder. Stressful life events such as divorce and job loss increase the risk of alcohol disorders, but epidemiologic consensus on the specificity of these associations across gender has not been reached. Finally, both perceptions of discrimination and objective indicators of discrimination are associated with alcohol use and alcohol use disorders among racial/ethnic and sexual minorities.ConclusionTaken together, these literatures demonstrate that exposure to stress is an important component in individual differences in risk for alcohol consumption and alcohol use disorders. However, many areas of this research remain to be studied, including greater attention to the role of various stressors in the course of alcohol use disorders and potential risk moderators when individuals are exposed to stressors.

Stigma and Treatment for Alcohol Disorders in the United States

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (β = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (β = 1.0; P < 0.01), education (β = 1.48; P < 0.01), and being previously married (β = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (β = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.

Effect of Same-Sex Marriage Laws on Health Care Use and Expenditures in Sexual Minority Men: A Quasi-Natural Experiment

OBJECTIVES We sought to determine whether health care use and expenditures among gay and bisexual men were reduced following the enactment of same-sex marriage laws in Massachusetts in 2003. METHODS We used quasi-experimental, prospective data from 1211 sexual minority male patients in a community-based health center in Massachusetts. RESULTS In the 12 months after the legalization of same-sex marriage, sexual minority men had a statistically significant decrease in medical care visits (mean = 5.00 vs mean = 4.67; P = .05; Cohens d = 0.17), mental health care visits (mean = 24.72 vs mean = 22.20; P = .03; Cohens d = 0.35), and mental health care costs (mean =

Introduction to the special issue on structural stigma and health

2442.28 vs mean =

LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach

2137.38; P = .01; Cohens d = 0.41), compared with the 12 months before the law change. These effects were not modified by partnership status, indicating that the health effect of same-sex marriage laws was similar for partnered and nonpartnered men. CONCLUSIONS Policies that confer protections to same-sex couples may be effective in reducing health care use and costs among sexual minority men.

Inclusive Anti-bullying Policies and Reduced Risk of Suicide Attempts in Lesbian and Gay Youth

Stimulated by the pioneering work of Goffman (1963), research into the causes and consequences of stigma has proliferated over the past five decades. Progress has been made in the construction of new concepts, measures, and methodological approaches that have illuminated how stigma works to the disadvantage of those targeted by it. The culmination of this intense scrutiny has created the capacity to more deeply understand this powerful human phenomenon, opening the possibility to address its unwanted effects. At the same time, in the midst of this growth and advancement, the stigma concept has been criticized on several fronts. One of the most consistent criticisms has been that stigma research is too individually focused (Link & Phelan, 2001; Parker & Aggleton, 2003). According to Oliver (1992), the central thrust of stigma research has been focused on the perceptions of individuals and the consequences of such perceptions for micro-level interactions, rather than on structural issues underlying stigma. In part to address this criticism, researchers have recently expanded the stigma construct to consider how broader, macrosocial forms of stigmadtermed structural stigmadmay also disadvantage the stigmatized. For instance, Link and Phelan’s (2001) influential conceptualization of stigma distinguished between discrimination at individual and structural levels and noted that the concept of structural stigma “sensitizes us to the fact that all manner of disadvantage can result outside of a model in which one person does something bad to another” (p. 382). Despite initial attempts to define (Link & Phelan, 2001) and measure (Corrigan et al., 2005) structural stigma, there has been limited empirical investigation of the extent to which structural stigma represents a risk indicator for adverse health outcomes among stigmatized individuals. This dearth of empirical research on structural stigma has led researchers to conclude that this under-representation represents “a dramatic shortcoming in the literature on stigma, as the processes involved are likely major contributors to unequal outcomes” (Link, Yang, Phelan, & Collins, 2004, pp. 515e16). Recent research, however, has begun to generate a tantalizing set of findings concerning the role of structural stigma in the production of negative outcomes for members of stigmatized groups, including individuals with mental illness (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012), sexual minorities (Hatzenbuehler, 2011), Blacks (Krieger, 2012), and individuals infected with HIV/ AIDS (Miller, Grover, Bunn, & Solomon, 2011). In one example of this work, Hatzenbuehler, Keyes, and Hasin (2009) coded states for levels of structural stigma surrounding lesbian, gay, and bisexual (LGB) individuals, operationalized as the absence of

Protective School Climates and Reduced Risk for Suicide Ideation in Sexual Minority Youths

OBJECTIVES We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. METHOD Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. RESULTS Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. CONCLUSION This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual mens co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record

Structural Stigma and the Health of Lesbian, Gay, and Bisexual Populations

PURPOSE To evaluate whether anti-bullying policies that are inclusive of sexual orientation are associated with a reduced prevalence of suicide attempts among lesbian, gay, and bisexual youths. METHODS A total of 31,852 11th-grade public school students (1,413 lesbian, gay, and bisexual individuals; 4.4%) in Oregon completed the Oregon Healthy Teens survey in 2006-2008. The independent variable was the proportion of school districts in the 34 counties participating in the Oregon Healthy Teens survey that adopted anti-bullying policies inclusive of sexual orientation. The outcome measure was any self-reported suicide attempt in the past 12 months. We stratified results by sexual orientation. RESULTS Lesbian and gay youths living in counties with fewer school districts with inclusive anti-bullying policies were 2.25 times (95% confidence interval [CI], 1.13-4.49) more likely to have attempted suicide in the past year compared with those living in counties where more districts had these policies. Inclusive anti-bullying policies were significantly associated with a reduced risk for suicide attempts among lesbian and gay youths, even after controlling for sociodemographic characteristics (sex, race/ethnicity) and exposure to peer victimization (odds ratio, .18; 95% CI, .03-.92). In contrast, anti-bullying policies that did not include sexual orientation were not associated with lower suicide attempts among lesbian and gay youths (odds ratio, .38; 95% CI, .02-7.33). CONCLUSIONS Inclusive anti-bullying policies may exert protective effects for the mental health of lesbian and gay youths, including reducing their risk for suicide attempts.