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Advancing Mental Health Disparities Research Focused on Bi+ People Through an Intersectional Lens



TAMARA LEWIS JOHNSON: Good afternoon and welcome to the 2023 National Institute of Mental Health, LGBTQ+ Mental Health Research Webinar. My name is Tamara Lewis Johnson and I am the program director of the Women’s Mental Health Research Program at the Office for Disparities Research and Workforce Diversity at the National Institute of Mental Health.

The purpose of this webinar is to spotlight research on mental health disparities, women’s mental health, minority mental health, and rural mental health. This afternoon we are spotlighting the research of Drs. Brian Feinstein and Christina Dyar. Their research was funded by the National Institute of Mental Health Division of Translational Research and the National Institute of Drug Abuse.

Now, a little bit about the webinar. The prevalence of mental health disparities is higher among bisexual and other multi-gender-attracted individuals compared to monosexual individuals. In the United States, the prevalence of mood anxiety disorders is higher among bi+ women compared to heterosexual and lesbian women while bi+ men are at increased risk for mood and anxiety disorders compared to heterosexual men. The pattern is different for bi, also known as pansexual, queer, and collectively bi individuals versus gay men. Bi+ individuals also report higher suicidality compared to heterosexual and lesbian gay persons. Despite this risk for negative mental health outcomes, there are few mental health interventions that are designed specifically for the bi+ population. In this webinar, the researchers will share information on this emerging area of research by presenting findings on identifying modifiable targets and mechanisms of action at the individual, family, and system levels to improve mental health services and form the development and testing of theory-based interventions that address mental health disparities in bi+ populations.

Now, allow me to introduce our speakers this afternoon. Dr. Brian Feinstein is the associate professor in the Department of Psychology at the Rosaline Franklin University of Medicine and Science where his program of research focuses on understanding and addressing the health disparities affecting sexual and gender minority populations, especially bisexual and other multi-gender-attracted populations.

In particular, his research focuses on the role of stigma-related stress and the development and maintenance of mental and behavioral health problems among SGM people. He has also conducted research on the unique experiences of sexual minorities including bi+ people with additional minoritized identities such as people of color, biased attitudes at the intersection of sexual orientation, gender identity, race, and ethnicity and interventions designed to improve the health of SGM individuals.

Dr. Feinstein’s program of research has been continuously funded by the National Institute of Health since 2016 first through a F32 focused on stigma-related stress as a risk factor of substance use and sexual risk behavior among male, same-sex couples, and currently through a K08, focused on drivers of substance use and sexual risk behavior among bi+ youth. His K08 also included developing and testing an intervention to reduce substance use and sexual risk behavior among bi+ male youth.

Most recently, he received an R01 from the National Institute of Mental Health focused on examining the development of rejection sensitivity among sexual minority adolescents, its longitudinal and daily associations with mental and behavioral health and mediators and moderators of these associations. His program of research has resulted in over 146 peer reviewed publications, nearly all of which focused on sexual and gender minority health.

Dr. Christina Dyar is the assistant professor at the Center for Healthy Aging, Self-Management and Complex Care in the College of Nursing at Ohio State University. Her research examines health disparities affecting sexual minorities with a particular focus on identifying driving disparities and substance use and mental health among sexual minority women and gender-diverse individuals. She has examined prospective associations between minority stressors, mental health, and substance use as well as mechanistic processes to which minority stressors are linked to increases in mental health and substance use problems among sexual minority women and gender-diverse individuals.

Her research often examines how health disparities vary across subpopulations of sexual and gender minorities and identifies subgroup specific factors that confer increased risk for substance use, mental health, and physical health problems for specific subgroups of sexual gender minority individuals particularly bisexual individuals.

Dr. Dyar utilizes a range of study designs and quantitative methodologies in her research. Her current K01 award exemplifies many components of her research. This project utilizes ecological momentary assessment to identify risk factors for problematic alcohol and cannabis use among sexual minority women. It also determines how risk factors may differ among sexual minority women based upon sexual identity.

With no further ado, we will start with Dr. Feinstein.

BRIAN FEINSTEIN: Alright. Hi everybody. My name is Brian Feinstein. My pronouns are he/him and I am an associate professor at Rosalind Franklin University in the Department of Psychology. I am really pleased to be here today presenting on bi+ mental health with a particular focus on what we know about risk resilience and implications for interventions.

I want to start by thanking the NIMH for organizing this webinar and for inviting myself and my colleague, Dr. Christina Dyar, to be a part of it. I would also like to acknowledge the funding that I currently receive from the NIMH and also from NIDA as well and just to state that I have no additional disclosures.

As a brief overview, today I will be providing some information about what we mean when we refer to the bi+ population and who is in it. I will be going into some detail about the mental health disparities affecting bi+ people and the unique stigma-related stressors that underlie these disparities. I will be talking about some of what we know with respect to resilience in this population and I will be ending with a focus on intervention implications. I also just want to acknowledge that a lot of the work that I will be describing today comes from collaborations between myself and our second presenter, Dr. Dyar.

To get started, when we use the term bi+ or bisexual+, we are broadly referring to people who experience attraction to more than one gender or who experience attraction to people regardless of gender. They may use a variety of different identity terms to describe this pattern of attractions, ranging from bisexual, pansexual, queer, to fluid.

One thing that we found in some of our research is that at least half of bi+ people use multiple identity terms to describe their sexual orientation so this suggests that while some people use specific terms to connotate differences in what these terms mean to them, others use these terms somewhat interchangeably or experience multiple terms as reflecting their attractions.

Overall, we know from decades of research now that bisexual and bi+ folks represent the largest sexual minority subgroup in large population-based studies. As you can see in this figure here, data from the General Social Survey has revealed that there have been substantial increases in the proportion of people in the US who identify as bisexual over time. From 2008 to 2018, the proportion of adults in the US who identified as bisexual nearly doubled from 1.6 percent to 3.3 percent and that is nearly twice as high as the proportion of people who identify as lesbian or gay.

These increases in bisexual identification over time are largely driven by women, young people, and people who are black or African American, all of whom identify as bisexual at higher rates compared to other groups.

My colleagues and I have found that these increases that we see in bisexual identification are mirrored when looking at high school aged youth as well so wel use data ranging from 2005 to 2015 from the Youth Risk Behavior Survey, which is a population-based sample of high school aged youth in the US. And looking at the left panel of this figure, you can see that the proportion of female youth in the US who identify as bisexual increased from about 5 percent to almost 10 percent from 2005 to 2015. While the proportions are quite a bit smaller for male youth, we saw similar increase with merely a doubling of the rate from 1.6 percent to almost 3 percent in 2015. Overall, we are seeing similar increases in bisexual identification among youth as well as adults.

