Abstract
Purpose: Sexual minority youth (SMY), particularly bisexual youth and youth unsure of their sexual identity, are at greater risk of poor mental and sexual health outcomes than heterosexual youth. The purpose of this study was to examine disparities in intimate partner violence (IPV) and mental and sexual health for Black and Latino/a bisexual and unsure youth compared with their White bisexual and unsure and Black and Latino/a heterosexual peers.
Methods: We used aggregated state and school district 2015 Youth Risk Behavior Survey data to demonstrate differences in mental health (e.g., depressive symptoms and suicidality), sexual health (e.g., number of sexual partners and contraceptive use), and physical and sexual IPV between Black and Latino/a bisexual and unsure youth, and their White bisexual and unsure and Black and Latino/a heterosexual peers.
Results: Bisexual and unsure youth had higher odds of depressive symptoms, suicidal ideation and plans, and physical IPV than their same-race heterosexual peers. Black and Latina bisexual and unsure females were more likely to report sexual health risk behaviors than Black and Latina heterosexual females. There were few differences between bisexual and unsure youth of color and White youth.
Conclusion: We add to a growing body of literature showing disparities in IPV and mental and sexual health among bisexual and unsure youth of color. Pronounced risk for poor health outcomes among bisexual and unsure females of color needs to be especially addressed by prevention and intervention efforts. We encourage further research on the health of SMY with multiple marginalized identities.
Keywords: adolescence, mental health, race/ethnicity, sex, sexual health, sexual minority youth
Introduction
Adolescence is a period marked by major physical, emotional, and social transitions1 and—although most adolescents thrive during this time—increased risk-taking behaviors that have implications for health outcomes in adolescence and across the life span. Sexual minority health disparities are especially pronounced in adolescence,2 suggesting that sexual minority youth (SMY) are particularly vulnerable to risk-related health outcomes. SMY are disclosing their identities to others at earlier ages,3,4 as the climate in the United States has become increasingly tolerant toward sexual minority people.5 This earlier disclosure often occurs in middle adolescence, an age period in which 14- to 17-year-old youth struggle to navigate stigmatized social differences.3,4 Understanding SMY's health risk during this period is critical for promoting healthy development throughout adolescence and beyond.
Adolescence is also a period when challenges related to mental health, sexuality, and relationships are prominent, with implications for health across the life span: poor outcomes in these areas are associated with mental and physical health problems in later life.6 Disparities in mental and sexual health between SMY and heterosexual youth are particularly concerning.7 Moreover, these disparities vary depending on sexual identity. We focus on youth at elevated risk of poor sexual and mental health outcomes: bisexual youth and youth unsure of their sexual identity. Meta-analyses show that bisexual people, including youth, are at greater risk of depression and suicidality compared with heterosexual people.8–10 Bisexual youth are also more likely to engage in sexual health risk behaviors, including unprotected sex,11 and are at higher risk for experiencing intimate partner violence (IPV) than heterosexual youth.12 There has been less research on youth unsure of or questioning their sexual identity; however, a growing body of literature shows elevated rates of depression and suicide risk,13 sexual health risk behaviors,11,13,14 and IPV15 in comparison with heterosexual youth.
Although there is increasing evidence that bisexual youth and youth unsure of their sexual identity are at higher risk of sexual and mental health concerns relative to heterosexual and gay/lesbian youth,8,10–13 little research has examined these disparities for bisexual and unsure youth of color. Considering both minority stress16 and intersectional perspectives,17,18 SMY of color likely experience stigma-based stressors related to their multiple marginalized identities that neither their White SMY nor heterosexual peers of color do. Examining broad population-level disparities in mental and sexual health outcomes among Black and Latino/a bisexual and unsure youth, while focusing specifically on comparisons at the within-group level (i.e., marginalized categories of sexual identity, race, and ethnicity), can point to important areas for understanding the role of multiple minority stressors in health. In doing so, we also can move research away from deficit-based models that consider White heterosexual youth to be the standard by which SMY are compared.
Examining the health of these youth has been difficult given few large nationally representative, population-based studies of youth that include measures of sexual and gender identities7,19; however, research on the health of adolescents at the intersection of multiple marginalized statuses of race, sexual minority status, and gender highlights the variability in mental and sexual health disparities among SMY of color by race, ethnicity, and gender. For example, one study found that Black SMY had lower risk and Latino/a SMY had higher risk of feeling sad compared with White SMY.20 Further, these differences were driven by female Black SMY and male Latino SMY. However, combining SMY into a single group prevents understanding the within-group experiences of bisexual and unsure youth of color.20
Recent studies, however, have provided more nuanced understandings of racial and ethnic differences in health by focusing on specific sexual minority subpopulations. In one study, the authors compared mental health outcomes by race within a sample of bisexual youth,21 and found that Black bisexual youth were less likely to report sadness/hopelessness and suicidal ideation than White bisexual youth and other bisexual youth of color. Rarely have studies had adequate sample sizes to examine health outcomes by sexual identity, race, and ethnicity; that is, bisexual and unsure youth of color compared with White bisexual and unsure youth and heterosexual youth of color. The complexity of disparities in mental and sexual health when sexual identity, race, and ethnicity are considered warrants a closer examination to elucidate disparities and similarities in health outcomes.
In this study, we used a large sample of high school students to examine health disparities between bisexual youth and youth unsure of their sexual identity compared with heterosexual youth. Specifically, we examined Black and Latino/a bisexual and youth unsure of their sexual identity in comparison with Black and Latino/a heterosexual youth and White bisexual and unsure youth, separately by sex, to understand mental and sexual health disparities at the intersection of race and ethnicity, sex, and sexual identity. In doing so, we fill an important gap in the literature on understanding disparities among youth with multiple marginalized identities in key health outcomes of adolescence.
