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Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

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Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

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The sexual satisfaction of couples during pregnancy is an under-researched area of study. Several limitations exist within the current literature, including a lack of inquiry into attitudes about sex during pregnancy, analysis of the relationship between sexual satisfaction and sexual behaviors, and analysis of dyadic interactions within the couple. The purpose of the current study was to examine the relationships between attitudes toward having sex during pregnancy, various sexual behaviors, and sexual satisfaction among expectant couples via multilevel structural equation modeling. Recruitment focused on mixed-gender monogamous couples where the pregnant individual was between 8 and 12 weeks of gestation, and both partners were soon-to-be first time parents. Touching, hugging, or holding, kissing, vaginal and oral sex, and rubbing each other's genitals were all common behaviors among the 116 couples in the current investigation. Anal sex and sex toy use were less common, but far from absent. According to our model, attitudes toward having sex during pregnancy significantly predicted sexual satisfaction by operating through specific sexual behaviors: kissing, vaginal fingering, and vaginal intercourse, while use of a toy alone and use of a toy with partner were independent predictors of sexual satisfaction. Gender had a direct relationship with satisfaction (men were more satisfied), as well as indirect relationship with satisfaction through an interaction with vaginal fingering and use of a sex toy alone. While multiple past month sexual behaviors were likely to increase satisfaction among pregnant and non-expectant couples alike, this improvement might depend on which behaviors are included and the gender of the individual.

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Purpose: This study assessed within a Midwestern LGBT population whether, and the extent to which, transgender identity was associated with elevated odds of reported discrimination, depression symptoms, and suicide attempts. Methods: Based on survey data collected online from respondents who self-identified as lesbian, gay, bisexual, and/or transgender persons over the age of 19 in Nebraska in 2010, this study performed bivariate t- or chi-square tests and multivariate logistic regression analysis to examine differences in reported discrimination, depression symptoms, suicide attempts, and self-acceptance of LGBT identity between 91 transgender and 676 nontransgender respondents. Results: After controlling for the effects of selected confounders, transgender identity was associated with higher odds of reported discrimination (OR=2.63, p<0.01), depression symptoms (OR=2.33, p<0.05), and attempted suicides (OR=2.59, p<0.01) when compared with nontransgender individuals. Self-acceptance of LGBT identity was associated with substantially lower odds of reporting depression symptoms (OR=0.46, p<0.001). Conclusion: Relative to nontransgender LGB individuals, transgender individuals were more likely to report discrimination, depression symptoms, and attempted suicides. Lack of self-acceptance of LGBT identity was associated with depression symptoms among transgender individuals.

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PURPOSE: Researchers have documented that lesbian, gay, bisexual, and transgender (LGBT) people have a higher proportion of tobacco use as compared to general population smoking rates. This study examined the relationships between tobacco use and social determinants of health in a sample of self-identifying LGBT people who spend time in Nebraska. METHODS: A community-based participatory research approach was used to develop an online survey to assess the physical, mental, social, and sexual health of LGBT populations who live, work, or play in Nebraska. Chi-squared and logistic regression analyses explored the use of tobacco among respondents. RESULTS: Of the 770 people who completed the survey, 763 respondents completed questions about smoking status. The prevalence of current smoking among these 763 respondents was 26.47%. Some LGBT-specific social determinants of health had significant relationships to smoking status. However, after controlling for known risk factors of smoking in logistic regression models, these variables were not related to smoking status. CONCLUSIONS: This study shows that there is a significant relationship between smoking and several general social determinants of health, including employment status, education, and income as well as binge drinking. Limitations include lack of adequate survey respondents to divide subgroups of LGBT individuals and inherent limitations of convenience sampling, which may not allow for an accurate representation of the situation faced by LGBT in Nebraska. In addition to this, the list of LGBT-specific determinants of health used in the survey may not be exhaustive, and there may be additional factors facing LGBT individuals. Public health professionals can use this information in designing smoking reduction campaigns for LGBT populations in Nebraska and culturally similar regions of the United States. These programs and interventions may want to consider a more holistic approach to smoking cessation grounded in the social-ecological model.

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Research into the health and wellbeing of rural lesbian, gay, bisexual, and transgender (LGBT) populations is limited. A community-based participatory research (CBPR) approach was used to develop an online survey for LGBT Nebraskans. The 770 participants replied to an array of questions on social determinants of health and basic health outcomes. Only significant differences in having health insurance were found between urban and rural participants. Social determinants of health were explored. Results of this study suggest that regional culture may be more salient to health for lesbian, gay, bisexual, and transgender persons living in the Midwest than rural or urban residence.

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The aim of this investigation is to outline correlates of suicide ideation among LGBT individuals living in Nebraska. A community-based participatory research approach was utilized to develop a 30-minute, online anonymous survey. Almost half of the sample had seriously considered suicide at some point in their lives. Significant correlates of increased likelihood of suicide ideation are age, gender, transgender identity, income, depression, and discrimination. Suicide ideation is a serious concern for the health of LGBT Nebraskans. Steps should be taken to incorporate individuals who fall into these high-risk categories in suicide outreach programs.