And decades of research now including a number of meta-analyses have demonstrated that bi and bi+ people experience mental health disparities across a wide range of outcomes, including but not limited to depression, anxiety, suicidal ideation, and suicide attempt.

As an example, these are data from a meta-analysis conducted by Travis Salway and colleagues and you can see in the blue bars that 21 percent of bisexual people across studies reported suicidal ideation and 16 percent of bisexual people across studies reported attempting suicide just in the past year alone. And these proportions were significantly greater than the proportions of both heterosexual and lesbian and gay people who reported past year suicidal ideation or suicide attempt.

These disparities have been documented among adolescents and adults and they are generally greatest for bisexual women relative to bisexual men.
While most research in this area has focused on people who specifically identify as bisexual, emerging research focused on people who identify as pansexual or queer conducted by my colleagues and I have found that pansexual and queer folks report higher levels of depression and anxiety even relative to bisexual people.

Now these specific group differences are at least partly explained by the fact that people who are transgender or nonbinary are more likely to identify as pan or queer and they also experience unique mental health disparities relative to cisgender people but that does not entirely explain these group differences, suggesting that there are still unique factors that contribute to higher rates of or higher levels of depression and anxiety among pan and queer folks compared to bi folks.

Now, when thinking about the mental health of bi+ people through an intersectional lens, there has really been quite a lack of research specifically on the experiences of bi+ people of color. In a relatively large systematic review of over 300 studies of sexual and gender minority mental health, only 7 percent of studies specifically reported findings for bisexual POC (people of color). This really leads to this question of does the mental health of bi+ POC differ from that of white bi+ people, a question for which we have very little data to answer at this moment.

In an exception, my colleagues and I use data from the Youth Risk Behavior Survey, pooling data from local versions from years 2011 to 2015, resulting in a sample of over 18,000 bisexual youth with the goal of looking at racial and ethnic differences in mental health specifically among bi youth.

Here you can see looking at the red bars that we found that black bisexual youth have lower levels of reported sadness or hopelessness as well as suicidal ideation in the past year compared to all other racial and ethnic groups. And of note, these associations remain significant even after accounting for bullying experiences suggesting that there is something unique about the experiences of black bisexual youth contributing to their lower rates of depression and suicidal ideation relative to other racial and ethnic groups.

We also found that both black and Hispanic bisexual youth reported lower levels or were less likely to endorse both in-person and online bullying in the past year, relative to white bisexual youth. One potential explanation for this is black and Hispanic bisexual youth might be less likely to disclose their sexual orientation and in turn they might be less likely to experience bullying related to their sexual orientation but as I mentioned before, the lower endorsement of depressive symptoms and suicidal ideation among black bisexual youth remain significant even after accounting for bullying experiences, suggesting that there is still something unique going on here where black bisexual youth might be experiencing unique resilience factors that are protected with respect to their mental health.

So overall the mental health disparities affecting bisexual and other bi+ populations can generally be attributed at least in part to the unique experiences they have related to stigma. As an example, while attitudes towards lesbian and gay people have generally been increasing and becoming more positive, in recent years worldwide but certainly in the US, in particular, attitudes toward bisexual people remain neutral at best and are often explicitly negative.

So for example, in a US population-based sample, approximately one-third of people in the US reported that they agreed to some extent that bisexual people were confused about their sexual orientation and 31 to 44 percent reported that they agreed that people should be concerned about having sex with a bisexual partner because of potential risk for HIV or other sexually transmitted infections.

In a recent meta-analysis that my colleagues and I conducted focused on attitudes toward bisexuality, we found that overall men tended to have more negative attitudes toward bisexuality compared to women. This was especially true when considering male bisexuality, in particular.

We also found that heterosexual men tended to have more negative attitudes toward bisexuality compared to heterosexual women where this gender difference was not observed for gay men compared to lesbian women’s attitudes toward bisexuality.

And last in a separate study, we found that these negative attitudes that people often expressed toward bisexual people tend to be particularly negative not only toward bisexual men but also toward bisexual people who are transgender compared to those who are cisgender and also the attitudes tend to be more negative for black and Latinx bisexual people compared to white bisexual people.

And whe thinking about these negative attitudes, they manifest in a variety of different ways. One of those ways is that bi+ people experience discrimination not only from heterosexual people but also from lesbian and gay people or within the broader LGBTQ+ community in general and this is sometimes referred to as double discrimination.

And we also find that while being in a romantic relationship is often a protective factor and associated with better mental health for people in general. When focused on bi+ people in particular, romantic relationship involvement can function as a unique stressor.

One reason for this is that when bi+ people are in a relationship, their sexual orientation often becomes invisible to others as people typically make assumptions about a person’s sexual orientation based on the gender of their partner.

We have also found in our work that approximately 10 percent of bi+ people have experienced pressure from their romantic partners to change how they label their sexual orientation.

In a mixed methods study, we have bi+ participants who described experiences like saying my partner was very insecure and did not want competition from both genders and also a participant who said it was what my partner wanted to remain in a relationship. These findings suggest that while bi+ people can experience discrimination from heterosexual as well as gay and lesbian people, they can also experience this unique discrimination in the context of their romantic relationships.

And generally, while bisexual and bi+ people are less likely to be out or to have disclosed their sexual orientation to important people in their lives, we have found that even when bisexual people disclose their identity to others, those people still often assume that they are heterosexual or lesbian or gay simply based on the gender of their partner, suggesting that there are unique challenges for bi+ people to being perceived or having their sexual orientation recognized when they are in a romantic relationship.

Now all of these findings related to the unique stressors that bi+ people experience when they are open about their sexual orientation has led us to wonder about how being open or disclosing one’s sexual orientation relates to a variety of different health outcomes and whether this might be different for bisexual compared to lesbian and gay people.

As an example of this work, in one study, we used longitudinal data from a sample of about 250 LGBTQ youth ages 16 to 20 in the Chicagoland area. And we use four waves of data between the years of 2007 and 2014. And what we found as represented by the sort of  yellow or orange upward trending line is that being more open or more out about one’s sexual orientation was associated with increases over time in depression symptoms for bisexual people but not for lesbian and gay people.

We found that the same pattern of results extended to substance use as well, including alcohol, marijuana, and other illicit drug use where again being more open or out about one’s sexual orientation was associated with increases in these substance use outcomes only for bisexual people and not for lesbian and gay people.

