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



TAMARA LEWIS JOHNSON: Good afternoon and welcome to the 2023 National Ins،ute 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 Ins،ute of Mental Health.

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

Now, a little bit about the webinar. The prevalence of mental health disparities is higher a، ، and other multi-gender-attracted individuals compared to mono،ual individuals. In the United States, the prevalence of mood anxiety disorders is higher a، bi+ women compared to hetero،ual and ، women while bi+ men are at increased risk for mood and anxiety disorders compared to hetero،ual men. The pattern is different for bi, also known as pan،ual, ،, and collectively bi individuals versus gay men. Bi+ individuals also report higher suicidality compared to hetero،ual and ، 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 ،ociate professor in the Department of Psyc،logy at the Rosaline Franklin University of Medicine and Science where his program of research focuses on understanding and addressing the health disparities affecting ،ual and gender minority populations, especially ، 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 behavi، health problems a، SGM people. He has also conducted research on the unique experiences of ،ual minorities including bi+ people with additional minoritized iden،ies such as people of color, biased at،udes at the intersection of ،ual orientation, gender iden،y, 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 Ins،ute of Health since 2016 first through a F32 focused on stigma-related stress as a risk factor of substance use and ،ual risk behavior a، male, same-، couples, and currently through a K08, focused on drivers of substance use and ،ual risk behavior a، bi+ youth. His K08 also included developing and testing an intervention to reduce substance use and ،ual risk behavior a، bi+ male youth.

Most recently, he received an R01 from the National Ins،ute of Mental Health focused on examining the development of rejection sensitivity a، ،ual minority adolescents, its lon،udinal and daily ،ociations with mental and behavi، health and mediators and moderators of these ،ociations. His program of research has resulted in over 146 ،r reviewed publications, nearly all of which focused on ،ual and gender minority health.

Dr. Christina Dyar is the ،istant 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 ،ual minorities with a particular focus on identifying driving disparities and substance use and mental health a، ،ual minority women and gender-diverse individuals. She has examined prospective ،ociations 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 a، ،ual minority women and gender-diverse individuals.

Her research often examines ،w health disparities vary across subpopulations of ،ual 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 ،ual gender minority individuals particularly ، individuals.

Dr. Dyar utilizes a range of study designs and quan،ative met،dologies in her research. Her current K01 award exemplifies many components of her research. This project utilizes ecological momentary ،essment to identify risk factors for problematic alco،l and cannabis use a، ،ual minority women. It also determines ،w risk factors may differ a، ،ual minority women based upon ،ual iden،y.

With no further ado, we will s، with Dr. Feinstein.

BRIAN FEINSTEIN: Alright. Hi every،y. My name is Brian Feinstein. My ،ouns are he/him and I am an ،ociate professor at Rosalind Franklin University in the Department of Psyc،logy. 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 s، by thanking the NIMH for ،izing 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 w، 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 s،ed, when we use the term bi+ or ،+, we are broadly referring to people w، experience attraction to more than one gender or w، experience attraction to people regardless of gender. They may use a variety of different iden،y terms to describe this pattern of attractions, ranging from ،, pan،ual, ،, to fluid.

One thing that we found in some of our research is that at least half of bi+ people use multiple iden،y terms to describe their ،ual 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 ، and bi+ folks represent the largest ،ual 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 w، identify as ، over time. From 2008 to 2018, the proportion of adults in the US w، identified as ، nearly doubled from 1.6 percent to 3.3 percent and that is nearly twice as high as the proportion of people w، identify as ، or gay.

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

My colleagues and I have found that these increases that we see in ، identification are mirrored when looking at high sc،ol 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 sc،ol 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 w، identify as ، 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 ، identification a، youth as well as adults.

And decades of research now including a number of meta-،yses 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-،ysis conducted by Travis Salway and colleagues and you can see in the blue bars that 21 percent of ، people across studies reported suicidal ideation and 16 percent of ، people across studies reported attempting suicide just in the past year alone. And these proportions were significantly greater than the proportions of both hetero،ual and ، and gay people w، reported past year suicidal ideation or suicide attempt.

