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. Author manuscript; available in PMC: 2021 Jan 9.
Published in final edited form as: J Health Care Poor Underserved. 2020;31(4):1693–1711. doi: 10.1353/hpu.2020.0127

The Confluence of Housing Instability and Psychosocial, Mental, and Physical Health in Sexual Minority Young Adults: The P18 Cohort Study

Caleb LoSchiavo 1, Kristen D Krause 1, Stuart N Singer 1, Perry N Halkitis 1
PMCID: PMC7794398  NIHMSID: NIHMS1656269  PMID: 33416747

Abstract

Sexual and gender minority (SGM) youth experience housing instability, including homelessness, at higher rates than heterosexuals. Few studies have examined differences within SGM populations and intersections of housing and health. Data were drawn from a study of SGM young adults who were assigned male at birth. Nearly one-quarter of the sample reported homelessness, unstable housing, or both in the six months prior to assessment. Housing instability was higher among those of lower income and educational attainment. Additionally, those who experienced any housing instability reported higher levels of depression, poorer self-rated health, and greater gay-related stigma; in multivariable models, only self-rated health was related to housing status. Stigma and discrimination may lead to poorer mental health; housing instability and homelessness may be a manifestation of stigma perpetuated by social conditions and mental health burdens directed by familial rejection. Findings indicate the importance of a biopsychosocial perspective in addressing housing instability in SGM youth.

Keywords: Mental health, health disparities, housing status, sexual and gender minorities, LGBT homelessness

Housing instability, which includes homelessness as well as precarious housing situations such as frequent moving and “couch surfing,” is a significant problem for sexual minority (lesbian, gay, bisexual, queer, or otherwise non-heterosexual) and gender minority (transgender and gender non-conforming) youth, who account for at least 40% of homeless youth in New York City1,2 and 20–40% across the U.S.3 A recent study found that sexual and gender minority (SGM) young adults were 120% more likely to experience homelessness in the previous year, along with increased risk for young adults who were people of color, were low-income, and had not completed high school or an equivalent General Education Diploma (GED).4 These high proportions may be underestimations, as housing status questionnaires often do not include items on sexual orientation and transgender identity, and because SGM youth are less likely to disclose their identities on surveys.5

Sexual and gender minority (SGM) youth and young adults who experience homelessness are more likely to do so because of familial rejection due to their sexual orientation or gender identity, which leads to poor health outcomes.6,7 Once SGM youth leave their homes, they are often exposed to more victimization and discrimination than their non-SGM peers, including violence and abuse faced in homeless shelters.3,8,9 Homeless SGM youth are also more likely than non- SGM homeless youth to experience worse physical and mental health, including depression, suicidality, substance abuse, and post-traumatic stress disorder6,8,10-13 and to be vulnerable to human trafficking.14-16

While many studies have examined associations between housing status and health, most research on SGM youth has compared SGM with non-SGM youth experiencing homelessness, wherein the health disparities may not be attributable to housing but to the psychosocial burdens experienced by individuals of sexual and/or gender minority status. Few studies have delineated differences between SGM youth who have and have not experienced housing instability. Rosario et al.11 report that that sexual minority youth with a history of homelessness are more likely than those without a history of homelessness to report subsequent psychological symptoms, including anxiety, depression, and substance abuse, even when controlling for factors such as history of sexual abuse and sexual orientation factors. Similarly, Krause et al.5 found that sexual minority men experiencing housing instability were more likely than those who were stably housed to report a history of childhood physical abuse, previous arrests, and a lack of basic needs in childhood— all psychosocial stressors that may be associated with poor health outcomes later in life. This more nuanced portrayal of housing status assesses not only where people are living—e.g., in a homeless shelter or on the streets—but also the precarious situations of those in unstable or unsustainable living arrangements— e.g., in a halfway house or temporarily staying with friends/family— which may be a precursor to or result of the same situation that may led to homelessness.5

Additionally, a small set of other studies found increased prevalence of depressive symptoms, substance use, and suicidality among SGM youth who experienced homelessness or housing instability, compared with SGM youth who did not.17-20 Our analysis adds to the existing literature by filling this gap, providing a comparison between SGM young adults who have and have not experienced housing instability.

Finally, through this analysis, we hope to redirect the perspective on the well-being of sexual minority young adults from one rooted in deficit to one rooted in resilience, a psychosocial construct defined by adversity and positive adaptation.21-23 A majority of research on homeless in SGM youth is deficit-focused, examining mental illness and other psychosocial burdens, and a far more limited set of literature has examined the roles of resilience and other strength-based factors. None of the 21 studies in a 2017 systematic review of literature on youth homelessness and resilience specifically discussed SGM youth,24 while only one of 14 studies in a 2019 review of homelessness among LGBTQ+ youth discussed resilience.25 The limited extant literature suggests that SGM youth who experience homelessness demonstrate resilience in order to thrive in their circumstances, and may rely on religion and spirituality as sources of resilience.26-28 Thus, this work adds to the growing body of literature by incorporating grit, a psychological trait combining perseverance and resilience, which may mediate the relationship between housing status and mental illness.29,30

Drawing on data from an investigation of emerging adult sexual minority men in New York City, we examine associations between housing status and health in a diverse sample of SGM young adults in New York City.

Methods

Study design.

The data for this cross-sectional analysis were drawn from the baseline of the second wave of the P18 Cohort Study, a prospective cohort study that examines the production of the syndemic of HIV, substance use, and mental health burden in a cohort of sexual and gender minority young adults in New York City; methods have been described in detail in previous publications.31 Briefly, recruitment for the study was conducted in two waves, beginning in 2009–2011 with a sample of participants who were age 18 or within the first quarter of their 19th birthday. Participants in the ensuing analyses were drawn from the second wave of the cohort study, which included both participants from the original cohort and new, age-matched participants recruited between 2014 and 2016. During this second wave of recruitment, participants were identified through a number of active and passive methods, including online (e.g., websites and mobile applications), in-person (e.g., community events), and referrals from other participants. Eligibility criteria for participants were: 22–23 years old, assigned male at birth, self-reported HIV negative or unknown HIV status, willing to receive testing for HIV and other STIs, and self-reported sexual activity with a male partner in the previous six months. Additional details regarding the P18 study design, recruitment, procedures, and data collection are available elsewhere.31,32

At baseline, this second wave of the cohort study included a racially/ethnically and socioeconomically diverse sample of 665 participants. Participants provided information on sociodemographic characteristics, mental health, and housing status via audio-computer assisted self-interview (ACASI) survey. Additionally, an Alere Determine™ rapid HIV-1/2 Ag/Ab combination test was conducted to confirm HIV serostatus. Prior to engaging in any study activity, participants provided written, informed consent. New York University’s Institutional Review Board approved all P18 study procedures and materials.

