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Open Access 01-12-2022 | Research

Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis

Authors: Cory J. Cascalheira, Emily C. Helminen, Thomas J. Shaw, Jillian R. Scheer

Published in: BMC Public Health | Issue 1/2022

Abstract

Background

Research indicates that tailored programming for sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, queer) people, compared to non-tailored programming, is effective for reducing the disproportionate health burden SGM people experience relative to the general population. However, the availability of SGM-tailored programming is often over-reported and inconsistent across behavioral health (i.e., substance use and mental health) facilities in the United States (U.S.).

Methods

Using panel analysis, the National Survey of Substance Abuse Treatment Services (N-SSATS), and the National Mental Health Services Survey (N-MHSS), this study examines structural stigma and government funding as two structural determinants affecting the availability of SGM-tailored programming in the U.S.

Results

Results indicated that from 2010 to 2020, reductions in structural stigma (i.e., increases in state-level supportive SGM policies) were positively associated with increases in the proportion of substance use treatment facilities offering SGM-tailored programming. This effect was significant after controlling for over-reporting of SGM-tailored programming and time- and state-specific heterogeneity. On average, the effect of reduced structural stigma resulted in approximately two new SGM-tailored programs in the short term and about 31 new SGM-tailored programs in the long term across U.S. substance use treatment facilities. Structural stigma did not predict the availability of SGM-tailored programming in mental health treatment facilities. Government funding was not significant in either data set. However, without correcting for over-reporting, government funding became a significant predictor of the availability of SGM-tailored programming at substance use treatment facilities.

Conclusions

Because SGM-tailored programming facilitates access to healthcare and the current study found longitudinal associations between structural stigma and the availability of SGM-tailored programming in substance use treatment facilities, our findings support claims that reducing structural stigma increases access to behavioral health treatment specifically and healthcare generally among SGM people. This study’s findings also indicate the importance of correcting for over-reporting of SGM-tailored programming, raising concerns about how respondents perceive the N-SSATS and N-MHSS questions about SGM-tailored programming. Implications for future research using the N-SSATS and N-MHSS data and for public health policy are discussed.

Available only for authorised users

Thank you to the anonymous reviewer for emphasizing the point about measurement error.

Thank you to the anonymous reviewer who raised this possibility.

Medley G, Lipari R, Bose J, Cribb D, Kroutil L, McHenry G. Sexual orientation and estimates of adult substance use and mental health: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review; 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm

Day JK, Fish JN, Perez-Brumer A, Hatzenbuehler ML, Russell ST. Transgender youth substance use disparities: results from a population-based sample. J Adolesc Health. 2017;61(6):729–35. https://doi.org/10.1016/j.jadohealth.2017.06.024.CrossRefPubMedPubMedCentral

Alessi EJ, Meyer IH, Martin JI. PTSD and sexual orientation: an examination of criterion A1 and non-criterion A1 events. Psychol Trauma Theory Res Pract Policy. 2013;5(2):149–57. https://doi.org/10.1037/a0026642.CrossRef

Bränström E, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. AJP. 2020;177(8):727–34. https://doi.org/10.1176/appi.ajp.2019.19010080.CrossRef

Kidd SA, Howison M, Pilling M, Ross LE, McKenzie K. Severe mental illness in LGBT populations: a scoping review. Psychiatr Serv. 2016;67(7):779–83. https://doi.org/10.1176/appi.ps.201500209.CrossRefPubMedPubMedCentral

Ross LE, Salway T, Tarasoff LA, MacKay JM, Hawkins BW, Fehr CP. Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: a systematic review and meta-analysis. J Sex Res. 2018;55(4–5):435–56. https://doi.org/10.1080/00224499.2017.1387755.CrossRefPubMed

Substance Abuse and Mental Health Services Administration. 2018 National Survey on Drug Use and Health: Lesbian, gay, & bisexual (LGB) adults. Substance Abuse and Mental Health Services Administration; 2020. https://www.samhsa.gov/data/report/2018-nsduh-lesbian-gay-bisexual-lgb-adults

Cochran BN, Peavy KM, Robohm JS. Do specialized services exist for LGBT individuals seeking treatment for substance misuse? A study of available treatment programs. Subst Use Misuse. 2007;42(1):161–76. https://doi.org/10.1080/10826080601094207.CrossRefPubMed

Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83(5):875–89. https://doi.org/10.1037/ccp0000037.CrossRefPubMedPubMedCentral

10.

