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Tran NM, Henkhaus LE, Gonzales G. Adverse Childhood Experiences and Mental Distress Among US Adults by Sexual Orientation. JAMA Psychiatry. 2022;79(4):377–379. doi:10.1001/jamapsychiatry.2022.0001
Sexual minority individuals (eg, lesbian, gay, bisexual, and queer people) experience high rates of bullying and violence, a predictor of worse mental health,1 but little research has examined adverse childhood experiences (ACEs) occurring before age 18 years among sexual minority individuals. This study uses a large, multistate probability sample to (1) characterize population-level prevalence of ACEs by sexual orientation and (2) estimate the association between level of ACE exposure and mental distress in adulthood by sexual orientation.
This cross-sectional study uses a probability-based sample from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) among states implementing both the optional sexual orientation and the ACE modules. The exposure variable was sexual minority identity. Methodology for BRFSS ACE modules has been published elsewhere.2 No research has found that ACEs cause sexual minority identity; rather, it is hypothesized that perpetrators target socially vulnerable youth (eg, individuals with low income or a disability), including sexual minority individuals.3 Outcomes included weighted prevalence and odds of ACEs and frequent mental distress4 (≥14 bad mental health days in the past month) and the number of bad mental health days in the past month, stratified by ACE exposure level. Self-identified race and ethnicity were used to assess demographic differences in subsamples. This study was deemed exempt from review by the Vanderbilt University institutional review board because BRFSS data are publicly available. Statistical analysis was conducted via Stata version 17.0. Logistic regression was used to estimate unadjusted and adjusted odds ratios (ORs), controlling for sex, age, and race and ethnicity.
The sample included 61 871 adults; 6.7% identified as sexual minority individuals. Compared with heterosexual adults, sexual minority adults were more likely to identify as female (57% vs 52%), be younger (88% vs 73% age <65 years), and identify with minoritized racial or ethnic identities (36% vs 29%). Table 1 presents full sample characteristics.
Among heterosexual adults, 64% experienced at least 1 ACE, and 26% experienced 3 or more ACEs. Among sexual minority adults, 83% experienced at least 1 ACE, and 52% experienced 3 or more ACEs. Table 2 presents prevalence, unadjusted ORs, and adjusted ORs for all outcomes. Adjusted ORs indicate that sexual minority adults had higher odds for all 8 types of ACEs compared with heterosexual adults. Disparities by sexual minority identity were greatest for sexual abuse (adjusted OR, 2.94; 95% CI, 2.46-3.51), household mental illness (adjusted OR, 2.43; 95% CI, 2.06-2.87), and emotional abuse (adjusted OR, 2.30; 95% CI, 1.97-2.68).
Sexual minority people experienced more bad mental health days per month at all levels of ACE exposure than heterosexual people: 4.3 vs 2.4 days with no ACEs, 10.2 vs 5.1 days with 1 or more ACEs, and 12.3 vs 7.0 days for people with 3 or more ACEs.
Population-level estimates found that sexual minority individuals experienced higher exposure to all ACEs compared with heterosexual adults, with the most elevated odds of exposure to sexual abuse, household mental illness, and emotional abuse. The number of bad mental health days in the past month was greater for sexual minority individuals at all levels of ACE exposure than for heterosexual individuals. Weighted results are representative of approximately 33 million adults in sampled states. The cross-sectional study design limits assessment of causality, and self-reported outcomes were subject to recall bias. Controlling for binary sex may bias results for respondents who are transgender or gender nonconforming. Although 2019 was the first year the BRFSS survey explicitly asked participants whether they were male or female during screening rather than make implicit assumptions, ascertaining gender identity during screening would significantly strengthen the survey design. As a household survey, the BRFSS likely yields lower ACE estimates than the true prevalence because sexual minority people experience higher rates of housing insecurity than heterosexual populations. Findings highlight the importance of earlier ACE screening5 and clinician training on effective approaches to reduce sexual minority mental health disparities6 across the life course.
Accepted for Publication: January 1, 2022.
Published Online: February 23, 2022. doi:10.1001/jamapsychiatry.2022.0001
Corresponding Author: Nathaniel M. Tran, BA, Department of Health Policy, Vanderbilt University, 2525 West End Ave, Ste 1275, Nashville, TN 37203 (firstname.lastname@example.org).
Author Contributions: Mx Tran had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tran, Gonzales.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Supervision: Henkhaus, Gonzales.
Conflict of Interest Disclosures: None reported.