Measures.

Sociodemographic characteristics.

Data regarding sociodemographic characteristics, including race/ethnicity, sexual orientation, gender identity, education, and income were assessed using survey instruments included in the ACASI computer survey. Self-reported race/ethnicity was categorized as Hispanic/Latino, White non-Hispanic, Black non-Hispanic, and other non-Hispanic, which included those who identified as Asian or Pacific Islander, American Indian or Native American, other, and mixed race. Sexual identity was measured using the seven-point Kinsey scale33 and was dichotomized to “exclusively homosexual” and “not exclusively homosexual,” consistent with previous studies of this cohort.34 Gender identity was ascertained by asking participants if they identified as male, female, trans female, genderqueer, or with no gender; for the purpose of this study, responses were dichotomized as “male” or “transgender.” Highest level of educational attainment included junior high school diploma, high school diploma or GED, associate’s degree, bachelor’s degree, or graduate degree; these responses were then categorized as “high school or less” and “any college degree.” Participants also reported their total annual income, and responses were categorised, consistent with previous studies of this population, as less than $5,000, $5,000 to $25,000, and more than $25,000.34

Housing status.

Participants were asked two questions to assess their housing status during the past six months.35 Homelessness was measured by asking participants if, in the past six months, they had slept in any of the following places: the street, a park, abandoned building or automobile, public place (e.g., subway or bus station), shelter, limited stay/single room occupancy (SRO), and/or a welfare motel/hotel. Housing instability was measured by asking if, in the past six months, participants had lived in any of the following places: temporary or transitional housing, jail, drug treatment facility, halfway house, and/or temporarily living with friends/family. Based on their responses to these items, participants were categorized as housed, homeless, unstably housed, or both homeless and unstably housed in the past six months.

Mental health.

Mental health variables assessed included depression, anxiety, and post-traumatic stress. Depression was measured using the Beck Depression Inventory (BDI), a 21-item scale that measures symptoms and severity of depression.36 Based on clinical guidelines,37 BDI scores were then categorized as “none or minimal,” “mild to moderate,” “moderate to severe,” and “severe depression,” with the final three categories collapsed for analytic purposes. Anxiety was measured using the Beck Anxiety Inventory (BAI), a 21-item scale which measures symptoms and severity of anxiety.38 Based on clinical guidelines,39 BAI scores were then categorized as “none or minimal,” “mild to moderate,” “moderate to severe,” and “severe anxiety,” with the final three categories collapsed for analytic purposes. The PTSD (post-traumatic stress disorder) Checklist (PCL), a 17-item self-report scale, was used to assess post-traumatic stress disorder.40 Based on DSM-IV criteria and recommendations from the Mental Illness Research, Education and Clinical Centers (MIRECC) of the U.S. Department of Veterans Affairs, PCL scores were categorized as “symptomatic” and “not symptomatic.”41

General health.

Self-rated general health was assessed by asking participants to rate their health as excellent, very good, good, fair, or poor. For analytic purposes, the variable was dichotomised to “less than very good” and “very good or excellent” health, based on response rates for each level of the variable.

Other psychosocial covariates.

Additionally, grit and gay-related stigma were assessed as potential psychosocial covariates in the relationship between health and housing status. Grit was measured using the eight-item Short Grit Scale (Grit-S), and item scores were summed to create a single, linear variable.42 A higher score is indicative of being ‘extremely gritty’ while the lowest score suggests one is ‘not at all gritty.’42{Duckworth, 2009 #416} Gay-related stigma was adapted from a revised version of Berger’s stigma scale.43,44 The adapted gay-related stigma scale used five items—the personalized stigma and public attitudes subscales—to assess participants’ experiences with others’ reactions to their coming out and how they think LGBT people are perceived. The five items were summed to create a single, linear variable with higher scores indicating higher levels of gay-related stigma.

Analytic plan.

Data analysis was conducted using SPSS (IBM SPSS Statistics, Version 25.0). Univariate analyses were conducted to describe sample characteristics, experiences of housing instability, health, and other covariates. Bivariate analyses were undertaken using chi-squared tests of independence to determine associations of both sociodemographic factors and health variables with housing status (housed, homeless, unstably housed, both). Finally, separate binary logistic regression models were constructed to explain the combined effects of housing status and sociodemographic factors in associations with mental and general health.

Results

Sample characteristics.

A total of n = 665 participants with complete ACASI data were included in this analysis (Table 1). The average age of the sample was 22.98 years old (SD = 0.64). In terms of race and ethnicity, 32.2% (n = 214) were Hispanic/Latino, 27.4% (n = 182) were Black non-Hispanic, 25.1% (n = 167) were White non-Hispanic, and 15.3% (n = 102) were Asian/Pacific Islander, Native American, mixed, or another race. The majority of participants were born in the U.S. (84.2%, n = 560), identified as male (93.4%, n = 621), and tested HIV-negative (94.7%, n = 630). About half the sample had completed an associate’s, bachelor’s, or graduate degree (52.0%, n = 346) and about half identified as exclusively homosexual (50.1%, n = 333). About a third of the sample (32.9%, n = 219) had a total annual income of less than $5,000, 41.2% (n = 274) reported $5,000–24,999, and 21.1% (n = 140) reported $25,000 or greater.

Table 1.