Chen D, Watson RJ, Caputi TL, Shover CL. Proportion of U.S. clinics offering LGBT-tailored mental health services decreased over time: a panel study of the National Mental Health Services Survey. Ann LGBTQ Public Popul Health. 2021;2(3):174–84. https://doi.org/10.1891/LGBTQ-2020-0071.CrossRefPubMedPubMedCentral

11.

Qeadan F, et al. Factors associated with the availability of tailored programs for LGBT clients in substance use disorder treatment facilities in the U.S. from 2008 to 2018. J Gay Lesbian Soc Serv. 2021;1–22. https://doi.org/10.1080/10538720.2021.1954125.

12.

Pachankis JE, et al. A transdiagnostic minority stress intervention for gender diverse sexual minority women’s depression, anxiety, and unhealthy alcohol use: a randomized controlled trial. J Consult Clin Psychol. 2020;88(7):613–30. https://doi.org/10.1037/ccp0000508.CrossRefPubMedPubMedCentral

13.

Schwinn TM, Thom B, Schinke SP, Hopkins J. Preventing drug use among sexual-minority youths: findings from a tailored, web-based intervention. J Adolesc Health. 2015;56(5):571–3. https://doi.org/10.1016/j.jadohealth.2014.12.015.CrossRefPubMed

14.

Vogel EA, Ramo DE, Meacham MC, Prochaska JJ, Delucchi KL, Humfleet GL. The Put It Out Project (POP) Facebook intervention for young sexual and gender minority smokers: outcomes of a pilot, randomized, controlled trial. Nicotine Tob Res. 2020;22(9):1614–21. https://doi.org/10.1093/ntr/ntz184.CrossRefPubMed

15.

Craig SL, McInroy L, Austin A, Smith M, Engle B. Promoting self-efficacy and self-esteem for multiethnic sexual minority youth: an evidence-informed intervention. J Soc Serv Res. 2012;38(5):688–98. https://doi.org/10.1080/01488376.2012.718194.CrossRef

16.

SAMHSA. National Survey Of Substance Abuse Treatment Services (N-SSATS): 2020 - data on substance abuse treatment facilities. Substance Abuse and Mental Health Services Administration; 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt35313/2020_NSSATS_FINAL.pdf

17.

SAMHSA. National Mental Health Services Survey (N-MHSS): 2019 - data on mental health treatment facilities. Substance Abuse and Mental Health Services Administration; 2020. https://wwwdasis.samhsa.gov/dasis2/nmhss/2019-NMHSS-R.pdf

18.

Williams ND, Fish JN. The availability of LGBT-specific mental health and substance abuse treatment in the United States. Health Serv Res. 2020;55(6):932–43. https://doi.org/10.1111/1475-6773.13559.CrossRefPubMedPubMedCentral

19.

Helminen EC, Cascalheira CJ, Shaw TJ, Zollweg S, Hughes TL, Scheer JR. A latent class analysis of tailored substance use treatment programs: Implications for treating syndemic conditions facing sexual and gender minority populations. Drug Alcohol Depend. 2022;238:109550. https://doi.org/10.1016/j.drugalcdep.2022.109550.CrossRefPubMedPubMedCentral

20.

Association of State and Territorial Health Officials. ASTHO profile of state and territorial public health, volume 4. ASHTO; 2016. https://www.astho.org/globalassets/pdf/profile/profile-stph-vol-4.pdf

21.

Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med. 2014;103:1–6. https://doi.org/10.1016/j.socscimed.2013.12.017.CrossRefPubMed

22.

Flentje A, et al. Minority stress, structural stigma, and physical health among sexual and gender minority individuals: examining the relative strength of the relationships. Ann Behav Med. 2021;kaab051. https://doi.org/10.1093/abm/kaab051.

23.

Hatzenbuehler ML, Jun HJ, Corliss HL, Austin Sb. Structural stigma and sexual orientation disparities in adolescent drug use. Addict Behav. 2015;46:14–8. https://doi.org/10.1016/j.addbeh.2015.02.017.CrossRefPubMedPubMedCentral

24.

Horne SG, McGinley M, Yel N, Maroney MR. The stench of bathroom bills and anti-transgender legislation: anxiety and depression among transgender, nonbinary, and cisgender LGBQ people during a state referendum. J Couns Psychol. 2021;69(1):1–13. https://doi.org/10.1037/cou0000558.CrossRefPubMed

25.

Pachankis JE, Hatzenbuehler ML, Starks TJ. The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Soc Sci Med. 2014;103:67–75. https://doi.org/10.1016/j.socscimed.2013.10.005.CrossRefPubMedPubMedCentral

26.