So wrapping this up, being open and disclosing one’s bisexual identity can present unique challenges for bi and bi+ people. And in the next presentation, Dr. Dyar will be talking more about the associations between some of these unique stressors, health outcomes, and their underlying mechanisms.

Now, I wanted to make sure to not only focus on risk factors related to mental health among bi+ people but to also acknowledge that there is accumulating research demonstrating that bi+ people also have a number of different positive experiences related to their sexual orientation.

As an example, in a recent study that my colleagues and I conducted, we interviewed 57 bi+ male youth ages 14 to 17. And we found that they described a variety of different positive experiences related to being bi+. As an example, one of the positive experiences they identified was feeling a sense of belonging and community. An example of this was a participant who said I found some online friends very recently and they are also bi and it is just really nice being able to talk to people about that being able to sort of relate with what they are saying.

Participants also described not feeling limited by gender when it comes to their romantic and sexual experiences and this being a positive aspect of being bi+. So one of our participants said it is being able to just like somebody for who they are rather than having to limit myself to one gender. It means I can meet a whole bunch of other people who are really nice.

And third, participants described the ability to simply be oneself without fear of judgment. As an example, one participant said everybody accepted me for it. It felt freeing like I did not have to pretend to be somebody I am not.

And similarly, research conducted with bisexual adults has also found that they describe these three same aspects of being bisexual as positive aspects of their identity. They described a sense of community or involvement with and support from a larger LGBTQ+ community as being positive. They described intimacy or this belief that one’s identity enhances the capacity for intimacy and sexual freedom and this ability for authenticity or being able to be comfort with one’s identity and expressing it to others.

Building on this, my colleagues and I were interested in whether maintaining a positive sense of bi+ identity might have the potential to mitigate some of the mental health consequences of discrimination.

So in order to test this hypothesis, we used data from approximately 400 bi+ young adults who completed three surveys, a baseline survey and then surveys at one month and two-month follow up.

And what we found was that if you look at the top lines that are trending upward with the asterisk next to them, we found that anti-bisexual discrimination was only associated with increases in suicidal ideation one month later for bi+ participants who reported low levels of community and intimacy.

Similarly, we found that anti-bisexual discrimination was also only associated with increases in suicidal ideation one month and two months later for bi+ participants who reported low levels of authenticity.

In contrast, when we looked at a broad general measure of trait resilience, we found that that did not buffer the associations between anti-bisexual discrimination and suicidal ideation, suggesting that having these positive aspects of one’s bi+ identity might be uniquely able to offer resilience in the face of discrimination that bi+ people experience.

So all of these findings and all of this work really lead to this question do bi+ people need interventions tailored to their unique experiences. While there has not been a lot of work in this area, accumulating recent research suggests that even after receiving evidence-based care, bisexual people continue to report higher levels of depression, anxiety, and functional impairment. They continue to report greater suicidal ideation and they are more likely to be hospitalized and they also report worse perceptions of care and less satisfaction with treatment. These disparities in treatment outcomes are observed generally in comparison to heterosexual people but often in comparison to lesbian and gay people as well.

And these findings are consistent with qualitative evidence that bi+ people describe a range of negative experiences with mental health providers, including having providers who express judgment toward their identity or who make statements pathologizing bisexuality.

These findings are also consistent with evidence that clinicians themselves report feeling less competent in providing affirmative care to bisexual clients relative to lesbian and gay clients.

Despite this evidence suggesting that bi+ people continue to report worse outcomes even after receiving evidence-based care were really lacking in interventions that are tailored to address their unique experiences.

So to date, the most work that has been conducted in this area has focused on HIV prevention with still only a handful of trials that are specifically focused on HIV prevention for bisexual or bi+ people, in this case, typically men. And one intervention that was developed by Tania Israel and her colleagues focused on reducing internalized stigma among bisexual people.

Now while there have been increases in recent years in the development and testing of evidence-based interventions to improve the mental health of LBGTQ+ people broadly, it is unknown if the effects of these interventions are the same for lesbian and gay people relative to bisexual or bi+ people, which will be a really critical area for future research as we think about whether tailored interventions are needed in this population or if existing interventions that are being developed for LGBTQ+ folks broadly might generally have the same efficacy for bi and bi+ people specifically.

In the meantime, that kind of leaves us with this question of where do we go from here and what can be done to improve the mental health of bi+ populations. I think these findings generally suggest that first and foremost, clinicians need more training to specifically address implicit as well as explicit bias that they might have against bi and bi+ people.

They also need training to be able to incorporate some of these unique risk and protective factors that bi+ people experience indicates conceptualization and their plans for treatment.

Until then, clinicians can draw on existing LGBTQ+ affirmative interventions. As an example, some of the recent work from John Pachankis and his colleagues to help increase awareness of the impact of the stigma-related stressors on mental health when working with bi+ clients to help bi+ folks to externalize their experience of discrimination so to recognize the external sources of the discrimination that they experience as oppose to internalizing these experiences and feeling as though it is related to their identity itself and to help bi+ people to be able to foster some of these protective or resilience factors like authenticity, building community, and the sort of felt sense of intimacy or their identity being able to promote being more – having this freedom and flexibility in their romantic and sexual relationships.

All that said, ultimately, we need structural and systemic changes to address the root causes of these mental health inequities affecting bi+ people. In the meantime, certainly part of the strategy to improve bi+ mental health is to be able to provide affirmative interventions to help them to cope with the challenges that they might be experiencing. Ultimately, we really need these changes at a societal and structural level to reduce what is causing these health inequities in the first place so that ultimately one day we won’t have to focus on helping people to cope with these challenges after they have already experienced them.

I want to thank everybody for attending this webinar today and for listening to my part of this presentation. Next, I will hand this off to my colleague, Dr. Christina Dyar, to continue this presentation.

CHRISTINA DYAR: Thanks, Brian. Fantastic talk. I am Christina Dyar. I am an assistant professor at Ohio State University. I use she/her pronouns and I am going to spend some time today building on the concepts that Brian covered in the first half of the webinar today.

We are specifically going to focus on recent research that we have done examining mechanisms through which bi+ stigma may contribute to internalizing symptoms and indirectly to substance use.

As Brian mentioned and talked a bit about a lot of the cross-sectional research that we have linking bi+ stigma specifically experiences of enacted stigma so things like microaggressions about bisexual individuals’ identities with anxious and depressive symptoms. But so far, we have relatively little research that has longitudinally looked at these associations or looked at the mechanisms that may link bi+ stigma with mental health so the ways in which bi+ stigma might get under the skin and impact anxiety and depression, for example.