BASELINE SAMPLE CHARACTERISTICS AND ASSOCIATIONS WITH HOUSING STATUS AMONG SEXUAL MINORITY YOUNG ADULTS IN NYC (N = 665)

Housing status past six months, % (n)
% (n) Housed Homeless Unstably
housed		 Both p
75.9 (505) 4.2 (28) 11.3 (75) 8.6 (57)
Agea 22.98 (0.64) 23.00 (0.64) 22.72 (0.65) 23.03 (0.68) 22.86 (0.56) .055
Race
 White non-Hispanic 25.1 (167) 83.8 (140) 0.6 (1) 11.4 (19) 4.2 (7)
 Hispanic/Latino 32.2 (214) 74.3 (159) 4.7 (10) 10.7 (23) 10.3 (22)
 Black non-Hispanic 27.4 (182) 71.4 (130) 6.0 (11) 11.5 (21) 11.0 (20)
 Other non-Hispanic 15.3 (102) 74.5 (76) 5.9 (6) 11.8 (12) 7.8 (8) .085
Gender
 Male 93.4 (621) 77.3 (480) 4.2 (26) 11.3 (70) 7.2 (45)
 Transgender 6.6 (44) 56.8 (25) 4.5 (2) 11.4 (5) 27.3 (12) <.001
Education status
 High school/GED or less 47.8 (318) 70.4 (224) 6.0 (1 9) 11.0 (35) 12.6 (40)
 Any college degree 52.0 (346) 80.9 (280) 2.6 (9) 11.6 (40) 4.9 (17) <.001
Total annual income
 < $5,000 32.9 (219) 67.6 (148) 5.9 (1 3) 11.9 (26) 14.6 (33)
 $5,000–24,999 41.2 (274) 75.9 (208) 4.7 (1 3) 12.0 (33) 7.3 (20)
 $25,000+ 21.1 (140) 89.3 (125) 0.7 (1) 7.1 (10) 2.9 (4) <.001
Country of origin
 Born in the US 84.2 (560) 76.8 (430) 3.9 (22) 11.3 (63) 8.0 (45)
 Not born in the US 15.6 (104) 72.1 (75) 5.8 (6) 11.5 (12) 10.6 (11) .652
HIV status
 Negative 94.7 (630) 76.3 (481) 3.8 (24) 11.4 (72) 8.4 (53)
 Positive 5.0 (33) 69.7 (23) 12.1 (4) 6.1 (2) 12.1 (4) .085
Sexual identity
 Not exclusively homosexual 49.9 (332) 72.0 (239) 5.1 (17) 12.0 (40) 10.8 (36)
 Exclusively homosexual 50.1 (333) 79.9 (266) 3.3 (11) 10.5 (35) 6.3 (21) .072
Depression (BDI)
 None or minimal 63.6 (423) 79.4 (336) 3.8 (16) 9.7 (41) 7.1 (30)
 Mild, moderate, or severe 31.9 (212) 69.3 (147) 5.7 (12) 1 3.7 (29) 11.3 (24) .045
Anxiety (BAI)
 None or minimal 69.8 (464) 78.7 (365) 4.1 (1 9) 10.1 (47) 7.1 (33)
 Mild, moderate, or severe 27.7 (184) 70.7 (130) 4.3 (8) 1 3.6 (25) 11.4 (21) .140
PTSD (PCL)
 Non- symptomatic 89.6 (596) 77.2 (460) 3.7 (22) 10.7 (64) 8.4 (50)
 Symptomatic 10.4 (69) 65.2 (45) 8.7 (6) 15.9 (11) 10.1 (7) .088
Self-rated general health
 Very good or excellent 73.4 (488) 78.3 (382) 4.5 (22) 10.5 (51) 6.8 (33)
 Less than very good 26.2 (174) 70.1 (122) 3.4 (6) 13.8 (24) 12.6 (22) .045
Grit-Sa 3.42 (0.66) 3.42 (0.67) 3.43 (0.52) 3.47 (0.67) 3.37 (0.67) .842
Gay-related stigmaa 10.38 (3.27) 10.03 (3.14) 12.93 (3.52) 10.31 (2.89) 12.52 (3.47) <.001
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Notes

a

Descriptive statistics reported as mean (standard deviation, range).

GED= General Education Diploma

BDI= Beck Depression Inventory

BAI= Beck Anxiety Inventory

PCL= PTSD (post-traumatic stress disorder) Checklist

The majority of participants reported experiencing neither homelessness nor unstable housing (75.9%, n = 505). In the previous six months, 4.2% (n = 28) reported only homelessness, 11.3% (n = 75) reported only unstable housing, and 8.6% (n = 57) reported both homelessness and unstable housing.

Most participants did not report clinically significant levels of depression (63.6%, 423), anxiety (69.8%, n = 464), or PTSD (89.6%, n = 596). About a quarter of participants rated their health as less than very good (26.2%, n = 174), with the rest reporting their health as very good or excellent (73.4%, n = 488). The average grit score was 3.42 (SD = 0.66, range: 1–5) indicating moderately high levels of grittiness in the sample. The average score on the gay-related stigma scale was 10.38 (SD = 3.27, range: 5–20), which demonstrates moderate experiences of perceived stigma based on one’s sexual orientation.

Bivariate analysis.

Table 1 summarizes the relationships between housing status and sociodemographic and health factors. Housing status was significantly associated with gender (p < .001), education (p < .001), income (p < .x001), depression (p < .05), self-rated health (p < .05), and gay-related stigma (p < .001). Those who were transgender, were less educated, were lower-income, had higher BDI scores, had poorer self-rated health, and had higher stigma scores were more likely than those in their respective comparison groups to report homelessness, unstable housing, or both.

Multivariable modeling.

Unadjusted binary logistic regression models were constructed for depression, anxiety, PTSD, and self-rated health (Table 2). All four health variables were significantly associated with each other, all at the p < .001 level, such that those with depression were more likely to be anxious (OR = 12.27, 95% CI: 8.17–18.42), symptomatic for PTSD (OR = 18.16, 95% CI: 8.80–37.48), and report poorer health (OR = 3.96, 95% CI: 2.73–5.74). Those with anxiety were also more likely to be symptomatic for PTSD (OR = 9.50, 95% CI: 5.37–16.82) and report poorer health (OR = 3.15, 95% CI: 2.18–5.57). Those who met criteria for PTSD were also more likely to rate their general health more poorly (OR = 2.57, 95% CI: 1.54–4.28). Additionally, increased grit was significantly associated with lower odds of depression (OR = 0.31, 95% CI: 0.23–0.41), anxiety (OR = 0.33, 95% CI: 0.24–0.44), PTSD (OR = 0.39, 95% CI: 0.26–0.58), and poorer self-rated health (OR = 0.50, 95% CI: 0.38–0.66), while higher stigma scores were associated with increased odds of depression (OR = 1.09, 95% CI: 1.04–1.15), anxiety (OR = 1.08, 95% CI: 1.02–1.13), and PTSD (OR = 1.18, 95% CI: 1.02–1.13).

Table 2.