Pachankis JE, Bränström R. Hidden from happiness: Structural stigma, sexual orientation concealment, and life satisfaction across 28 countries. J Consult Clin Psychol. 2018;86(5):403–15. https://doi.org/10.1037/ccp0000299.CrossRefPubMed

27.

Hughto JMW, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–31. https://doi.org/10.1016/j.socscimed.2015.11.010.CrossRef

28.

Saxby K, de New SC, Petrie D. Structural stigma and sexual orientation disparities in healthcare use: evidence from Australian Census-linked-administrative data. Soc Sci Med. 2020;255:113027. https://doi.org/10.1016/j.socscimed.2020.113027.CrossRefPubMed

29.

Baldwin AM, Dodge B, Schick V, Sanders SA, Fortenberry JD. Sexual minority women’s satisfaction with health care providers and state-level structural support: Investigating the impact of lesbian, gay, bisexual, and transgender nondiscrimination legislation. Women’s Health Issues. 2017;27(3):271–8. https://doi.org/10.1016/j.whi.2017.01.004.CrossRefPubMed

30.

Roulston C, McKetta S, Price M, Fox KR, Schleider JL. Structural correlates of mental health support access among sexual minority youth of color during COVID-19. J Clin Child Adolesc Psychol. 2022. https://doi.org/10.1080/15374416.2022.2034633.CrossRefPubMed

31.

Dillender M. Evidence and lessons on the health impacts of public health funding from the fight against HIV/AIDS. National Bureau of Economic Research, Working Paper 28867; 2021. Available: https://doi.org/10.3386/w28867

32.

Grembowski D, Bekemeier B, Conrad D, Kreuter W. Are local health department expenditures related to racial disparities in mortality? Soc Sci Med. 2010;71(12):2057–65. https://doi.org/10.1016/j.socscimed.2010.09.004.CrossRefPubMed

33.

Cooper Z, Kowalski A, Neff Powell E, Wu J. Politics, hospital behavior, and health care spending. Yale University, Cowles Foundation discussion paper No. 3006; 2017. Available: https://cowles.yale.edu/sites/default/files/files/pub/d30/d3006.pdf

34.

Leider JP, Tung G, Castrucci B, Sprague JB. Health spending and political influence: the case of earmarks and health care facilities. J Public Health Manag Pract. 2015;21(2):161–6. https://doi.org/10.1097/PHH.0000000000000116.CrossRefPubMedPubMedCentral

35.

Livingston JD. A framework for assessing structural stigma in health-care contexts for people with mental health and substance use issues. Mental Health Commission of Canada; 2021. https://mentalhealthcommission.ca/wp-content/uploads/2021/09/Structural_Stigma_Assessment_Report_eng.pdf

36.

Bell J. Beyond the politics of the closet: gay rights and the American state since the 1970s. Philadelphia: University of Pennsylvania Press; 2020.

37.

Levario A. Trump’s proposed budget cuts critical programs impacting LGBTQ people. Human Rights Campaign; 2017. https://www.hrc.org/news/trumps-proposed-budget-cuts-critical-programs-impacting-lgbtq-people

38.

Fieldstadt E. Activists say Florida Gov. DeSantis’ funding cuts will hurt Pulse survivors, other LGBTQ programs. NBC News; 2021. https://www.nbcnews.com/news/us-news/activists-say-florida-gov-desantis-funding-cuts-will-hurt-pulse-n1269649

39.

Hatzenbuehler ML, Jun H-J, Corliss HL, Austin SB. Structural stigma and cigarette smoking in a prospective cohort study of sexual minority and heterosexual youth. Ann Behav Med. 2014;47(1):48–56. https://doi.org/10.1007/s12160-013-9548-9.CrossRefPubMed

40.

Baltagi BH. Econometric analysis of panel data. 6th ed. Springer; 2021. Available: https://doi.org/10.1007/978-3-030-53953-5.

41.

National Academies of Sciences, Engineering, and Medicine. Understanding the well-being of LGBTQI+ populations. Washington: The National Academies Press; 2020. https://doi.org/10.17226/25877.CrossRef

42.

Salganik M. Bit by Bit. Princeton: Princeton University Press; 2019. Available: https://press.princeton.edu/books/paperback/9780691196107/bit-by-bit. Accessed 18 Jan 2022.

43.

Movement Advancement Project. “Mapping LGBTQ equality: 2010 to 2020,”. 2020. https://www.lgbtmap.org/2020-tally-report.

44.

Tran NK, Hatzenbuehler ML, Goldstein ND. Potential relationship between HIV criminalization and structural stigma related to sexual orientation in the United States. J Acquir Immune Defic Syndr. 2019;80(5):e106–8. https://doi.org/10.1097/QAI.0000000000001961.CrossRefPubMed

45.