In our work recently, we really pulled from Hatzenbuehler’s Psychological Mediation Framework. And in this framework, he posits two sets of processes that may mediate associations between experiences of sexual minority stigma broadly and symptoms of anxiety and depression.

First, we have general psychological processes. And these are experiences of stress that link stress and anxiety and depression in many different populations. These are things like processes like rumination, things like social isolation, and feelings of hopelessness. These are theorized to link everything from microaggression to internalized stigma and anticipated stigma so internalize negative attitudes about women’s own sexual identity as well as anticipating negative experiences or other experiences of microaggression. These types of stigma-related experiences contribute to these general psychological processes like rumination, which in turn contribute to anxiety and depression.

On the other hand, Hatzenbuehler posits some group-specific processes. They may specifically mediate the link between what I am going to call enacted bi+ stigma, which are experiences like microaggressions, experiences of discrimination, experiences of victimization, those types of experiences and anxiety and depression specifically. Here is where we break out the different types of stigmas.

These microaggressions are theorized to contribute to internalizing anticipated stigma so feelings that – negative feelings an individual might have about their sexual identity as well as anxious expectations about experiencing more microaggressions or discrimination in the future, which in turn are directly linked or theorized directly linked to anxiety and depression.

What we have done here is we have taken it and we have really applied it specifically to bi+ individuals and look at the specific types of bi+ stigma that these groups experience and looked at potential mechanisms here.

But before I get to that study, I want to really briefly talk about the types of evidence that we have linking bi+ stigma to internalizing symptoms. First, we have cross-sectional evidence. This is when you ask all of the questions about participants at the same time. One survey – this is most of the evidence that we have linking bi+ stigma to anxiety and depression.

This can tell us a lot. It can tell us whether people who tend to experience more bi+ stigma also have more internalizing symptoms. But it cannot get at some of these mechanistic processes and some of the temporality and directionality of these associations. It cannot tell us whether experiences of bi+ stigma occur before subsequent increases in anxiety and depression, which is where we can really get at understanding how these processes unfold over time. For that, we need longitudinal evidence.

Now this longitudinal evidence can really help us to determine whether experiencing more or less of a stressor than we typically experience predicts either concurrent or prospective increases in internalizing symptoms. Do these increases in internalizing symptoms happenSo on the same day as the bi+ stigma happens or are they happening on the next day? Are we seeing a gap in time between the experiences of a microaggression and the experience of anxiety and depression?

Concurrent associations are when we have both of these variables, the stigma and the internalizing symptoms at the same time point. This can really tell us that these two things are happening together in time. For example, on a day when an individual is experiencing a bi+ microaggression, are they also experiencing more anxiety and depression? But it does not give us the directionality piece, which is what we really want in this longitudinal evidence.

So prospective associations let us see whether that bi+ stigma is happening before we are seeing increases in anxiety and depression, which really helps us get more support for the idea that this is the direction in which things are unfolding. And it also really helps us understand how mechanistic processes are unfolding as well over time. So we will go back to that study that I mentioned a little a while ago.

In order to examine some of these longitudinal associations among bi+ stigma, the proposed mechanisms like rumination and internalizing symptoms, we use data from FAB400, a longitudinal study of sexual and gender minority individuals who are assigned female at birth. Now, we focused specifically on the bi+ subsample of this group and this is a longer-term longitudinal study so participants completed five waves that we used for this analysis and they were six months between each of the waves. This tells us how this process is unfolding over a two-year period.

With regard to this general psychological mechanism that we looked at rumination, we ended up finding that when individuals experienced more microaggression, they felt worse about their bi+ identity or they were more anxious about experiencing microaggression that enacted internalized and anticipated bi+ stigma during one 6-month period. That predicted subsequent increases in rumination over the subsequent six months, which in turn predicted increases in symptoms of anxiety and depression.

You may notice some of those variables that I just mentioned are missing from the slide here and that is because I just wanted to present a subset of the results for brevity here. All of the other associations were in the same direction followed a similar pattern.

Another brief note about analyses before I move on to some of the other results. I am only really briefly presenting the within-person associations from the multi-level models here. If you are curious about some other aspects of the models, I point you to the instructions of the papers. I usually have a pretty beefy analytic method section, if you are curious about that and also, I will take any questions that you have about these and I will use a similar approach moving forward in talking about these associations.

So with regard to group-specific mechanisms that internalize an anticipated bi+ stigma, we also found support for these. We found that when individuals experience more microaggressions than usual during one 6-month period, that predicted that they would feel more negative about their bi+ identity over the subsequent six months and be more anxious about experiencing more of these microaggressions. These increases in internalized and anticipated stigma in turn predicted increases in anxious and depressive symptoms.

So that tells us a little bit how these long-term – these processes unfold kind of the longer term. But when we think about how we expect microaggressions impact someone, you really are thinking about how they are unfolding within a day. It is happening relatively rapidly. Microaggressions lead pretty immediately to these rumination on the microaggression and then on increases in anxiety and depression. We think this is happening relatively quickly.

We were really curious about looking at how these mechanistic processes unfold at the daily level and see if we could get some insight into more about how they unfold in near real time. For this, we used data from the Bi Visibility project which includes a 28-day daily diary study with about 208 bi+ individuals. We had one assessment per day for this study.

So we ended up finding evidence concurrently for these associations. What I mean by this is that we found that on days when bi+ individuals experienced microaggressions related to their bi+ identities, they also reported feeling worse about being bi+, being more anxious about experiencing additional microaggressions and that in turn predicted feeling more anxious and depressed affect on that same day. But this was all at the same observation on the same day.

Unfortunately, with this study, we did not find significant lag associations. The reason we think that we are not seeing that enacted stigma is predicting subsequent changes in internalized and anticipated stigma all has to do with the time of our observations. Since we asked participants about their experiences every day, finding a significant perspective effect would literally mean that we were seeing an effect of what in most cases was a single microaggression continuing to predict increases in anxious and depressed affect two full days later, which is a relatively long period of time to see anxious and depressed affect continue to increase.

So I rt is likely that future studies with more assessments per day will be able to do a better job of capturing the directionality and temporality of these associations.

Brian talked a little bit about outness and the experiences that the additional risk factors or unique experiences that bi+ individuals may experience when they are out. Part of this Bi Visibility project and where the name really comes from here is we really wanted to look at how these things are happening on a daily basis again. Our previous work on outness had really focused on the big picture. Is outness differentially associated with mental health and substance use for bi compared to lesbian and gay individuals?

Here, we were really curious about both the impact of visibility or outness as a bi+ individual on anxiety and depression but also on more behavioral things right. Essentially, are individuals who are out as bi+ more likely to be exposed to microaggressions related to their identity? This theoretically will mean that outness or visibility of bi+ on a particular day might be associated with increases in anxiety and depression.