UNADJUSTED BINARY LOGISTIC REGRESSIONS PREDICTING MENTAL AND GENERAL HEALTH

Depression
OR (95% CI)		 Anxiety
OR (95% CI)		 PTSD
OR (95% CI)		 Self-rated health
OR (95% CI)
Housing status
 Housed 1.00 1.00 1.00 1.00
 Homeless 1.71 (0.79–3.71) 1.18 (0.51–2.77) 2.79 (1.08–7.23)* 0.85 (0.34–2.15)
 Unstably housed 1.62 (0.97–2.70) 1.49 (0.88–2.52) 1.76 (0.86–3.57) 1.47 (0.87–2.49)
 Both 1.83 (1.03–3.24)* 1.79 (1.00–3.20) 1.43 (0.61–3.34) 2.09 (1.17–3.72)*
Race
 White non-Hispanic 1.00 1.00 1.00 1.00
 Hispanic/Latino 1.22 (0.78–.89) 0.95 (0.61–1.49) 2.87 (1.27–6.50)* 1.09 (0.69–1.71)
 Black non-Hispanic 0.79 (0.50–1.27) 0.53 (0.32–0.87)* 2.18 (0.92–5.16) 0.73 (0.45–1.20)
 Other non-Hispanic 1.78 (1.06–3.00)* 1.05 (0.62–1.79) 3.70 (1.52–8.99)** 1.07 (0.62–1.85)
Gender
 Male 1.00 1.00 1.00 1.00
 Transgender 2.34 (1.23–4.45)** 3.01 (1.62–5.59)*** 2.80 (1.32–5.96)** 2.05 (1.09–3.84)*
Education status
 High school/GED or less 1.00 1.00 1.00 1.00
 Any college degree 0.67 (0.48–0.94)* 0.93 (0.66–1.31) 0.48 (0.29–0.81)** 0.94 (0.67–1.34)
Total annual income
 < S5.000 1.00 1.00 1.00 1.00
 55,000–24,999 0.90 (0.62–1.31) 1.25 (0.83–1.86) 0.72 (0.41–1.25) 0.89 (0.59–1.33)
 525,000+ 0.58 (0.36–0.93)* 1.22 (0.76–1.96) 0.56 (0.27–1.16) 0.80 (0.49–1.31)
Country of origin
 Born in the US 1.00 1.00 1.00 1.00
 Not born in the US 0.99 (0.63–1.55) 1.13 (0.70–1.84) 0.87 (0.45–1.68) 0.91 (0.57–1.45)
HIV status
 Negative 1.00 1.00 1.00 1.00
 Positive 0.57 (0.24–1.33) 0.43 (0.16–1.14) 0.54 (0.13–2.32) 1.05 (0.48–2.30)
Sexual identity
 Not exclusively homosexual 1.00 1.00 1.00 1.00
 Exclusively homosexual 0.63 (0.45–0.87)** 0.61 (0.43–0.86)** 0.37 (0.21–0.64)*** 0.87 (0.62–1.24)
Anxiety (BAI)
 None or minimal 1.00 — — —
 Mild, moderate, or severe 12.27 (8.17–18.42)*** — — —
PTSD
 Not symptomatic 1.00 1.00 — —
 Symptomatic 18.16 (8.80–37.48)*** 9.50 (5.37–16.82)*** — —
Self-rated general health
 Very good or excellent 1.00 1.00 1.00  —
 Less than very good 3.96 (2.73–5.74)*** 3.15 (2.18–5.57)*** 2.57 (1.54–4.28)***  —
Grit-S 0.31 (0.23–0.41)*** 0.33 (0.24–0.44)*** 0.39 (0.26–0.58)*** 0.50 (0.38–0.66)***
Gay-related stigma 1.09 (1.04–1.15)*** 1.08 (1.02–1.13)** 1.18 (1.09–1.27)*** 1.03 (0.99–1.10)
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Notes

*

p < .05

**

p < .01

***

p < .001

GED= General Education Diploma

BAI= Beck Anxiety Inventory

PTSD= post-traumatic stress disorder

More severe depression was significantly independently associated with greater odds of experiencing both homelessness and unstable housing in the past six months (OR = 1.83, 95% CI: 1.03–3.24); identifying as a race other than White, Hispanic/Latino, or Black (OR = 1.78, 95% CI: 1.06–3.00); and being transgender (OR = 2.34, 95% CI: 1.23–4.45). Depression was also associated with lower odds of having any college degree (OR = 0.67, 95% CI: 0.48–0.94), an annual income of $25,000 or greater (OR = 0.58, 95% CI: 0.36–0.93), and an exclusively homosexual identity (OR = 0.63, 95% CI: 0.45–0.87). Anxiety was significantly associated with lower odds of identifying as Black compared with White (OR = 0.53, 95% CI: 0.32–0.87) and exclusively homosexual identity (OR = 0.61, 95% CI: 0.43–0.86), as well as greater odds of being transgender (OR = 3.01, 95% CI: 1.62–5.59), but was not associated with housing status.

Adjusted binary logistic regression analyses were constructed to explain the combined effects of housing status and covariates on depression, PTSD, and self-rated health (Table 3). When adjusting for significant covariates identified in unadjusted analyses, depression was no longer associated with housing, but was significantly associated with annual income ($25,000+ versus <$5,000; AOR = 0.51, 95% CI: 0.27–0.98), anxiety (AOR = 6.61, 95% CI: 4.07–10.72), PTSD (AOR = 8.07, 95% CI: 3.36–19.37), poorer self-rated health (AOR = 2.66, 95% CI: 1.63–4.36), and decreased grit (AOR = 0.48, 95% CI: 0.34–0.69). Post-traumatic stress disorder (PTSD) symptomatology was also no longer associated with housing in the adjusted model, but was associated with dichotomized sexual identity (AOR = 0.47, 95% CI: 0.25–0.91), depression (AOR = 8.46, 95% CI: 3.53–20.28), and anxiety (AOR = 3.42, 95% CI: 1.68–6.97). Self-rated health was significantly associated with housing status, such that those with poorer self-rated health were twice as likely to report both homelessness and housing instability (AOR = 2.01, 95% CI: 1.02–3.97), and was also associated with depression (AOR = 2.45, 95% CI: 1.54–3.91), anxiety (AOR = 1.66, 95% CI: 1.04–2.65), and decreased grit (AOR = 68, 95% CI: 0.49–0.92).

Table 3.