Methods
Data and sample
Data came from aggregated state and urban school district responses to the 2015 Youth Risk Behavior Survey (YRBS), a school-based survey of 9th–12th grade students conducted by the Centers for Disease Control and Prevention (CDC) to assess adolescent risk behaviors. These data are representative of students in 17 large urban school districts and 24 states (Supplementary Table S1) that assessed sexual identity (n = 197,438). We limited the sample (n = 131,363) (Supplementary Table S2) to adolescents who identified their race or ethnicity as White (62.8%), Latino/a (18.5%), or Black (18.7%) and their sexual identity as bisexual (7.0%), unsure about their sexual identity (3.9%), and heterosexual (89.2%; weighted percentages shown). We did not include Asian American, American Indian/Native Alaskan, or Pacific Islander/Native Hawaiian youth due to small sample sizes. This project was approved by the Institutional Review Board at the University of Texas at Austin (protocol number 2017-01-0036).
Measures
The YRBS consists of risk behavior questions that the CDC has determined to be related to the most common causes of poor mental and physical health, disability, and death among adolescents.22 Thus, we included all available items for each of the three areas of interest for this study (IPV, mental health, and sexual health) because of their associations with negative health outcomes during and beyond adolescence.23
Intimate partner violence
Physical IPV was measured with the question, “During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)” Sexual IPV in a relationship was measured with the question, “During the past 12 months, how many times did someone you were dating or going out with force you to do sexual things that you did not want to do? (Count such things as kissing, touching, or being physically forced to have sexual intercourse.)” These items were dichotomized such that response options of “0 times” = 0 and response options of “1 time,” to “6 or more times” = 1. Those who responded “I did not date or go out with anyone during the past 12 months” were excluded.
Mental health
Depressive symptoms were measured with one question, “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” (yes/no). Suicidal ideation was measured with the question, “During the past 12 months, did you ever seriously consider attempting suicide?” (yes/no). Having a suicide plan was measured with the question, “During the past 12 months, did you make a plan about how you would attempt suicide?” (yes/no). Suicidal behavior was measured with the question, “During the past 12 months, how many times did you actually attempt suicide?” Response options ranged from “0 times” to “6 or more times,” and were dichotomized (0 times = 0, 1 or more times = 1). Treatment for suicidal behavior was assessed with the question, “If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?” (yes/no).
Sexual health
Ever had sexual intercourse was measured with the question, “Have you ever had sexual intercourse?” (yes/no). Those who reported “no” were excluded from subsequent sexual health analyses. Sex before age 13 was measured with the question, “How old were you when you had sexual intercourse for the first time?” Responses ranged in yearly increments from “11 years old or younger” to “17 years old or older,” and were recoded to 0 = sex before age 13 and 1 = sex after age 13. Number of sexual partners was measured with the question, “During your life, with how many people have you had sexual intercourse?” and dichotomized (“1 person” to “4 people” = 0; “5 people” to “6 or more people” = 1). Recent sexual activity was measured with the question, “During the past 3 months, with how many people did you have sexual intercourse?” Responses were dichotomized (“I have had sexual intercourse, but not during the past 3 months” = 0; “1 person” to “6 or more people” = 1).
Condom use at last sexual intercourse was measured with the question, “The last time you had sexual intercourse, did you or your partner use a condom?” (yes/no). Contraceptive use at last intercourse was measured with the question, “The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?” Reported use of birth control pills, an intrauterine device or implant, or a shot, patch, or birth control ring was coded as 1; responses of “no method was used to prevent pregnancy,” “withdrawal or some other method,” and “not sure” were coded as 0.
Analysis plan
Data were analyzed using Stata 15 (StataCorp LLC, College Station, TX) with the svyset and svy complex survey commands to account for sampling design and weights. Black and bisexual, Latino/a and bisexual, Black and unsure about sexual identity, and Latino/a and unsure about sexual identity were entered as predictors into a logistic regression with dichotomous outcomes. We controlled for grand-mean-centered age (M = 3.80). In addition, we controlled for the sex of sexual partners (no sexual contacts, other sex only, both sexes, same sex only), considering that risk for negative mental and sexual health behavior differs depending on sex of sexual partners.24,25 We included sex of sexual partners with three variables effect coded as either −1, 0, or 1. Results are thus estimated for the average participant in the data. Analyses were stratified by sex.
Results
Bisexual and unsure males of color compared with Black heterosexual males
Bisexual and unsure males of color had higher odds of physical and sexual IPV victimization, depressive symptoms, and suicidal ideation compared with their Black heterosexual peers (Table 1). Further, except for Black unsure males, bisexual and unsure males of color had higher odds of having a suicide plan. Latino bisexual males had lower odds of having had five or more lifetime sexual partners.
Table 1.