On the other side of things, there is also research suggesting that outness being more out as bi+ can also lead individuals to have more access to support related to their identity and more affirming experiences, which in turn we would expect would be associated with reductions in anxiety and depression. We kind of pitted these two hypotheses against one another.

We used the BVP again, the Bi Visibility project. We asked participants about their bi+ visibility attempts on a particular day. Some of this includes the types of questions that you often see in questionnaires about disclosure or outness. This includes things like directly telling somebody about one’s bi+ identity. But it also includes less direct things, things like talking about bi+ or LGBTQ issues, engaging in bi+ or LGBT activities, visual cues, things like wearing bi+ pride colors, putting the bi pride flag somewhere in your house or office, those types of things as well as gender displays. We asked participants previously to tell us how they tried to make their identity visible and some of them explicitly talked about ways that they tried to appear more androgynous in a way to make their bi+ identity more visible. We found that participants made bi+ visibility attempts relatively frequently, about one in every three days.

Interestingly, we found evidence for both sides of our hypotheses. On days when participants reported that they tried to make their bi+ identity visible, they also reported more positive affect, less negative affect, and more bi+ identity pride. And these potential positive effects were specifically associated with making bi+ visibility attempts in context that were likely more supportive so when they reported that they made these attempts with their friends or their partners.

Now, we also found that on days when participants made bi+ visibility attempts, they also experienced more microaggressions related to their bi+ identity and were more anxious about experiencing microaggressions based on their identity.

Now these types of associations were particularly coming from a context in which individuals tried to make their identity visible with straight individuals, family members, and strangers so contacts that may have been less supportive.

Now, you may notice that again we are looking at both a predictor and the outcome at the same time point. Again, we did not find significant perspective effects. Bi+ visibility attempts did not predict these outcomes on the next day. We could not determine directionality.

In some cases, you still have a pretty strong theoretical reason for expecting the association to go in a particular direction like with experiences of stigma, anxiety, and depression. But in this case, you can honestly theorize either direction. You could expect, for example, that making your identity visible would make one more likely to be exposed to microaggressions. But on the other hand, you might also see that, for example, for some bi+ individuals, they might experience a microaggression. That might lead them to try to make their identity visible or known. And they might do this in order to counter a stereotype about bi+ people or to educate mainly the person who made the microaggression about bi+ people and their experiences.

Given this potential bidirectional association, future research is really needed to explore the context under which one direction might be more likely compared to another.

So far, we have provided evidence supporting roles of rumination and internalize an anticipated bi+ stigma as potential mechanisms linking bi+ stigma with anxiety and depression. And we also found evidence suggesting that bi+ stigma may act as a risk factor for experiencing more bi+ stigma particularly when they occur in unaccepting and unsupportive context, but they may have beneficial effects when they occur in more safe and supportive environments.

So far, we have talked mostly about effects on anxiety and depression and internalizing disorders. However, as Brian mentioned, we know that bi+ individuals and particularly bi+ women are also at elevated risk for experiencing disparities in substance use disorders. For example, bi+ women are at elevated risk for both alcohol and cannabis use disorders compared to heterosexual and lesbian women in most studies.

Unfortunately, we have recently uncovered evidence that these disparities in cannabis use disorder are increasing.  So we found evidence that rates of cannabis use disorder nearly doubled from 2015 to 2019 among bisexual women while they remained much more stable for other gender and sexual identity groups. This is a really emerging area of increasing concern.

What might contribute to these elevated rates of alcohol and cannabis use disorders for bi+ individuals? We can go back to the psychological mediation framework, which posits that experiences of sexual minority stigma deplete sexual minority’s probing resources because it is experienced on top of the general life stressors that everyone experiences.

Now, because of this coping depletion, sexual minorities may be more likely to turn to substances to cope with feelings of anxiety and depression that arise from these experiences. Unfortunately, from research with the general population, we know that using substances to cope is a risk factor for the development of a substance use disorder. This is one potential mechanistic process.

Going back to data from FAB400 to test this process and found evidence really to support it. We found that during periods – when participants experienced more microaggressions related to their bi+ identity over one six-month period, they experienced subsequent increases in coping motives for their cannabis use, which in turn predicted subsequent increases in cannabis use disorder symptoms. This provides a relatively robust set of observational evidence that coping motives might act as a mechanism through which these bi+ microaggressions might contribute to cannabis use disorder highlighting another consequence of bi+ stigma.
So most of what we have talked about so far has really focused on experiences that are shared by all bi+ people. But it is really important to attend to the ways in which experiences might differ among bi+ individuals based on their other identities. We will really briefly talk about some initial work we have been doing in this area and highlight some potential directions for future research.

Intersectionality theory is fascinating. It has many different components. I am just going to talk about a little sliver of it here. But one of the interesting things about intersectionality theory is that there are two broad perspectives that guide hypotheses about the experiences of individuals with multiple marginalized identities. First, we have the greater risk perspective and that says what it does on the box. It posits that individuals with multiple marginalized identities experience stigma based on multiple identities and that can overburden their coping resources. This is theorized to result in poor health outcomes for people with multiple marginalized identities and amplify the impact of stigma on health for these groups.

On the other hand, we have the greater resilience perspective, which posits that individuals with multiple marginalized identities may actually have unique resources and resilience for coping with stigma, which may reduce the impact of stress on health and lead to similar or even better health outcomes for individuals with multiple marginalized identities compared to individuals with the single marginalized identity. And Brian highlighted some really interesting results on this, demonstrating that black bi+ individuals have lower rates of anxiety and depression compared to bi+ individuals from other racial and ethnic groups.

We pivot these two hypotheses against each other, using data from FAB400 again of cross-sectional data this time. Specifically, we were curious whether associations between bi+ enacted stigma so this is microaggressions and bi+ internalized stigma were associated – there are associations with internalizing symptoms so anxiety and depression and substance use and related problems differ based on individuals additional identities. Whether they differed for cisgender compared to trans and nonbinary bi+ individuals and whether they differed based on race and ethnicity.

We found some evidence to support our hypotheses in both directions again. Interestingly, of the four associations we looked at moderation for, only one was moderated based on gender and that was the association between bi+ microaggressions and substance use and related problems.

We found that experiencing more of these bi+ microaggressions were associated with heavier use for both cisgender women and gender minorities. But this association was significantly stronger for gender minorities, really suggesting that when trans and nonbinary individuals experience more levels of bi+ microaggressions, they maybe engaging in heavier substance use compared to cisgender women who experience the same level of microaggressions.