ADJUSTED BINARY LOGISTIC REGRESSIONS EXPLAIN ASSOCIATIONS BETWEEN HOUSING STATUS AND HEALTH

Depression
AOR (95% CI)		 PTSD
AOR (95% CI)		 Self-rated health
AOR (95% CI)
Housing status
 Housed 1.00 1.00 1.00
 Homeless 1.38 (0.49–3.85) 1.59 (0.48–5.29) 0.84 (0.31–2.26)
 Unstably housed 1.47 (0.72–2.99) 1.29 (0.53–3.13) 1.52 (0.85–2.73)
 Both 0.94 (0.40–2.20) 0.48 (0.16–1.47) 2.01 (1.02–3.97)*
Race
 White non-Hispanic 1.00 1.00 —
 Hispanic/Latino 1.05 (0.57–1.93) 2.49 (0.95–6.56) —
 Black non-Hispanic 0.76 (0.39–1.45) 2.96 (1.05–8.40)* —
 Other non-Hispanic 1.62 (0.81–3.27) 2.93 (1.03–8.34)* —
Gender
 Male 1.00 1.00 1.00
 Transgender 0.75 (0.28–2.03) 1.67 (0.60–4.64) 1.31 (0.60–2.86)
Education status
 High school/GED or less 1.00 1.00 —
 Any college degree 0.65 (0.41–1.05) 0.64 (0.34–1.20) —
Total annual income
 < $5,000 1.00 — —
 $5,000–24,999 0.88 (0.53–1.46) — —
 $25,000+ 0.51 (0.27–0.98)* — —
Sexual identity
 Not exclusively homosexual 1.00 1.00 —
 Exclusively homosexual 0.99 (0.62–1.55) 0.47 (0.25–0.91)* —
Depression (BDI)
 None or minimal — 1.00 1.00
 Mild, moderate, or severe — 8.46 (3.53–20.28)*** 2.45 (1.54–3.91)***
Anxiety (BAI)
 None or minimal 1.00 1.00 1.00
 Mild, moderate, or severe 6.61 (4.07–10.72)*** 3.42 (1.68–6.97)** 1.66 (1.04–2.65)*
PTSD
 Not symptomatic 1.00 — 1.00
 Symptomatic 8.07 (3.36–19.37)*** — 0.99 (0.53–1.83)
Self-rated general health
 Very good or excellent 1.00 1.00 —
 Less than very good 2.66 (1.63–4.36)*** 1.00 (0.53–1.91) —
Grit-S 0.48 (0.34–0.69)*** 0.74 (0.45–1.22) 0.68 (0.49–0.92)*
Gay-related stigma 1.05 (0.97–1.13) 1.09 (0.98–1.20) 0.99 (0.93–1.05)
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Notes

*

p < .05

**

p < .01

***

p < .001

GED= General Education Diploma

BDI= Beck Depression Inventory

BAI= Beck Anxiety Inventory

PTSD= post-traumatic stress disorder

Discussion

The findings of this study indicate that subgroups of sexual and gender minority (SGM) young adults experience disparities in housing status, which may be associated with disparate health outcomes. Those who identified as transgender, had a high school education or less, had lower annual incomes, met criteria for mild, moderate, or severe depression, rated their general health more poorly, and experienced greater levels of gay-related stigma were more likely than those in their respective comparison groups to report experiencing homelessness, unstable housing, or both forms of housing instability in the previous six months. These findings align with a syndemic model, wherein disparities such as mental health, physical health, and social determinants of health are viewed as co-occurring, synergistic, and mutually reinforcing.22,45

We also detected disparities in mental and overall physical health based on key covariates. Transgender participants, while only constituting 6.6% of the sample, were significantly more likely than male participants to report depression, anxiety, PTSD, and poorer general health. This finding aligns with numerous investigations that indicate that gender minority individuals experience heightened mental health challenges.46-48 While our study did not have a large enough proportion of transgender participants to investigate this finding in more detail, this relationship merits further investigation, particularly as it relates to housing instability, which may further increase risk for poor physical and mental health. Depression was associated with lower educational attainment and lower income, and PTSD was significantly more common among Hispanic/Latino participants and those who identified as mixed or another race. Racial and ethnic minorities also have been previously shown to experience heightened health disparities.49-51 Those who identified as exclusively homosexual had significantly lower odds of meeting criteria for depression, anxiety, and PTSD, compared with those who were not exclusively homosexual. Halkitis21 documents that sexual identity disclosure and negotiation ultimately protect the health of sexual minority men, and thus this finding aligns with this understanding.

An increase in grit scores was associated with decreased odds of reporting poorer health and meeting criteria for any of the three mental health factors and supports the protective effects of resilience.52,53 This has key implications for clinical care and research, as it points to the ways in which grit and other resilience-related constructs may improve health and reduce the negative health effects of adverse experiences. Meanwhile, increased gay-related stigma was associated with increased odds of meeting criteria for depression, anxiety, and PTSD. The role of stigma in creating health burdens for gay men has long been documented.54 However, stigma was not a significant covariate in the associations between housing and health, particularly when accounting for grit and other mental health symptoms, suggesting that resilience may act as a buffer in this relationship as well.

Controlling for variables associated with depression and PTSD in bivariate analyses explained the relationships between those health factors and housing status in our regression models, such that there were no longer mental health disparities by housing status. Housing status remained significantly associated with self-rated health, however, such that those who experienced both homelessness and housing instability in the past six months were twice as likely as stably housed participants to rate their general health poorly.

In considering these findings, it emerges that housing instability among this sample is not associated with depression, anxiety, or PTSD when controlling for stigma and grit. This suggests that discrimination and stigma experienced by SGM and racial/ethnic minority individuals may lead to poorer mental health states, as controlling for these factors explains the significant relationship between housing and mental health, and that the impact may be buffered by the positive effects of grit. Thus, while housing instability may be a manifestation of these mental health burdens, it may also be a result of familial and societal discrimination and stigma—assessment of these bidirectional relationships is beyond the scope of the present study. Additionally, housing instability and homelessness significantly increased the risk of participants’ poorer self-rating of general health more broadly. These results align with findings from other studies examining self-rated health and housing instability in people living with HIV/AIDS,55 sex workers,56 and non-SGM identified adults entering supportive housing,57 suggesting these perceptions can occur in numerous circumstances.

In considering this study in the context of previous literature, it is noteworthy that this study examined a large sample of sexual and gender minority young adults, and compared subgroups of housed versus unstably housed and homeless, whereas much of the previous literature has looked at samples of unstably housed and homeless people, and compared subgroups of sexual and gender minority versus non-SGM individuals. When comparing subgroups of SGM versus non-SGM in a larger sample of homeless/unstably housed people, previous findings have consistently shown significantly increased levels of mental health conditions such as depression, anxiety and PTSD among the SGM subgroups.8,11 When comparing subgroups of those who reported homelessness and/or unstable housing versus those with stable housing within a larger group of SGM, there is no significant difference in prevalence of increased psychological disorders like anxiety, depression and PTSD.