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Limited quantitative information exists about the demographics and needs of lesbian, gay, bisexual, and transgender (LGBT) persons in South Carolina, a predominately rural Southern state. Responses to a needs assessment survey (n = 715) were analyzed to understand the diversity and needs of members of the LGBT community in SC. The purpose was to inform future programming and guide the development of a more comprehensive portfolio of services to be offered by a local LGBT community center. Findings suggest that a diverse LGBT community exists in SC and needs include increased programming for community members as well as efforts to provide policy-level support and increased acceptability and understanding of LGBT persons in South Carolina.

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PURPOSE: Lesbian women are more likely to experience negative physical and mental health outcomes compared with heterosexual women, although most research on this population has relied on small convenience samples. This study compared health behaviors and health care utilization among lesbian women living in the South to representative subsamples of women from the general population. METHODS: We conducted a Web-based survey of 1,141 self-identified lesbian women aged 19 and older living in the South. We compared descriptive results from our study to the U.S. Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System. We also calculated adjusted logistic regression models to further explore correlates of Southern lesbian women's physical and mental health. MAIN FINDINGS: Southern lesbians were less likely to be in poor physical health, but more likely to experience recent depression than women in the general population. Lesbians reported more risky health behaviors relative to other Southern and non-Southern women. Southern lesbians and other Southern women experienced similar barriers to routine health care, including lack of health insurance, not having a regular provider, and having to forgo care owing to cost. Many of these health behaviors and barriers to care were associated with poor physical and mental health among Southern lesbians. CONCLUSION: Southern lesbians' patterns of health behaviors and utilization of care may place them at increased risk for negative health outcomes relative to the general population.

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OBJECTIVE: Research has demonstrated a high frequency and intensity of alcohol use among lesbian women. This work explores age differences in risk factors for problematic alcohol use among self-identified Southern lesbians. Risk factors of interest include depression, general stress, and three measures of sexual minority stress (i.e., experiences of discrimination, lesbian/gay-related stigma, and internalized homophobia). METHOD: We analyze data from the Lesbian Social Life study, which recruited 1,141 self-identified Southern lesbians for participation in an anonymous Web-based survey. We present results from a series of regression models predicting scores on the CAGE scale, a self-reported measure of problematic alcohol use. Results are reported separately by age group (19-29, 30-49, >or=50). RESULTS: Frequent and intense alcohol use was most common among lesbian women ages 19-29. Depression and stress were the most consistent psychosocial correlates of problematic alcohol use, although these patterns varied by age. Each of the minority stress measures was associated with problematic alcohol use, although no clear age-related pattern appeared. CONCLUSIONS: Our findings suggest that depression and stress are strong predictors of problematic alcohol use among lesbians, which is comparable to previous findings in heterosexual populations. Additional research is needed to understand how the association between sexual minority stress and problematic alcohol use changes across the life course.

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BACKGROUND: Homeless persons depend disproportionately on the health-care safety net for medical services. National reports identify financial strains to this safety net. Whether this has affected homeless persons is unknown. OBJECTIVES: We quantified changes in the proportion of homeless persons reporting unmet need for health care in Birmingham, Alabama, comparing two periods, 1995 and 2005. We assessed whether a period effect was independent of characteristics of persons surveyed. DESIGN: Analysis of two surveys conducted with identical methods among representative samples of homeless persons in 1995 (n = 161) and 2005 (n = 161). MEASUREMENTS: Report of unmet need (inability to obtain care when needed) was the dependent variable. Two survey periods (1995 and 2005) were compared, with multivariable adjustment for sociodemographic and health characteristics. Reasons for unmet need were determined among the subset of persons reporting unmet need. RESULTS: Unmet need for health care was more common in 2005 (54%) than in 1995 (32%) (p < 0.0001), especially for non-Blacks (64%) and females (65%). Adjusting for individual characteristics, a survey year of 2005 independently predicted unmet need (odds ratio 2.68, 95% CI 1.49-4.83). Among persons reporting unmet need (87 of 161 in 2005; 52 of 161 in 1995), financial barriers were more commonly cited in 2005 (67% of 87) than in 1995 (42% of 52) (p = 0.01). CONCLUSION: A rise in unmet health-care needs was reported among Birmingham's homeless from 1995 to 2005. This period effect was independent of population characteristics and may implicate a local safety net inadequacy. Additional data are needed to determine if this represents a national trend.

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This paper explores the role of social capital in mediating the effects of stressors on depression among a disadvantaged population. Utilizing a survey of 155 homeless people in a mid-sized southern U.S. city, the authors address the relevance of social capital for quality of life. The paper provides a critical test of whether social support and other forms of social capital matter when monetary and human capital is extremely limited. Under these resource-restricted circumstances does social capital add to our understanding of the distress process or does it merely restate the well established relationship between social support and quality of life outcomes? Various forms of social capital are measured: religious social capital, group participation, social trust, and bridging social capital along with a commonly used measure of social support -- perceived strong tie support. Findings suggest that social capital matters for even the most resource poor populations. In addition, social capital variables add significantly to the variance explained in depressive symptomatology over and above that traditionally explained by perceived social support.

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Suicide ideation is a sensitive indicator of personal well-being. While ideation occurs in roughly 3 percent of the US population annually, in this study rates are 10 times higher. This article explores the role of social capital in mediating negative life circumstances on ideation for a sample of 161 homeless adults in a mid-sized Southern US metropolitan area. Our results imply that social capital does not function the same way for homeless persons as it does for the general population. This finding supports growing evidence that social capital's much touted benefits for personal well-being may not apply to disadvantaged populations.

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