This pattern is really consistent with the greater risk perspective, really suggesting that experiencing stressors based on both one’s gender and one’s sexual identity may be overburdening trans and nonbinary individuals, bi+ individuals coping resources and amplifying the impact of this type of bi+ stigma on substance use, in particular.

Now, with regard to variation in these associations based on race and ethnicity, we found that three of the four associations differed for at least two racial and ethnic groups. And a very consistent pattern for those significant moderations emerged. In all cases, experiencing more bi+ stressors were significantly associated with worse health for white bi+ individuals. But this association was not significant for black or Latin bi+ individuals. This is consistent of course with a greater resilience perspective, suggesting that bi+ people of color may have unique coping resources and resilience for dealing with these types of stressors.

So I am going to talk a little bit more about some of these findings so particularly the findings that we have around evidence for resilience to bi+ stressors among bi+ people of color. While this is broadly consistent, this pattern of findings for resilience for SGM people of color, sexual and gender minorities of color, is really something that we find relatively frequently in the literature. Of the relative few studies that have looked at the intersectional experiences of sexual and gender minorities of color and compared them to white sexual and gender minorities, they tend to find support for the greater resilience perspective instead of the greater risk perspective. Although there is certainly quite mixed evidence on this topic.

Now, there are a lot of potential explanations that have been proposed for why we find evidence for greater resilience for bi+ people of color or SGM of color – why we find support for this greater resilience. Some theories really suggest that people of color learn strategies for coping with racism from their family starting at an early age and that this resilience to SGM stressors may rise from adapting these strategies for coping with racism to also helping them cope with SGM stressors, which may help them to cope better in the face of these sexual and gender minority stressors, reducing their impact on health.

Other people have suggested that what is actually going on here is that cultural factors like stoicism may lead to underreporting of symptoms of anxiety and depression and may lead some of our measures of anxiety and depression to actually not function as well among people of color. If this is the case, it may make it look like bi+ people of color are more resilient in the face of stressors when what is actually happening is we are not doing a good job of capturing their experiences with anxiety and depression. This is an incredibly important area for future research.

In order to understand when we find evidence for greater resilience, what is going on here? Are there unique coping resources that we should better understand? Are there ways that we can better our measures of anxiety and depression to work better for everyone?

Okay we have learned so much about bi+ health and factors contributing to health disparities in internalizing symptoms and substance use disorders in this population in the past decade.

I just kind of summarized all of the findings here. I will not go through them again. But they all have some potential implication for informing the development of interventions that aim to reduce the impact of bi+ stigma for a bi+ population.

As Brian mentioned, he covered a little bit of this already. I will abbreviate my portion of what I was going to talk about here. But there are very few interventions developed specifically for bi+ people. There are recent interventions using cognitive behavioral therapy to teach skill building around dealing with sexual minority stressors broadly. And they have proven relatively effective in reducing internalizing symptoms and substance use in these populations. These are the esteem and equip interventions development by John Pachankis and colleagues.

They were not developed specifically for bi+ individuals. Incorporating content that is also specific to the experiences of bi+ individuals, talking about the unique microaggressions that they experience may also help to make these types of interventions more effective for bi+ populations.

Now the RISE intervention, which Brian briefly mentioned, was developed specifically for reducing internalized bi+ stigma, and this is a really interesting intervention because it takes a different approach from taking cognitive behavioral therapy or something and making it adapted for sexual and gender minority individuals. Instead, it directly challenges bi+ stereotypes and stigma and has resulted in reductions and internalized stigma, increases in bi+ identity pride and positive effect.

Given that we know that internalized bi+ stigma is one mechanism linking enacted bi+ stigma with internalizing symptoms, pairing this intervention with additional skill building and emotion regulation strategies and ways to cope with the experiences of sexual or bi+ stigma may make it more effective.

Overall, we have come a really long way but we still have a long way to go particularly because of the lack of interventions, because we have so little research on intersectionality, the intersectional experiences of bi+ individuals. I am really looking forward to the next decade of research on bi+ populations and seeing where we go from here.

TAMARA LEWIS JOHNSON: Thank you, Dr. Dyar and Dr. Feinstein, for those outstanding presentations. We have a number of questions from the audience, and I will start with the questions from the audience. Thank you, viewers, for submitting your questions. If you have not submitted a question, feel free to do so at this time because it may take a little bit of time to think about what questions you may have now that you have heard both talks.

First, I wanted to share this comment that one of the viewers said that these excellent talks and just wanted to know how to help bi patients when they are much less likely to be out to clinicians and are passing as heterosexual. Any thoughts? I think this is a question for you, Brian, first.

BRIAN FEINSTEIN: It is a great question. It certainly a particular challenge with all folks from minoritized backgrounds if you do not know their identity. Being able to address identity-related stressors and help them with those is certainly going to be a challenge. I think that really starts with training clinicians and health care providers to be inclusive and affirming so that we see reductions in these negative experiences that bi+ folks have reported in health care settings, including with mental health care providers. Certainly more attempts to have intake paperwork and language that is being used that is affirming that lets people label themselves and identify the ways in which that that they want to. Again, coming back to having this training because we see that the biases that are present in clinical settings are not only implicit biases that people are not aware of but also explicitly biased language and comments being made so increasing awareness among clinicians and clinicians in training so that they are able to challenge and learn more about bi+ folks to reduce some of these microaggressions in treatment.

TAMARA LEWIS JOHNSON: Great. And Christina, do you have comments? Thank you so much for that, Brian.

CHRISTINA DYAR: I think that was fantastic. I think one of the great things that we can do in order to signal inclusivity is to try to reduce the assumptions that we make about people. I think oftentimes when somebody presents or looks straight and make assumptions about the gender of their partner – your husband might say to a feminine-appearing individual and if we can just try to intend not to do that in some contexts and that in and of itself is not going to offend anyone. But it may make somebody more likely to disclose their identity and feel comfortable.

TAMARA LEWIS JOHNSON: Great. Here is another question from viewers. It says ideally mental health providers would not be queer phobic. I have not experienced this to be case. In fact, attending counseling and being discriminated against by the counselor heightens dysphoria. What are suggestions for finding care for queer individuals where they may not be discriminated against by the provider? The fact is there are queer phobic individuals in every walk of life including mental health care providers.

BRIAN FEINSTEIN: That is a really hard question to answer unfortunately and is very dependent on contacts and where folks are living. I can speak the most to the United States given that that is where I live. There have been attempts to create indices where you could look up a particular health care provider or facility to identify who is broadly more affirming of LGBTQ+ folks in general. That said, that does not necessarily mean that all providers with a high rating on an index like that would be specifically affirming of bi+ folks.