The inconsistency between these two frameworks suggests a need to further investigate the relationships between housing and health, to better explain differences in mental and physical health among SGM individuals of different housing statuses. When looking at a large sample of homeless and unstably housed individuals and comparing mental health symptomatology among SGM versus non-SGM, it is difficult to know if the conditions are a attributable to homelessness or to SGM status. Because our study found no significant difference among groups when comparing subgroups of SGM young adults with different housing status histories, it is possible that the differences that preious studies have found are attributable to SGM status rather than homelessness. If no difference in mental health exists because of housing status, it is also possible that there is something about SGM status that may be a protective factor against psychological disorders among those who are unstably housed or homeless. Resilience and/or grit may act as protective factors among SGM people, who have already faced adversity in many areas of their lives. This hypothesis is supported by our finding that controlling for grit was a key part in the lack of association between mental health symptomatology and housing, and aligns with the limited literature on the role of resilience in buffering the negative effects of homelessness for SGM populations.26-28 Further research is needed to better understand if and how resilience and/or grit operates among SGM populations who experience different forms of housing instability.

This study is not without limitations. It is important to note that this study took place in New York City, in which there are numerous available resources for those who are experiencing homelessness and unstable housing. Further, in New York City, there are many resources specifically available for SGM people who are homeless or unstably housed. Similar resources are generally not available in other parts of the country, meaning that the findings of this study may not be generalizable to both non-urban settings as well as urban settings that are not New York City. It is also important to consider the impact of social desirability bias. Although the use of ACASI aims to mitigate these effects,58 individuals may not have felt comfortable disclosing homelessness, housing instability, and symptoms of psychological distress, as there is still significant stigma around these topics. Another limitation may be the Aidala measure itself, which may not capture certain dimensions of housing instability among this particular subgroup of emerging adults, such as college students who are sleeping in libraries or student centers. A housing instability measure that has a greater range of age-specific options for emerging adults may be a useful focus for future research on housing instability among these groups. Finally, the cross-sectional nature of these data may limit the ability to determine causality in relationship to housing status and mental health. A longitudinal analysis after the completion of the second wave of the P18 Cohort Study will allow for further determination of the ways in which a change in housing status might affect mental health over time.

Further research is needed to better understand the relationship between housing and mental health among communities of SGM. This research may address the nature of housing as a pathway to intervene in improving health generally. From a research perspective, this may mean integrating housing into the assessment of social determinants of health generally, as well as the implementation of longitudinal research designs that assess changes in mental health state in relationship to changes in housing status. From a clinical perspective, it is important to consider the degree to which health care providers, specifically mental health care providers, are assessing housing status and providing necessary referrals that might address and ultimately decrease housing instability, particularly among SGM. This integration of housing into both primary and mental health care may help increase access to social services and case management, which may ultimately decrease housing instability and improve health outcomes.59 Finally, researchers and clinicians must consider how to incorporate a strength-based perspective (e.g., resilience and grit) into conversations around the intersectionality of health disparities. For too long, SGM in particular have been left out of these conversations, so integrating positive psychology principles into clinical training, research, and practice is a critical step in fostering positive social institutions and bolstering character strengths, including grit and perseverance.60 Furthermore, understanding how SGM individuals develop, harness, and grow these principles throughout adolescence and into emerging adulthood may help educators and practitioners create and tailor appropriate interventions and programs to address syndemic health conditions and intersectional health disparities.

Acknowledgments

Funding. Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award #s R01DA025537 and 2R01DA025537. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