Odds Ratios Comparing Black and Latino Bisexual and Unsure Males with Black Heterosexual Males
| Black bisexual |
Latino bisexual |
Black unsure |
Latino unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 7944) | 3.87** | 1.53–9.77 | 2.79** | 1.45–5.36 | 4.45*** | 2.04–9.73 | 3.95*** | 1.78–8.78 |
| Sexual IPV (n = 7626) | 3.17* | 1.17–8.61 | 2.35* | 1.15–4.79 | 4.51** | 1.70–11.94 | 2.50* | 1.19–5.25 |
| Depressive symptoms (n = 12,465) | 2.65** | 1.39–5.05 | 3.83*** | 2.22–6.60 | 1.55* | 1.00–2.39 | 2.28* | 1.17–4.46 |
| Suicidal ideation (n = 12,145) | 5.25*** | 2.90–9.53 | 7.96*** | 4.33–14.60 | 3.33*** | 1.77–6.28 | 4.40*** | 2.50–7.77 |
| Suicide plan (n = 11,321) | 3.71*** | 1.94–7.10 | 3.49*** | 1.77–6.91 | 1.75 | 0.81–3.79 | 2.87** | 1.37–6.01 |
| Suicide attempt (n = 551) | 1.81 | 0.43–7.57 | 1.38 | 0.54–3.54 | 1.07 | 0.28–4.05 | 1.77 | 0.52–6.07 |
| Suicide treatment (n = 201) | 1.00 | 0.17–5.82 | 0.29 | 0.05–1.86 | 0.99 | 0.14–7.01 | 1.14 | 0.22–5.96 |
| Ever had sexual intercourse (n = 9490) | 2.20 | 0.66–7.40 | 2.00 | 0.54–7.40 | 1.29 | 0.31–5.28 | 1.63 | 0.56–4.71 |
| Sex before age 13 (n = 4714) | 0.85 | 0.24–3.00 | 2.21 | 0.94–5.23 | 0.68 | 0.18–2.57 | 1.79 | 0.75–4.28 |
| Sex with five or more partners (n = 4626) | 0.37 | 0.12–1.12 | 0.41* | 0.17–0.99 | 0.70 | 0.20–2.37 | 0.45 | 0.10–1.97 |
| Recent sexual activity (n = 4677) | 1.06 | 0.31–3.57 | 0.94 | 0.35–2.51 | 0.77 | 0.19–3.07 | 1.04 | 0.33–3.32 |
| Condom use (n = 4515) | 0.48 | 0.14–1.69 | 1.09 | 0.42–2.81 | 0.54 | 0.17–1.66 | 0.31 | 0.08–1.22 |
| Contraceptive use (n = 4766) | 1.10 | 0.28–4.34 | 1.80 | 0.75–4.32 | 0.74 | 0.25–2.16 | 0.83 | 0.29–2.38 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
AOR, adjusted odds ratio; CI, confidence interval; IPV, intimate partner violence.
Bisexual and unsure males of color compared with Latino heterosexual males
Compared with Latino heterosexual males, bisexual and unsure males of color had higher odds of physical and sexual IPV and suicidal ideation (Table 2). All but Black unsure males had higher odds of depressive symptoms and having a suicide plan.
Table 2.
Odds Ratios Comparing Black and Latino Bisexual and Unsure Males with Latino Heterosexual Males
| Black bisexual |
Latino bisexual |
Black unsure |
Latino unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 9755) | 3.08* | 1.30–7.27 | 2.38** | 1.41–4.02 | 3.50** | 1.65–7.44 | 3.14* | 1.09–9.00 |
| Sexual IPV (n = 9231) | 3.02* | 1.20–7.61 | 2.25* | 1.05–4.82 | 4.43** | 1.81–10.80 | 2.31** | 1.23–4.33 |
| Depressive symptoms (n = 16,112) | 2.10* | 1.15–3.86 | 3.23*** | 1.69–6.18 | 1.32 | 0.87–2.03 | 2.03* | 1.08–3.79 |
| Suicidal ideation (n = 15,604) | 3.51*** | 1.89–6.52 | 5.56*** | 2.44–12.67 | 2.43** | 1.27–4.64 | 3.38*** | 2.23–5.12 |
| Suicide plan (n = 14,111) | 2.81** | 1.42–5.55 | 2.75** | 1.41–5.35 | 1.40 | 0.68–2.88 | 2.34** | 1.28–4.29 |
| Suicide attempt (n = 852) | 1.01 | 0.21–4.89 | 1.01 | 0.35–2.93 | 0.73 | 0.20–2.59 | 1.83 | 0.48–6.96 |
| Suicide treatment (n = 304) | 1.66 | 0.22–12.79 | 0.55 | 0.09–3.50 | 1.09 | 0.13–9.29 | 2.46 | 0.49–12.30 |
| Ever had sexual intercourse (n = 12,917) | 1.99 | 0.71–5.60 | 1.90 | 0.70–5.16 | 1.44 | 0.38–5.43 | 1.89 | 0.66–5.39 |
| Sex before age 13 (n = 5436) | 0.55 | 0.17–1.72 | 1.32 | 0.63–2.79 | 0.39 | 0.12–1.29 | 0.99 | 0.45–2.19 |
| Sex with five or more partners (n = 5368) | 0.64 | 0.22–1.84 | 0.74 | 0.37–1.50 | 1.30 | 0.40–4.27 | 0.89 | 0.22–3.68 |
| Recent sexual activity (n = 5395) | 0.63 | 0.23–1.77 | 0.59 | 0.19–1.82 | 0.60 | 0.17–2.16 | 0.87 | 0.32–2.39 |
| Condom use (n = 5230) | 0.89 | 0.26–3.06 | 1.88 | 0.67–5.31 | 0.88 | 0.28–2.71 | 0.48 | 0.13–1.76 |
| Contraceptive use (n = 5500) | 1.06 | 0.32–3.50 | 1.66 | 0.68–4.06 | 0.75 | 0.27–2.05 | 0.93 | 0.32–2.72 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Bisexual and unsure males of color compared with White bisexual and unsure males
Compared with White bisexual males, Black and Latino unsure males had lower odds of reporting depressive symptoms (Table 3); Black unsure males also had lower odds of reporting suicidal ideation, having a suicide plan, and having had sex before age 13. Black bisexual and unsure males and Latino unsure males had higher odds of reporting treatment for suicide. Finally, Black and Latino bisexual males had higher odds of ever having had sex. Compared with White unsure males (Table 4), Black and Latino bisexual males had higher odds of ever having had sex. Latino bisexual males also had higher odds of suicidal ideation, having had sex before age 13, and condom and contraceptive use, but lower odds of having had sex with five or more partners.