I think when it comes to that, there is a lot of power in the knowledge of communities if folks have access either in person or remotely. Certainly, online the internet has opened up access to bi and bi+ groups of various sorts. And if someone has access to one of those groups, asking for recommendations and getting insider community knowledge of who has been affirming or who is a provider that would be a good person to seek care from.

And I think another possibility is if there are LGBTQ+ centers near where somebody is living, looking specifically at the programming and services that they offer to see if they are programming specifically for bi+ folks. And I think when they do, that can be a sign or a signal that providers may be more affirming there of bi+ folks in general. Although again, that does not mean that they will be necessarily or that there are not providers who can be affirming and will be who are outside of those settings.

TAMARA LEWIS JOHNSON: Thank you. Christina, do you have comments to that?

CHRISTINA DYAR: No. That was wonderful, Brian.

TAMARA LEWIS JOHNSON: Here is another question. It says in studies that the speakers have mentioned rates of anxiety and depression and other issues, how do researchers determine whether participants have mental health conditions? Are they screened for symptoms or asked if they have a formal diagnosis?

CHRISTINA DYAR: I can take this one. Usually these large nationally represented surveys where we get this kind of data from have a questionnaire that asks the participants that really covers the symptoms of a particular disorder. For example, the National Study on Drug Use and Health has questions about a variety of different substance use disorders. The other surveys were more focused on internalizing symptoms and doing a better job of capturing symptoms of anxiety and depression. And based on that, these are normed measures where they can see how many symptoms an individual has and whether that lines up with a diagnosis. That is the way that they usually do that in many of those surveys.

Some other surveys do broader structured interviews with participants that also do that as well but most of what we see at this point at least for the larger ones is for these very structured questions around symptomology.

TAMARA LEWIS JOHNSON: Thank you so much. Here is a question from the audience. Both talks have focused on anxiety and depression. How about other mental health issues like PTSD and bipolar disorder? Is there evidence for more diagnosis of bipolar disorder, in particular, people that bi or bi+?

BRIAN FEINSTEIN: When it comes to PTSD, in particular, there is certainly evidence that bi+ folks are at increased risk for PTSD and that bi+ folks, particularly women, experience substantially higher rates of trauma both during childhood and adulthood.

With respect to other diagnoses, sometimes studies that focus on depressive disorders broadly will include within that category both major depression as well as bipolar disorders. There has been very little research to my knowledge that is focused specifically on bipolar disorder among bi+ folks. As I said, sometimes it is included in the broader category of depressive disorders.

TAMARA LEWIS JOHNSON: Here is a question for Christina. As she noted that perhaps mental health outcomes measures used were not appropriate for QPOC, are there any that she would suggest?

CHRISTINA DYAR: That is a fantastic question. I know there has been some recent research, looking at how these measures operate really among the general population so not specific to queer, trans, binary people but really focused on mostly heterosexual individuals and seeing how the measures function for white compared to black and other people of color. They found evidence that they do not really operate the same. I do not necessarily know that there has been additional push to really making measures that do function the same. I think it is an area where there is more research needed. I am not aware of any looking at measurement and variance for queer people of color compared to queer white individuals. Are you, Brian?

BRIAN FEINSTEIN: Not off the top of my head. I think often when looking at how some of these measures function among SGM populations especially the intersections of other identities, different studies will find that certain items on measures do not work or function the same across different groups and not necessarily the entire measure. But I think the field of measurement in general has not necessarily come up with solutions that I am aware of for new measures that would be better able to capture the ways in which things like depression and anxiety present in bi+ populations at different intersections.

TAMARA LEWIS JOHNSON: Great. Thank you so much.

Here is another question. Does an asexual person with romantic attraction to multiple genders fall under the bi+ umbrella?

BRIAN FEINSTEIN: Yes. Generally speaking, it depends I would say both on how that person identifies and whether they consider themselves to be a part of the bi+ community or see themselves as bi+ where there could be variability and the extent to which a given person identifies in that particular way.

I think when it comes to this area of research more broadly, it really depends on the specific study. There are a subset of studies that focus on recruiting people who report attraction whether it is sexual or romantic to people of more than one gender or regardless of gender, regardless of specific identity labels that they use and there are other studies that is specifically focused on people who identify as bisexual in which case some of those studies might not include ace folks who have romantic attractions to more than one gender. I think broadly, it really depends on the particular study but kind of conceptually or when it comes to the actual person and the community then certainly, they would be considered part of the bi+ community as long as they identify that way.

TAMARA LEWIS JOHNSON: Thank you so much.

Here is another question. Could the degree of intrusion of parents and families in the lives of youths and the degree that parents need to control children’s lives and thoughts about themselves and anything else be part of your research? If parents do not care to know or judge on this issue, does this lack of pressure to decide contribute to stress, anxiety, and depression? Navigating family associations amongst bi+ individuals during the youth or adolescence.

BRIAN FEINSTEIN: That is kind of a hard question to answer. Sorry. I am trying to keep it all in my head while I think about this. What I think about some of the work that I have done interviewing bi+ male youth specifically, generally speaking, they describe experiencing discrimination-related sexual orientation in a variety of different contexts. Certainly experiences with parents and in the context of families are one of those. Sometimes they describe experiences where parents or family members would be discriminating in explicit ways and other times where it was more subtle comments or a lack of openness to talking about or acknowledging a person's identity.

I am not aware of a lot of research that is focused specifically on relationships between bi+ folks and their parents and the family context. But I think there is certainly some evidence consistent with the broader field of SGM  health research that relationships with parents and families are an important context to consider and that having either negative or positive experiences in those contexts can have subsequent either disadvantages or advantages for mental health.


Here is a question. From a public health perspective, when thinking about educating the public around caring for youth who identifies as bi+, would you think it would be good practice for all youth who identify to have a therapist process their experience with whether or not they are indicating any sign of depression or suicidality?

BRIAN FEINSTEIN: I think this is probably – just as context, I am answering some of the questions that are more clinical in nature, given that my background is in clinical psychology while Christina’s is in social and health psychology. That said, I think that this could be a controversial question where I think there are some folks who believe that anybody could benefit from mental health care in some way and others, I am particularly thinking about it from a public health perspective, who focus more on given the limited resources that are available and the lack of access to health care broadly for people really making those resources available to those who want and need them as opposed to thinking that everybody needs to have mental health care. I think generally speaking – I think from my perspective, I do not necessarily think that somebody has to or should necessarily have a mental health care provider just because they identify in a particular way if they are not experiencing challenges related to experiences or interactions with others that are connected to their identity or if they are not experiencing symptoms that they would want to be focusing on the context of treatment.