  • 1.NYC Center for Innovation through Data Intelligence, NYC Department of Youth & Community Development. New York City youth count report 2017. New York, NY: The Center for Innovation through Data Intelligence, 2017. Available at: http://www1.nyc.gov/assets/cidi/downloads/pdfs/youth_count_report_2017_final.pdf. [Google Scholar]
  • 2.NYC Center for Innovation through Data Intelligence, NYC Department of Youth & Community Development. New York City youth count report 2016. New York, NY: The Center for Innovation through Data Intelligence, 2016. Available at: http://www1.nyc.gov/assets/cidi/downloads/pdfs/youth_count_report_2016.pdf. [Google Scholar]
  • 3.Quintana NS, Rosenthal J, Krehely J. On the streets: the federal response to gay and transgender homeless youth. Washington, DC: Center for American Progress, 2010. Available at: https://cdn.americanprogress.org/wp-content/uploads/issues/2010/06/pdf/lgbtyouthhomelessness.pdf. [Google Scholar]
  • 4.Morton MH, Dworsky A, Matjasko JL, et al. Prevalence and correlates of youth homelessness in the United States. J Adolesc Health. 2018. January;62(1):14–21. Epub 2017 Nov 15. 10.1016/j.jadohealth.2017.10.006 PMid:29153445 PMCid:PMC5826721 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Krause KD, Kapadia F, Ompad DC, et al. Early life psychosocial stressors and housing instability among young sexual minority men: the P18 cohort study. J Urban Health. 2016. June;93(3):511–25. 10.1007/s11524-016-0049-6 PMid:27169631 PMCid:PMC4899333 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Choi SK, Wilson BDM, Shelton J, et al. Serving our youth: the needs and experiences of lesbian, gay, bisexual, transgender, and questioning youth experiencing homelessness. Los Angeles, CA: The Williams Institute with True Colors Fund, 2015. Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Serving-Our-Youth-June-2015.pdf. [Google Scholar]
  • 7.Ryan C, Huebner D, Diaz RM, et al. Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009. January;123(1):346–52. 10.1542/peds.2007-3524 PMid:19117902 [DOI] [PubMed] [Google Scholar]
  • 8.Cochran BN, Stewart AJ, Ginzler JA, et al. Challenges faced by homeless sexual minorities: comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. Am J Public Health. 2002. May;92(5):773–7. 10.2105/AJPH.92.5.773 PMid:11988446 PMCid:PMC1447160 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Rew L, Whittaker TA, Taylor-Seehafer MA, et al. Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. J Spec Pediatr Nurs. 2005. Jan-Mar;10(1):11–9. 10.1111/j.1088-145X.2005.00003.x PMid:15673425 [DOI] [PubMed] [Google Scholar]
  • 10.Whitbeck LB, Chen X, Hoyt DR, et al. Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. J Sex Res. 2004. November;41(4):329–42. 10.1080/00224490409552240 PMid:15765273 [DOI] [PubMed] [Google Scholar]
  • 11.Rosario M, Schrimshaw EW, Hunter J. Homelessness among lesbian, gay, and bisexual youth: implications for subsequent internalizing and externalizing symptoms. J Youth Adolesc. 2012. May;41(5):544–60. Epub 2011 Jun 7. 10.1007/s10964-011-9681-3 PMid:21656284 PMCid:PMC3215813 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Rhoades H, Rusow JA, Bond D, et al. Homelessness, mental health and suicidality among LGBTQ youth accessing crisis services. Child Psychiatry Hum Dev. 2018. August;49(4):643–51. 10.1007/s10578-018-0780-1 PMid:29322361 [DOI] [PubMed] [Google Scholar]
  • 13.Keuroghlian AS, Shtasel D, Bassuk EL. Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. Am J Orthopsychiatry. 2014;84(1):66–72. 10.1037/h0098852 PMid:24826829 PMCid:PMC4098056 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.McClain NM, Garrity SE. Sex trafficking and the exploitation of adolescents. J Obstet Gynecol Neonatal Nurs. 2011. Mar-Apr;40(2):243–52. Epub 2011 Feb 1. 10.1111/j.1552-6909.2011.01221.x PMid:21284727 [DOI] [PubMed] [Google Scholar]
  • 15.Le PTD, Halkitis PN. Advancing the science on the biopsychosocial effects of human trafficking. Behav Med. 2018. Jul-Sep;44(3):175–6. 10.1080/08964289.2018.1465269 PMid:30020864 PMCid:PMC6167935 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Martinez O, Kelle G. Sex trafficking of LGBT individuals: a call for service provision, research, and action. Int Law News. 2013. Fall;42(4). [PMC free article] [PubMed] [Google Scholar]
  • 17.Clatts MC, Goldsamt L, Yi H, et al. Homelessness and drug abuse among young men who have sex with men in New York City: a preliminary epidemiological trajectory. J Adolesc. 2005. April;28(2):201–14. Epub 2005 Apr 9. 10.1016/j.adolescence.2005.02.003 PMid:15878043 PMCid:PMC2755549 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Kipke MD, Weiss G, Wong CF. Residential status as a risk factor for drug use and HIV risk among young men who have sex with men. AIDS Behav. 2007. November;11(6 Suppl):56–69. Epub 2007 Jan 30. 10.1007/s10461-006-9204-5 PMid:17265143 PMCid:PMC2930767 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Thiede H, Valleroy LA, MacKellar DA, et al. Regional patterns and correlates of substance use among young men who have sex with men in 7 US urban areas. Am J Public Health. 2003. November;93(11):1915–21. 10.2105/AJPH.93.11.1915 PMid:14600066 PMCid:PMC1448076 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Walls NE, Hancock P, Wisneski H. Differentiating the social service needs of homeless sexual minority youths from those of non-homeless sexual minority youths. J Child Poverty. 2007. September;13(2):177–205. 10.1080/10796120701520309 [DOI] [Google Scholar]
  • 21.Halkitis PN. Out in time: the public lives of gay men from Stonewall to the queer generation. New York, NY: Oxford University Press, 2019. 10.1093/oso/9780190686604.001.0001 [DOI] [Google Scholar]
  • 22.Halkitis PN, Wolitski RJ, Millett GA. A holistic approach to addressing HIV infection disparities in gay, bisexual, and other men who have sex with men. Am Psychol. 2013. May-Jun;68(4):261–73. 10.1037/a0032746 PMid:23688093 [DOI] [PubMed] [Google Scholar]
  • 23.Fletcher D, Sarkar M. Psychological resilience: a review and critique of definitions, concepts, and theory. Eur Psychol. 2013. April;18(1):12–23. 10.1027/1016-9040/a000124 [DOI] [Google Scholar]
  • 24.Cronley C, Evans R. Studies of resilience among youth experiencing homelessness: a systematic review. J Hum Behav Soc Environ. 2017. May;27(4):291–310. 10.1080/10911359.2017.1282912 [DOI] [Google Scholar]
  • 25.McCann E, Brown M. Homelessness among youth who identify as LGBTQ+: a systematic review. J Clin Nurs. 2019. June;28(11–12):2061–72. Epub 2019 Mar 11. 10.1111/jocn.14818 PMid:30786099 [DOI] [PubMed] [Google Scholar]
  • 26.Shelton J, Wagaman MA, Small L, et al. I’m more driven now: resilience and resistance among transgender and gender expansive youth and young adults experiencing homelessness. Int J Transgenderism. 2018. April;19(2):144–57. 10.1080/15532739.2017.1374226 [DOI] [Google Scholar]
  • 27.Alessi EJ, Greenfield B, Manning D, et al. Victimization and resilience among sexual and gender minority homeless youth engaging in survival sex. J Interpers Violence. 2020. January 10;886260519898434. [Online ahead of print.] 10.1177/0886260519898434 PMid:31920163 [DOI] [PubMed] [Google Scholar]
  • 28.Schmitz RM, Woodell B. Complex processes of religion and spirituality among mid-westen LGBTQ homeless young adults. Sex Cult. 2018. February;22:980–99. 10.1007/s12119-018-9504-8 [DOI] [Google Scholar]