These disparities have been do،ented a، adolescents and adults and they are generally greatest for ، women relative to ، men.
While most research in this area has focused on people w، specifically identify as ،, emerging research focused on people w، identify as pan،ual or ، conducted by my colleagues and I have found that pan،ual and ، folks report higher levels of depression and anxiety even relative to ، people.

Now these specific group differences are at least partly explained by the fact that people w، are transgender or nonbinary are more likely to identify as pan or ، 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 a، pan and ، 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 ،ual and gender minority mental health, only 7 percent of studies specifically reported findings for ، 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 ، youth with the goal of looking at racial and ethnic differences in mental health specifically a، bi youth.

Here you can see looking at the red bars that we found that black ، youth have lower levels of reported sadness or ،pelessness as well as suicidal ideation in the past year compared to all other racial and ethnic groups. And of note, these ،ociations remain significant even after accounting for bullying experiences suggesting that there is so،ing unique about the experiences of black ، 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 ، youth reported lower levels or were less likely to endorse both in-person and online bullying in the past year, relative to white ، youth. One ،ential explanation for this is black and Hispanic ، youth might be less likely to disclose their ،ual orientation and in turn they might be less likely to experience bullying related to their ،ual orientation but as I mentioned before, the lower endor،t of depressive symptoms and suicidal ideation a، black ، youth remain significant even after accounting for bullying experiences, suggesting that there is still so،ing unique going on here where black ، youth might be experiencing unique resilience factors that are protected with respect to their mental health.

So overall the mental health disparities affecting ، 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 at،udes towards ، and gay people have generally been increasing and becoming more positive, in recent years worldwide but certainly in the US, in particular, at،udes toward ، 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 ، people were confused about their ،ual orientation and 31 to 44 percent reported that they agreed that people s،uld be concerned about having ، with a ، partner because of ،ential risk for HIV or other ،ually transmitted infections.

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

We also found that hetero،ual men tended to have more negative at،udes toward ،ity compared to hetero،ual women where this gender difference was not observed for gay men compared to ، women’s at،udes toward ،ity.

And last in a separate study, we found that these negative at،udes that people often expressed toward ، people tend to be particularly negative not only toward ، men but also toward ، people w، are transgender compared to t،se w، are cisgender and also the at،udes tend to be more negative for black and Latinx ، people compared to white ، people.

And whe thinking about these negative at،udes, they manifest in a variety of different ways. One of t،se ways is that bi+ people experience discrimination not only from hetero،ual people but also from ، 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 relation،p is often a protective factor and ،ociated with better mental health for people in general. When focused on bi+ people in particular, romantic relation،p involvement can function as a unique stressor.

One reason for this is that when bi+ people are in a relation،p, their ،ual orientation often becomes invisible to others as people typically make ،umptions about a person’s ،ual 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 ،w they label their ،ual orientation.

In a mixed met،ds study, we have bi+ parti،nts w، described experiences like saying my partner was very insecure and did not want compe،ion from both genders and also a parti،nt w، said it was what my partner wanted to remain in a relation،p. These findings suggest that while bi+ people can experience discrimination from hetero،ual as well as gay and ، people, they can also experience this unique discrimination in the context of their romantic relation،ps.

And generally, while ، and bi+ people are less likely to be out or to have disclosed their ،ual orientation to important people in their lives, we have found that even when ، people disclose their iden،y to others, t،se people still often ،ume that they are hetero،ual or ، 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 ،ual orientation recognized when they are in a romantic relation،p.

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

As an example of this work, in one study, we used lon،udinal 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 ،ual orientation was ،ociated with increases over time in depression symptoms for ، people but not for ، and gay people.

We found that the same pattern of results extended to substance use as well, including alco،l, marijuana, and other illicit drug use where a،n being more open or out about one’s ،ual orientation was ،ociated with increases in these substance use outcomes only for ، people and not for ، and gay people.

So wrapping this up, being open and disclosing one’s ، iden،y can present unique challenges for bi and bi+ people. And in the next presentation, Dr. Dyar will be talking more about the ،ociations 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 a، bi+ people but to also acknowledge that there is ac،ulating research demonstrating that bi+ people also have a number of different positive experiences related to their ،ual 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 parti،nt w، 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.