Table 3.
Odds Ratios Comparing Black and Latino Bisexual and Unsure Males with White Bisexual Males
| Black bisexual |
Latino bisexual |
Black unsure |
Latino unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 1893) | 1.45 | 0.57–3.70 | 1.10 | 0.48–2.54 | 1.72 | 0.63–4.69 | 1.56 | 0.56–4.34 |
| Sexual IPV (n = 1589) | 1.21 | 0.44–3.28 | 0.97 | 0.56–1.70 | 1.62 | 0.59–4.45 | 0.85 | 0.32–2.25 |
| Depressive symptoms (n = 3057) | 0.61 | 0.31–1.22 | 0.86 | 0.50–1.50 | 0.33*** | 0.20–0.57 | 0.46* | 0.23–0.94 |
| Suicidal ideation (n = 2747) | 0.75 | 0.40–1.44 | 1.12 | 0.56–2.24 | 0.45* | 0.22–0.90 | 0.57 | 0.30–1.11 |
| Suicide plan (n = 2860) | 0.84 | 0.43–1.63 | 0.73 | 0.36–1.48 | 0.36* | 0.16–0.81 | 0.55 | 0.24–1.24 |
| Suicide attempt (n = 389) | 1.35 | 0.23–7.89 | 1.07 | 0.46–2.46 | 0.85 | 0.20–3.73 | 1.50 | 0.59–3.81 |
| Suicide treatment (n = 170) | 7.07* | 1.06–47.35 | 1.97 | 0.20–19.10 | 8.93** | 1.76–45.26 | 6.22* | 1.04–37.03 |
| Ever had sexual intercourse (n = 1911) | 3.33* | 1.14–9.69 | 3.12* | 1.22–8.01 | 2.81 | 0.52–15.06 | 3.66 | 0.70–18.98 |
| Sex before age 13 (n = 861) | 0.31 | 0.07–1.40 | 0.72 | 0.25–2.09 | 0.23* | 0.06–0.95 | 0.54 | 0.21–1.39 |
| Sex with five or more partners (n = 849) | 0.98 | 0.29–3.38 | 1.15 | 0.44–3.00 | 1.90 | 0.52–6.99 | 1.52 | 0.38–6.06 |
| Recent sexual activity (n = 861) | 0.94 | 0.30–2.97 | 0.86 | 0.32–2.28 | 0.94 | 0.24–3.59 | 1.41 | 0.43–4.63 |
| Condom use (n = 838) | 1.10 | 0.31–3.90 | 2.06 | 0.71–5.99 | 1.03 | 0.34–3.17 | 0.58 | 0.15–2.20 |
| Contraceptive use (n = 876) | 1.38 | 0.29–6.65 | 1.94 | 0.61–6.19 | 0.75 | 0.21–2.68 | 0.72 | 0.28–1.89 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Table 4.
Odds Ratios Comparing Black and Latino Bisexual and Unsure Males with White Unsure Males
| Black bisexual |
Latino bisexual |
Black unsure |
Latino unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 1663) | 1.49 | 0.54–4.08 | 1.01 | 0.50–2.05 | 1.70 | 0.69–4.18 | 1.57 | 0.55–4.47 |
| Sexual IPV (n = 1384) | 1.21 | 0.40–3.66 | 0.90 | 0.40–2.03 | 1.70 | 0.63–4.60 | 0.93 | 0.33–2.64 |
| Depressive symptoms (n = 2995) | 1.18 | 0.61–2.28 | 1.81 | 0.94–3.49 | 0.71 | 0.42–1.20 | 1.08 | 0.57–2.04 |
| Suicidal ideation (n = 2669) | 1.53 | 0.76–3.06 | 2.20* | 1.11–4.37 | 0.92 | 0.47–1.80 | 1.19 | 0.65–2.16 |
| Suicide plan (n = 2793) | 1.36 | 0.69–2.67 | 1.23 | 0.63–2.38 | 0.58 | 0.27–1.24 | 0.91 | 0.44–1.91 |
| Suicide attempt (n = 346) | 1.47 | 0.23–9.51 | 1.25 | 0.45–3.43 | 1.02 | 0.30–3.45 | 1.95 | 0.81–4.68 |
| Suicide treatment (n = 151) | 1.78 | 0.25–12.75 | 0.38 | 0.03–4.35 | 1.18 | 0.14–9.68 | 1.94 | 0.54–6.91 |
| Ever had sexual intercourse (n = 1830) | 3.10* | 1.11–8.71 | 2.84* | 1.10–7.30 | 2.39 | 0.58–9.87 | 3.01 | 0.88–10.27 |
| Sex before age 13 (n = 747) | 1.60 | 0.49–5.20 | 3.66* | 1.33–10.05 | 0.89 | 0.25–3.22 | 2.08 | 0.91–4.76 |
| Sex with five or more partners (n = 726) | 0.33 | 0.10–1.10 | 0.39* | 0.16–0.96 | 0.74 | 0.20–2.66 | 0.60 | 0.16–2.34 |
| Recent sexual activity (n = 743) | 0.47 | 0.16–1.40 | 0.44 | 0.17–1.15 | 0.47 | 0.12–1.82 | 0.71 | 0.20–2.44 |
| Condom use (n = 718) | 1.64 | 0.36–7.41 | 3.57* | 1.19–10.75 | 1.61 | 0.45–5.71 | 0.80 | 0.20–3.21 |
| Contraceptive use (n = 760) | 3.04 | 0.63–14.70 | 4.84** | 1.78–13.16 | 2.01 | 0.56–7.23 | 1.92 | 0.68–5.39 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01.