Watson RJ, Fish JN, Denary W, Caba A, Cunningham C, Eaton LA. LGBTQ state policies: a lever for reducing SGM youth substance use and bullying. Drug Alcohol Depend. 2021;221:108659. https://doi.org/10.1016/j.drugalcdep.2021.108659.CrossRefPubMedPubMedCentral

46.

Cohen P, Cohen J, Aiken LS, West SG. The problem of units and the circumstance for POMP. Multivar Behav Res. 1999;34(3):315–46. https://doi.org/10.1207/S15327906MBR3403_2.CrossRef

47.

R Core Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2022. Available: https://www.R-project.org/.

48.

Cascalheira CJ. Structural stigma over time. Github; 2021. https://github.com/CJCascalheira/structural_stigma

49.

Honaker J, King G, Blackwell M. Amelia II: a program for missing data. J Stat Softw. 2011;45(7):1–47. https://doi.org/10.18637/jss.v045.i07.CrossRef

50.

Lancaster T. Orthogonal parameters and panel. Rev Econ Stud. 2002;69:647–66.CrossRef

51.

Pickup M, Hopkins V. Transformed-likelihood estimators for dynamic panel models with a very small T. Political Sci Res Methods. 2020;1–20. https://doi.org/10.1017/psrm.2020.30.

52.

Pickup M, Gustafson P, Cubranic D, Evans G. OrthoPanels: an R package for estimating a dynamic panel model with fixed effects using the orthogonal reparameterization approach. The R Journal. 2017;9(1):60–76. https://doi.org/10.32614/RJ-2017-003.CrossRef

53.

Pickup M. Introduction to time series analysis, vol. 174. Sage Publications, 2014. Available: https://doi.org/10.4135/9781483390857

54.

Thabane L, et al. A tutorial on sensitivity analyses in clinical trials: the what, why, when and how. BMC Med Res Methodol. 2013;13(1):92. https://doi.org/10.1186/1471-2288-13-92.CrossRefPubMedPubMedCentral

55.

Ji C. 2020 LGBTQ specific substance use service survey: A study on the availability and perceived helpfulness of treatment programs. Master’s thesis, University of Montana; 2021. Available: https://scholarworks.umt.edu/etd/11727

56.

Beach LB, et al. Barriers and facilitators to seeking HIV services in Chicago among young men who have sex with men: perspectives of HIV service providers. AIDS Patient Care STDS. 2018;32(11):468–76. https://doi.org/10.1089/apc.2018.0094.CrossRefPubMedPubMedCentral

57.

Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363–85. https://doi.org/10.1146/annurev.soc.27.1.363.CrossRef

58.

Sharman Z, editor. The remedy: Queer and trans voices on health and health care. Vancouver: Arsenal Pulp Press; 2016.

59.

Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. HHS Publication No. SMA 15-4927, NSDUH Series H-50; 2015. Available: https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm

60.

Movement Advancement Project. Snapshot: LGBTQ equality by state. LGBT Map; 2022. https://www.lgbtmap.org/equality-maps

61.

Human Rights Campaign. State scorecards. The State Equality Index; 2021. https://www.hrc.org/resources/state-scorecards

62.

Lavietes M, Ramos E. Nearly 240 anti-LGBTQ bills filed in 2022 so far, most of them targeting trans people. NBC News; 2022. https://www.nbcnews.com/nbc-out/out-politics-and-policy/nearly-240-anti-lgbtq-bills-filed-2022-far-targeting-trans-people-rcna20418 . Accessed 12 Apr 2022.

63.

T. A. Press. Alabama Legislature votes to ban gender-affirming medical care for transgender youth. NPR; 2022. Available: https://www.npr.org/2022/04/07/1091510026/alabama-gender-affirming-care-trans-transgender. Accessed 12 Apr 2022.

64.

Sharrow E, Sederbaum I. Analysis | Texas isn’t the only state denying essential medical care to trans youths. Here’s what’s going on. Washington Post; 2022. Available: https://www.washingtonpost.com/politics/2022/03/10/texas-trans-kids-abortion-lgbtq-gender-ideology/. Accessed 12 Apr 2022

Title: Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis
Authors: Cory J. Cascalheira
Emily C. Helminen
Thomas J. Shaw
Jillian R. Scheer
Publication date: 01-12-2022
Publisher: BioMed Central
Published in: BMC Public Health / Issue 1/2022
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-022-14315-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Structural determinants of tailored behavioral health services for sexual and gender minorities in the United States, 2010 to 2020: a panel analysis

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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