That said, I also do not think that there is generally harm where I think broadly speaking providing access to supportive resources, social support, connections to community. I think those sorts of things. Kind of these informal ways of providing mental health support have a huge impact and can go a long way and are relevant regardless of somebody’s symptom presentation.

TAMARA LEWIS JOHNSON: Thank you for that.

This is a question. I think it is relevant to the US but could be relevant in other settings as well. The question is about how do you – talking about visibility, how do you think it is affected by the current social and political environment? How would you address some of these challenges in light of recent state level anti-LGBTQ policies?

CHRISTINA DYAR: I think that is going to affect everyone in the community. Their willingness to be out. It depends on context. It depends on an individual’s personality and the extent to which they are willing or feel ready in that day to act as an advocate or on days when they need to protect themselves more and be less visible.

TAMARA LEWIS JOHNSON: There was a question raised about people with disabilities. Do you have any data or insights on the intersections of other disabilities beyond anxiety or depression for bi+ individuals? Any information on that?

CHRISTINA DYAR: That is a fantastic question and a really important intersection that has not received a lot of attention. Brian, are you aware of anything out there?

BRIAN FEINSTEIN: Yeah, I think the one area that relates to disabilities specifically is there has been some work focused on experiences of chronic pain, particularly among bisexual and bi+ women. Again, very little research in this area. But there is some evidence of disparities related to chronic pain experiences and unique challenges and how identify-related stressors impact chronic pain. A little bit in that area but I think broadly speaking, when thinking about research on intersections of different identities, disability, in particular, has received much less attention than other identities and is an area that is – a lot of work is needed in that area particularly when thinking about relationships to health and health outcomes.

TAMARA LEWIS JOHNSON: Due to the dynamic nature of gender and sexual orientation while longitudinally testing for mental health outcomes if participants do no longer identify as bi+, how would that change be incorporated into the results of the study? Talking about gender fluidity and things like that.

CHRISTINA DYAR: You have done more work on identity-related change stuff, Brian.

BRIAN FEINSTEIN: Yes. That is a really good question. I think first and foremost, that requires that people are assessing sexual orientation at multiple waves in longitudinal studies, which does not always happen. Often people think of certain identity characteristics, including sexual orientation and gender identity as static even though we know that they do change and evolve for many people. There is not a lot that is known about how these changes influence health and how to best account for these changes in the context of research and the analyses that we are conducting.

In some of our work, we have focused specifically on waves at which or times at which a given person identified as bi+ and using the data from those times. In some our studies, we have specifically looked at the changes in the ways that people label, for example, their sexual orientation and whether those changes relate to health outcomes in different ways and generally speaking, we see that even for people who identify as gay, lesbian, bisexual, et cetera, already that changes in identity or the ways that people label their identity is often related to adverse health outcomes later on. I think in terms of why exactly that is, there has not been a lot of attention to those mechanisms. Overall, I think this is a question that the field is grappling with.

And as people continue to hopefully be assessing sexual orientation in multiple waves of these longer-term studies that follow people, I think we will be able to do a better job of figuring out what are the best ways analytically of capturing or modeling these changes over time.

TAMARA LEWIS JOHNSON: Thank you so much.

This is another question. Thinking about creating visual spaces and using language that is inclusive as treatment, how will providers know – how will you let bi+ people know that they can be out in the patient setting? What sort of things to encourage more inclusiveness?

BRIAN FEINSTEIN: Some of this is embedded in the ask of that particular question. But I think having signage and visual displays that indicate inclusivity I think – for too long perhaps, folks have thought of let us say, for example, a rainbow flag as the single signifier of inclusivity for LGBTQ+ folks broadly. That does not necessarily signal inclusivity or safety for some of the more underrepresented and more marginalized subgroups within the broader LGBTQ+ community. I think having flags that are specifically for bi and pan folks in and of itself would communicate at the very least an acknowledgement or understanding that there are folks who identify as bi and bi+.

I think beyond visual signifiers, I think having a lot of different options for identify on forms and health care settings, allowing people to just write in their identity rather than selecting from a list that is likely going to exclude certain people and as Christina mentioned earlier, really thinking about the assumptions that we make about people where it is a common assumption that regardless of how someone identifies, if you do not know how someone identifies, if they mention having a partner of the same gender, it is common to just assume and make a comment about them being lesbian or gay and that might very well not be how they identify so not making assumptions and instead just being more thoughtful in the language that we use.

TAMARA LEWIS JOHNSON: As we come to a close, I am just going to ask one question to both of the speakers and have you respond to this. We have talked a lot about anxiety and depression and addressing internalizing symptoms perhaps in clinical settings. Can you speak a little bit about non-traditional settings that could be helpful to bi+ people seeking affirming mental health services? This gets into the aspect of intersectionality, church settings, different settings for LGBTQ+ environments where people can get – bi+ individuals can be able to seek affirming mental health services. Christina, could you respond and then maybe Brian.

CHRISTINA DYAR: Sure. I think part of this all comes down to where people feel comfortable and where they find their community. There is definitely a history of the LGBTQ community and people’s color, finding community in different spaces. Churches are a great example when they are affirming.

There are also other contexts where people might seek treatment. For example, using yoga and mindfulness and things like that as less traditional treatment techniques in less clinical settings are often places where we know that bi+ individuals and sexual and gender minorities more broadly seek treatment because it can feel more affirming. That is what I have. Brian?

BRIAN FEINSTEIN: I think everything that I would add was captured in an earlier response around seeking the power of knowledge within a community, thinking about belonging to or joining social groups that can provide these informal supports that can boost mental health. I think again with so much moving online and remotely, it has increased access for people much more broadly than before. I think again  sort of using knowledge from community members to help inform decisions about where to seek care is ultimately going to be the closest that at least at the moment we can get to having that knowledge that someone is particularly likely to be affirming of bi+ folks.

TAMARA LEWIS JOHNSON: Thank you so much, Dr. Feinstein and Dr. Dyar. This was an outstanding presentation. Thank you so much to all the support team and to the audience.

We are going to close with our final slide just to make viewers aware that our next webinar coming face to face with suicide in America farming will be Wednesday, September 12th from 2:30 to 4 p.m. Eastern Standard Time. Please register for that and share that with others. Thank you so much for the stimulating and thought-provoking discussion. If you have any questions or information about the webinar, here is an email address where you can contact us. Thank you again for attending.