Bisexual and unsure females of color compared with Black heterosexual females
Except for Black bisexual females, bisexual and unsure females of color had higher odds of physical and sexual IPV compared with Black heterosexual females (Table 5). All groups of bisexual and unsure females of color had higher odds of depressive symptoms, suicidal ideation, and having a suicide plan. Black and Latina bisexual females had higher odds of ever having had sexual intercourse; Black bisexual females also had lower odds of having had sexual intercourse in the past 3 months and condom use at last sexual intercourse. Latina unsure females had higher odds of having had five or more lifetime sexual partners and lower odds of having had sexual intercourse before age 13, and condom and contraceptive use at last sexual intercourse. Finally, Black unsure females had lower odds of contraceptive use at last intercourse.
Table 5.
Odds Ratios Comparing Black and Latina Bisexual and Unsure Females with Black Heterosexual Females
| Black bisexual |
Latina bisexual |
Black unsure |
Latina unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 9817) | 1.46 | 0.86–2.50 | 2.16** | 1.20–3.86 | 4.41*** | 1.91–10.17 | 2.64*** | 1.59–4.36 |
| Sexual IPV (n = 9527) | 1.10 | 0.73–1.66 | 1.92** | 1.21–3.04 | 3.51* | 1.17–10.52 | 3.86*** | 2.29–6.49 |
| Depressive symptoms (n = 15,616) | 1.98*** | 1.45–2.71 | 5.31*** | 3.79–7.45 | 2.83*** | 1.94–4.14 | 3.61*** | 2.57–5.06 |
| Suicidal ideation (n = 15,344) | 1.84*** | 1.32–2.57 | 4.81*** | 3.43–6.73 | 2.74*** | 1.81–4.14 | 3.18*** | 2.28–4.45 |
| Suicide plan (n = 13,912) | 2.21*** | 1.46–3.35 | 5.33*** | 3.45–8.24 | 2.71*** | 1.72–4.26 | 3.48*** | 2.33–5.19 |
| Suicide attempt (n = 1155) | 0.86 | 0.41–1.81 | 1.50 | 0.73–3.05 | 1.86 | 0.57–6.12 | 0.95 | 0.40–2.26 |
| Suicide treatment (n = 531) | 0.81 | 0.24–2.78 | 0.77 | 0.32–1.86 | 0.53 | 0.08–3.44 | 0.79 | 0.22–2.77 |
| Ever had sexual intercourse (n = 13,323) | 1.76* | 1.03–3.01 | 1.75* | 1.09–2.81 | 0.96 | 0.44–2.10 | 1.53 | 0.64–3.63 |
| Sex before age 13 (n = 4894) | 0.71 | 0.36–1.40 | 0.80 | 0.49–1.30 | 0.33 | 0.08–1.36 | 0.39* | 0.18–0.86 |
| Sex with five or more partners (n = 4853) | 1.25 | 0.61–2.58 | 0.78 | 0.42–1.47 | 1.35 | 0.47–3.90 | 1.90* | 1.14–3.17 |
| Recent sexual activity (n = 4880) | 0.57* | 0.33–0.97 | 0.85 | 0.51–1.39 | 0.78 | 0.26–2.34 | 0.90 | 0.35–2.28 |
| Condom use (n = 4762) | 0.66* | 0.44–0.99 | 1.12 | 0.80–1.58 | 0.84 | 0.51–1.38 | 0.48* | 0.25–0.94 |
| Contraceptive use (n = 4946) | 0.74 | 0.43–1.27 | 0.82 | 0.49–1.37 | 0.62* | 0.38–0.99 | 0.29*** | 0.14–0.61 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Bisexual and unsure females of color compared with Latina heterosexual females
Compared with Latina heterosexual females, Black unsure and Latina bisexual and unsure females had higher odds of physical IPV (Table 6). Latina unsure females also had higher odds of sexual IPV. Bisexual and unsure females of color had higher odds of depressive symptoms, suicidal ideation, and having a suicide plan. Black and Latina bisexual females also had higher odds of ever having had sexual intercourse. In addition, Black bisexual females had lower odds of having had sexual intercourse in the past 3 months and condom use at last sexual intercourse. Latina unsure females had higher odds of having had five or more lifetime sexual partners, and lower odds of having sexual intercourse before age 13 and contraceptive use at last sexual intercourse.
Table 6.