  • 29.Duckworth AL, Peterson C, Matthews MD, et al. Grit: perseverance and passion for long-term goals. J Pers Soc Psychol. 2007. June;92(6):1087–101. 10.1037/0022-3514.92.6.1087 PMid:17547490 [DOI] [PubMed] [Google Scholar]
  • 30.Perkins-Gough D The significance of grit: a conversation with Angela Lee Duckworth. Educ Leadersh. 2013. September;71(1):14–20. [Google Scholar]
  • 31.Halkitis PN, Moeller RW, Siconolfi DE, et al. Measurement model exploring a syndemic in emerging adult gay and bisexual men. AIDS Behav. 2013. February;17(2):662–73. 10.1007/s10461-012-0273-3 PMid:22843250 PMCid:PMC3675898 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Halkitis PN, Kapadia F, Bub KL, et al. A longitudinal investigation of syndemic conditions among young gay, bisexual, and other MSM: The P18 cohort study. AIDS Behav. 2015. June;19(6):970–80. 10.1007/s10461-014-0892-y PMid:25192900 PMCid:PMC4362859 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Kinsey AC, Pomeroy WB, Martin CE, et al. Sexual behavior in the human male. Philadelphia, PA: Saunders, 1948. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Ristuccia A, LoSchiavo C, Halkitis PN, et al. Sexualised drug use among sexual minority young adults in the United States: The P18 cohort study. Int J Drug Policy. 2018. May;55:207–14. Epub 2018 Mar 31. 10.1016/j.drugpo.2018.03.014 PMid:29610012 PMCid:PMC5970984 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Aidala A, Cross JE, Stall R, et al. Housing status and HIV risk behaviors: implications for prevention and policy. AIDS Behav. 2005. September;9(3):251–65. 10.1007/s10461-005-9000-7 PMid:16088369 [DOI] [PubMed] [Google Scholar]
  • 36.Beck AT, Ward CH, Mendelson MM, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961. June;4(6):561–71. 10.1001/archpsyc.1961.01710120031004 PMid:13688369 [DOI] [PubMed] [Google Scholar]
  • 37.Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988. December;8(1):77–100. 10.1016/0272-7358(88)90050-5 [DOI] [Google Scholar]
  • 38.Beck AT, Epstein N, Brown G, et al. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988. December;56(6):893–7. 10.1037/0022-006X.56.6.893 PMid:3204199 [DOI] [PubMed] [Google Scholar]
  • 39.Julian LJ. Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res (Hoboken). 2011. November;63(Suppl 11):S467–72. 10.1002/acr.20561 PMid:22588767 PMCid:PMC3879951 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Blanchard EB, Jones-Alexander J, Buckley TC, et al. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996. August;34(8):669–73. 10.1016/0005-7967(96)00033-2 [DOI] [PubMed] [Google Scholar]
  • 41.American Psychiatric Association. Posttraumatic stress disorder In: American Psychiatric Association, ed. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association, 1994. [Google Scholar]
  • 42.Duckworth AL, Quinn PD. Development and validation of the short grit scale (grit-s). J Pers Assess. 2009. March;91(2):166–74. 10.1080/00223890802634290 PMid:19205937 [DOI] [PubMed] [Google Scholar]
  • 43.Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001. December;24(6):518–29. 10.1002/nur.10011 PMid:11746080 [DOI] [PubMed] [Google Scholar]
  • 44.Wright K, Naar-King S, Lam P, et al. Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth. J Adolesc Health. 2007. January;40(1):96–8. Epub 2006 Oct 27. 10.1016/j.jadohealth.2006.08.001 PMid:17185215 PMCid:PMC2001277 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Halkitis PN, Kupprat SA, Hampton MB, et al. Evidence for a syndemic in aging HIV-positive gay, bisexual, and other MSM: implications for a holistic approach to prevention and healthcare. Nat Resour Model. 2012. November 1;36(2):10 10.1111/napa.12009 PMid:24347817 PMCid:PMC3859453 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Bockting WO, Miner MH, Swinburne Romine RE, et al. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013. May;103(5):943–51. Epub 2013 Mar 14. 10.2105/AJPH.2013.301241 PMid:23488522 PMCid:PMC3698807 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Streed CG Jr, McCarthy EP, Haas JS. Association between gender minority status and self-reported physical and mental health in the United States. JAMA Intern Med. 2017. August 1;177(8):1210–2. 10.1001/jamainternmed.2017.1460 PMid:28558100 PMCid:PMC5818796 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet. 2016. July 23;388(10042):390–400. Epub 2016 Jun 17. 10.1016/S0140-6736(16)00683-8 [DOI] [PubMed] [Google Scholar]
  • 49.Sutter M, Perrin PB. Discrimination, mental health, and suicidal ideation among LGBTQ people of color. J Counsel Psychol. 2016. January;63(1):98–105. 10.1037/cou0000126 PMid:26751158 [DOI] [PubMed] [Google Scholar]
  • 50.Chen J, Vargas-Bustamante A, Mortensen K, et al. Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Med Care. 2016. February;54(2):140–6. 10.1097/MLR.0000000000000467 PMid:26595227 PMCid:PMC4711386 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015. September 23;10(9):e0138511 10.1371/journal.pone.0138511 PMid:26398658 PMCid:PMC4580597 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Halkitis PN, Krause KD, Vieira DL. Mental health, psychosocial challenges and resilience in older adults living with HIV In: Brennan-Ing M, DeMarco RF, eds. HIV and aging. Basel, Switzerland: Karger, 2017. 10.1159/000448564 PMid:27875833 [DOI] [PubMed] [Google Scholar]
  • 53.Lewis NM. Rupture, resilience, and risk: Relationships between mental health and migration among gay-identified men in North America. Health Place. 2014. May;27:212–9. Epub 2014 Mar 22. 10.1016/j.healthplace.2014.03.002 PMid:24662530 [DOI] [PubMed] [Google Scholar]
  • 54.Hatzenbuehler ML. Structural stigma and the health of lesbian, gay, and bisexual populations. Curr Dir Psychol Sci. 2014. April;23(2):127–32. 10.1177/0963721414523775 [DOI] [Google Scholar]
  • 55.Kidder DP, Wolitski RJ, Campsmith ML, et al. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health. 2007. December;97(12):2238–45. Epub 2007 Oct 30. 10.2105/AJPH.2006.090209 PMid:17971562 PMCid:PMC2089119 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Benoit C, Ouellet N, Jansson M. Unmet health care needs among sex workers in five census metropolitan areas of Canada. Can J Public Health. 2016. October;107(3):e266–71. 10.17269/CJPH.107.5178 PMid:27763841 PMCid:PMC6972162 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Henwood BF, Lahey J, Rhoades H, et al. Examining the health status of homeless adults entering permanent supportive housing. J Public Health (Oxf). 2018. June 1;40(2):415–8. 10.1093/pubmed/fdx069 PMid:28633500 PMCid:PMC6676969 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Ghanem KG, Hutton HE, Zenilman JM, et al. Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients. Sex Transm Infect. 2005. October;81(5):421–5. 10.1136/sti.2004.013193 PMid:16199744 PMCid:PMC1745029 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Nelson G, Aubry T, Lafrance A. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. Am J Orthopsychiatry. 2007. July;77(3):350–61. 10.1037/0002-9432.77.3.350 PMid:17696663 [DOI] [PubMed] [Google Scholar]
  • 60.Lytle MC, Vaughan MD, Rodriguez EM, et al. Working with LGBT individuals: incorporating positive psychology into training and practice. Psychol Sex Orientat Gend Divers. 2014. October;1(4):335–47. 10.1037/sgd0000064 PMid:25544947 PMCid:PMC4276565 [DOI] [PMC free article] [PubMed] [Google Scholar]

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