Odds Ratios Comparing Black and Latina Bisexual and Unsure Females with Latina Heterosexual Females
| Black bisexual |
Latina bisexual |
Black unsure |
Latina unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 11,918) | 1.41 | 0.88–2.27 | 2.06* | 1.14–3.72 | 4.22** | 1.56–11.42 | 2.76*** | 1.59–4.78 |
| Sexual IPV (n = 11,467) | 0.82 | 0.57–1.18 | 1.42 | 0.88–2.30 | 2.56 | 0.85–7.68 | 2.86*** | 1.67–4.88 |
| Depressive symptoms (n = 18,982) | 1.47* | 1.07–2.00 | 4.14*** | 2.91–5.89 | 2.21*** | 1.47–3.33 | 2.83*** | 1.98–4.06 |
| Suicidal ideation (n = 18,621) | 1.50* | 1.07–2.11 | 4.07*** | 2.93–5.66 | 2.32*** | 1.55–3.46 | 2.73*** | 1.94–3.83 |
| Suicide plan (n = 16,581) | 1.71** | 1.18–2.49 | 4.36*** | 2.70–7.04 | 2.19*** | 1.40–3.42 | 2.88*** | 1.97–4.21 |
| Suicide attempt (n = 1730) | 0.77 | 0.38–1.56 | 1.19 | 0.60–2.36 | 1.35 | 0.44–4.13 | 0.67 | 0.30–1.52 |
| Suicide treatment (n = 782) | 1.06 | 0.38–2.98 | 1.02 | 0.51–2.06 | 0.80 | 0.11–5.60 | 1.08 | 0.28–4.19 |
| Ever had sexual intercourse (n = 16,447) | 1.96* | 1.13–3.39 | 1.92** | 1.19–3.08 | 1.11 | 0.53–2.34 | 1.71 | 0.77–3.79 |
| Sex before age 13 (n = 6038) | 0.66 | 0.31–1.43 | 0.74 | 0.42–1.29 | 0.29 | 0.07–1.29 | 0.33* | 0.13–0.81 |
| Sex with five or more partners (n = 5991) | 1.60 | 0.82–3.11 | 1.00 | 0.57–1.77 | 1.77 | 0.60–5.19 | 2.60*** | 1.69–4.01 |
| Recent sexual activity (n = 6038) | 0.54* | 0.33–0.89 | 0.80 | 0.49–1.31 | 0.75 | 0.24–2.31 | 0.87 | 0.34–2.24 |
| Condom use (n = 5876) | 0.65* | 0.44–0.96 | 1.11 | 0.82–1.51 | 0.83 | 0.48–1.41 | 0.45 | 0.20–1.00 |
| Contraceptive use (n = 6105) | 0.69 | 0.41–1.17 | 0.77 | 0.47–1.25 | 0.58* | 0.34–0.98 | 0.30** | 0.13–0.70 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Bisexual and unsure females of color compared with White bisexual and unsure females
Compared with White bisexual females, Black bisexual females had lower odds, but Latina unsure females had higher odds, of reporting sexual IPV (Table 7). Black bisexual and unsure and Latina unsure females had lower odds of reporting depressive symptoms and suicidal ideation. Black bisexual females also had lower odds of reporting a suicide plan. Latina bisexual females had higher odds of condom use, while Latina unsure females had lower odds of having had sex before age 13 and contraceptive use. Compared with White unsure females (Table 8), Black unsure females had higher odds of reporting physical IPV. Black bisexual females had lower odds of reporting suicidal ideation, while Latina bisexual females reported higher odds of depressive symptoms and having a suicide plan, but lower odds of receiving treatment for suicide. Black bisexual and Latina bisexual and unsure females had higher odds of ever having had sexual intercourse, with Latina bisexual females having higher odds of condom use.
Table 7.
Odds Ratios Comparing Black and Latina Bisexual and Unsure Females with White Bisexual Females
| Black bisexual |
Latina bisexual |
Black unsure |
Latina unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 6251) | 0.79 | 0.49–1.29 | 1.15 | 0.69–1.91 | 2.30 | 0.84–6.32 | 1.44 | 0.79–2.63 |
| Sexual IPV (n = 5217) | 0.57* | 0.37–0.88 | 0.99 | 0.61–1.61 | 1.73 | 0.62–4.82 | 1.78* | 1.00–3.16 |
| Depressive symptoms (n = 8960) | 0.35*** | 0.26–0.49 | 0.93 | 0.68–1.27 | 0.49*** | 0.33–0.74 | 0.61* | 0.42–0.89 |
| Suicidal ideation (n = 8064) | 0.36*** | 0.25–0.50 | 0.92 | 0.68–1.25 | 0.51** | 0.34–0.78 | 0.59** | 0.41–0.84 |
| Suicide plan (n = 8118) | 0.59** | 0.40–0.86 | 1.39 | 0.89–2.19 | 0.69 | 0.46–1.05 | 0.88 | 0.61–1.28 |
| Suicide attempt (n = 1449) | 0.67 | 0.34–1.31 | 1.15 | 0.73–1.80 | 1.42 | 0.44–4.59 | 0.72 | 0.33–1.56 |
| Suicide treatment (n = 677) | 0.78 | 0.23–2.58 | 0.78 | 0.30–2.04 | 0.68 | 0.10–4.77 | 0.90 | 0.25–3.25 |
| Ever had sexual intercourse (n = 7002) | 1.17 | 0.71–1.93 | 1.14 | 0.70–1.86 | 0.65 | 0.31–1.36 | 0.91 | 0.49–1.71 |
| Sex before age 13 (n = 3324) | 0.80 | 0.40–1.63 | 0.90 | 0.54–1.49 | 0.35 | 0.09–1.35 | 0.41* | 0.19–0.88 |
| Sex with five or more partners (n = 3281) | 0.89 | 0.50–1.60 | 0.56 | 0.30–1.04 | 0.91 | 0.31–2.64 | 1.32 | 0.76–2.29 |
| Recent sexual activity (n = 3315) | 0.64 | 0.37–1.11 | 0.97 | 0.58–1.61 | 0.90 | 0.28–2.88 | 1.08 | 0.40–2.89 |
| Condom use (n = 3228) | 0.96 | 0.58–1.59 | 1.66* | 1.08–2.54 | 1.18 | 0.67–2.08 | 0.66 | 0.31–1.39 |
| Contraceptive use (n = 3357) | 0.89 | 0.50–1.60 | 1.02 | 0.57–1.83 | 0.79 | 0.42–1.49 | 0.33* | 0.14–0.81 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Table 8.
Odds Ratios Comparing Black and Latina Bisexual and Unsure Females with White Unsure Females
| Black bisexual |
Latina bisexual |
Black unsure |
Latina unsure |
|||||
|---|---|---|---|---|---|---|---|---|
| AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | AORa | 95% CI | |
| Physical IPV (n = 4349) | 0.94 | 0.45–2.00 | 1.41 | 0.69–2.87 | 2.96** | 1.36–6.45 | 1.72 | 0.98–3.03 |
| Sexual IPV (n = 3954) | 0.42 | 0.17–1.08 | 0.75 | 0.30–1.88 | 1.32 | 0.74–2.34 | 1.47 | 0.62–3.46 |
| Depressive symptoms (n = 6958) | 0.80 | 0.56–1.15 | 2.14*** | 1.51–3.01 | 1.16 | 0.76–1.77 | 1.43 | 0.99–2.06 |
| Suicidal ideation (n = 6512) | 0.50** | 0.32–0.78 | 1.31 | 0.89–1.93 | 0.75 | 0.46–1.23 | 0.86 | 0.62–1.18 |
| Suicide plan (n = 6175) | 0.81 | 0.49–1.33 | 1.97** | 1.21–3.22 | 1.00 | 0.53–1.86 | 1.25 | 0.74–2.10 |
| Suicide attempt (n = 948) | 0.90 | 0.34–2.34 | 1.41 | 0.59–3.39 | 1.57 | 0.42–5.93 | 0.74 | 0.28–2.00 |
| Suicide treatment (n = 463) | 0.29 | 0.08–1.06 | 0.29* | 0.09–0.93 | 0.26 | 0.03–2.24 | 0.26 | 0.06–1.11 |
| Ever had sexual intercourse (n = 5574) | 3.29*** | 1.92–5.64 | 3.22*** | 2.01–5.16 | 2.00 | 0.80–5.00 | 2.59** | 1.29–5.21 |
| Sex before age 13 (n = 2321) | 1.97 | 0.73–5.29 | 2.20 | 0.98–4.94 | 0.88 | 0.31–2.51 | 1.04 | 0.48–2.25 |
| Sex with five or more partners (n = 2292) | 1.08 | 0.49–2.39 | 0.68 | 0.33–1.41 | 1.15 | 0.32–4.08 | 1.42 | 0.72–2.81 |
| Recent sexual activity (n = 2308) | 0.73 | 0.34–1.60 | 1.10 | 0.50–2.41 | 1.07 | 0.36–3.17 | 1.19 | 0.44–3.22 |
| Condom use (n = 2246) | 1.48 | 0.79–2.76 | 2.53*** | 1.49–4.31 | 1.86 | 0.97–3.57 | 1.18 | 0.62–2.24 |
| Contraceptive use (n = 2346) | 1.48 | 0.78–2.81 | 1.65 | 0.84–3.24 | 1.22 | 0.67–2.21 | 0.61 | 0.31–1.17 |
Adjusted for age and sex of sexual contacts.
p < 0.05, **p < 0.01, ***p < 0.001.
Discussion
In this study, we examined mental and sexual health disparities by race and sexual identity between Black and Latino/a bisexual and unsure youth compared with White bisexual and unsure and Black and Latino/a heterosexual youth. Overall, we found that bisexual and unsure youth of color were at greater risk for experiencing IPV, depressive symptoms, and suicidality than heterosexual youth of color. We also found evidence of elevated rates of sexual health risk behaviors among bisexual and unsure Black and Latina females compared with heterosexual females of color, although results were more inconsistent than for IPV and mental health. These general trends add to a growing body of literature that shows that bisexual and unsure youth are at higher risk of poor mental8,9,26 and sexual health,11,13,14 and suggest that these disparities are particularly pronounced among youth of color. However, there were important nuances in our results that point to groups of bisexual and unsure youth of color at risk, and specific outcomes in which these youth appear differentially at risk than both their White bisexual and unsure peers and heterosexual peers of color.
Our finding that Black and Latino bisexual and unsure males were at higher risk for experiencing physical and sexual IPV compared with their same-race heterosexual peers is consistent with research that shows that sexual minority males experience high rates of IPV.27–29 Minority stressors have been shown to be related to elevated rates of IPV victimization among young men who have sex with men generally29–31 and young Black men who have sex with men.32 However, we found that bisexual and unsure males of color were not at greater risk for experiencing IPV than their White bisexual and unsure peers; thus, future research should disentangle race and sexual identity factors related to elevated risk of IPV among Black and Latino bisexual and unsure males specifically.
Black unsure and Latina bisexual and unsure females were more likely to experience physical IPV than Black and Latina heterosexual females. Black unsure females were also more likely to experience physical IPV than White unsure females. However, Black unsure and Latina bisexual females only had higher odds of sexual IPV compared with Black heterosexual females. These findings are consistent with previous studies that show that Black SMY are more likely to report verbal and physical, but not sexual IPV, compared with White SMY.15,33 Latina unsure females had higher odds of sexual IPV compared with Black and Latina heterosexual and White bisexual females. These outcomes suggest that although bisexual and unsure females are at high risk for experiencing physical IPV, sexual violence from partners is a common experience for young females regardless of sexual identity. Further research is needed on how to support young females in their relationships.
Consistently greater odds of depressive symptoms, suicidal ideation, and suicide plans among Black and Latino/a bisexual and unsure youth compared with their heterosexual peers of color may be related to homophobic bullying, which bisexual and unsure youth are more likely to experience than heterosexual youth.34 These mental health disparities may be a function of, or related to, the IPV and sexual health disparities found in this study.33,35 Among those who reported suicidal ideation, SMY of color were not more likely to report suicidal behavior or treatment for their suicidal behavior. It is unclear whether youth did not receive treatment because they did not need or could not access it; thus, there is the possibility that although suicidality might not be more severe, high rates of suicidal ideation among this group might still lead to higher overall rates of suicide if not treated adequately. Interestingly, these patterns were reversed when comparing bisexual and unsure youth of color with their White peers, in which Black and Latino/a youth were less at risk of poor mental health than White bisexual and unsure youth. These patterns might be explained through the prominence hypothesis of intersectionality: although discrimination of any form damages health, harm from multiple forms of discrimination might not compound.36 However, this does not necessarily explain why SMY of color reported lower risk. An unexplored area of research is whether SMY of color benefit from dual identity development.37 Research on the underlying processes behind disparities, or lack thereof, among SMY of color is critically needed.
There were few differences in sexual health outcomes between heterosexual and bisexual and unsure males of color. Sexual health disparities were more consistent among bisexual and unsure females of color than males. Black and Latina bisexual females were more likely to have engaged in sexual intercourse compared with heterosexual females of color and White unsure females. At the same time, Black bisexual females were less likely to have used condoms during sexual intercourse compared with heterosexual females of color. Latina unsure females were more likely to have had multiple sexual partners and less likely to have used contraceptives compared with heterosexual females of color. Overall, our results align with studies showing that prevention and intervention programs, such as comprehensive sexual education that includes information about sexual minority identities and relationships, could help reduce these sexual health disparities among bisexual and unsure females of color.38,39
Limitations and future directions
Although our study is one of the first to compare mental and sexual health outcomes between and within groups of heterosexual, bisexual, and unsure youth of color and White bisexual and unsure youth, there are limitations that must be considered. We compared youth on the basis of sex assigned at birth because only a few states and school districts included a separate gender identity question. Considering how adolescents understand their own gender identity and expression, such as whether they identify as transgender, would provide important context to these findings. The sexual behavior questions in the YRBS are also limited. For example, the questions do not define sexual intercourse, including whether the term refers to penetrative, oral, or anal sex. We attempted to address this issue by controlling for sex of sexual partners, which is also associated with mental health and IPV.40
Our cross-sectional study indicates the need for longitudinal data on outcomes considering that health disparities persist across the life course.41 It is unclear whether youth identified as unsure because they were questioning their sexual identity, did not identify with the labels provided, or did not understand the question. Small sample sizes of Asian, Native American, and other racial groups precluded examination of disparities among these populations. We did not compare across sexual identity (e.g., Black bisexual youth compared with gay/lesbian youth). Recent evidence suggests important differences by race within sexual identity21; we encourage further research in this area, particularly from an intersectional perspective. Finally, it is likely that small sample sizes for rarely occurring behaviors, such as suicidal behavior and treatment, may have resulted in a lack of power for detecting statistical differences in these outcomes.
Conclusion
Adolescence is a time defined by increased autonomy, identity development, and increased risk taking.1 Being sexually and mentally healthy has important ramifications for well-being across the life span. Our results show that bisexual and unsure youth of color are vulnerable to poorer sexual and mental health outcomes in adolescence compared with heterosexual youth of color, but not necessarily compared with White bisexual and unsure youth. Bisexuality is the largest and fastest growing sexual minority group,42 particularly among young women of color,43 and numbers of youth who are questioning their sexual identity are likely to increase as well.44 Examining the health of these youth is critical for researchers for understanding the overall health of sexual minority populations, identifying key populations and risk and protective factors for prevention and intervention efforts, and determining how best to support young people with multiple marginalized identities.
Supplementary Material
Authors' Contributions
Both Drs. A.M.P and A.B.M contributed to idea conception, institutional review board submission, data collection (i.e., submitting requests for Youth Risk Behavior Survey data), and critical revision of the article. Dr. A.M.P contributed to the majority of writing the article draft. Dr. A.B.M completed the data analyses and contributed additional writing. Both coauthors reviewed and approved the article before submission.
Acknowledgment
The authors thank Lisa Whittle, MPH, Health Scientist at the CDC for her support regarding the Youth Risk Behavior Survey data.
Disclaimer
Philadelphia Youth Risk Behavior Survey data were provided by The School District of Philadelphia. © 2013 The School District of Philadelphia. All rights reserved. Massachusetts Youth Risk Behavior Survey data were provided by the Massachusetts Department of Elementary and Secondary Education. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The authors acknowledge support for this research from the Priscilla Pond Flawn Endowment at the University of Texas at Austin. This work was supported by grant, P2CHD042849, Population Research Center, and by grant, T32HD007081, Training Program in Population Studies, both awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The research was also supported in part by the National Institute of Mental Health grant number F31MH115608 (awarded to A.B.M.) and the National Institute on Alcohol Abuse and Alcoholism grant number F32AA025814 (awarded to A.M.P.). This research was also supported by a National Institute on Minority Health and Health Disparities center grant, titled the Southwest Health Equity Research Collaborative at Northern Arizona University (U54MD012388).
Supplementary Material
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