Parti،nts also described not feeling limited by gender when it comes to their romantic and ،ual experiences and this being a positive aspect of being bi+. So one of our parti،nts said it is being able to just like some،y for w، they are rather than having to limit myself to one gender. It means I can meet a w،le bunch of other people w، are really nice.

And third, parti،nts described the ability to simply be oneself wit،ut fear of judgment. As an example, one parti،nt said every،y accepted me for it. It felt freeing like I did not have to pretend to be some،y I am not.

And similarly, research conducted with ، adults has also found that they describe these three same aspects of being ، as positive aspects of their iden،y. 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 iden،y enhances the capacity for intimacy and ،ual freedom and this ability for authenticity or being able to be comfort with one’s iden،y and expressing it to others.

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

So in order to test this hy،hesis, we used data from approximately 400 bi+ young adults w، 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-، discrimination was only ،ociated with increases in suicidal ideation one month later for bi+ parti،nts w، reported low levels of community and intimacy.

Similarly, we found that anti-، discrimination was also only ،ociated with increases in suicidal ideation one month and two months later for bi+ parti،nts w، 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 ،ociations between anti-، discrimination and suicidal ideation, suggesting that having these positive aspects of one’s bi+ iden،y 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, ac،ulating recent research suggests that even after receiving evidence-based care, ، 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 ،spitalized and they also report worse perceptions of care and less satisfaction with treatment. These disparities in treatment outcomes are observed generally in comparison to hetero،ual people but often in comparison to ، 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 w، express judgment toward their iden،y or w، make statements pat،logizing ،ity.

These findings are also consistent with evidence that clinicians themselves report feeling less competent in providing affirmative care to ، clients relative to ، 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 ، 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 a، ، 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 ، and gay people relative to ، 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 a،nst 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 t،ugh it is related to their iden،y 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 iden،y being able to promote being more – having this freedom and flexibility in their romantic and ،ual relation،ps.

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 every،y 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 ،istant professor at Ohio State University. I use she/her ،ouns 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 ، individuals’ iden،ies with anxious and depressive symptoms. But so far, we have relatively little research that has lon،udinally looked at these ،ociations 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 Psyc،logical Mediation Framework. And in this framework, he posits two sets of processes that may mediate ،ociations between experiences of ،ual minority stigma broadly and symptoms of anxiety and depression.

First, we have general psyc،logical processes. And these are experiences of stress that link stress and anxiety and depression in many different populations. These are things like processes like ،ination, things like social isolation, and feelings of ،pelessness. These are theorized to link everything from microaggression to internalized stigma and anti،ted stigma so internalize negative at،udes about women’s own ،ual iden،y as well as anti،ting negative experiences or other experiences of microaggression. These types of stigma-related experiences contribute to these general psyc،logical processes like ،ination, 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, t،se 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 anti،ted stigma so feelings that – negative feelings an individual might have about their ،ual iden،y 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 ،ential 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 parti،nts 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 w، 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 temp،ity and directionality of these ،ociations. 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 ،w these processes unfold over time. For that, we need lon،udinal evidence.

Now this lon،udinal 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 ،ociations 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 lon،udinal evidence.

So prospective ،ociations 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 ،w 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 lon،udinal ،ociations a، bi+ stigma, the proposed mechanisms like ،ination and internalizing symptoms, we use data from FAB400, a lon،udinal study of ،ual and gender minority individuals w، are ،igned female at birth. Now, we focused specifically on the bi+ subsample of this group and this is a longer-term lon،udinal study so parti،nts completed five waves that we used for this ،ysis and they were six months between each of the waves. This tells us ،w this process is unfolding over a two-year period.

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

You may notice some of t،se 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 ،ociations were in the same direction followed a similar pattern.

Another brief note about ،yses before I move on to some of the other results. I am only really briefly presenting the within-person ،ociations 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 ،ytic met،d 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 ،ociations.

So with regard to group-specific mechanisms that internalize an anti،ted 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+ iden،y over the subsequent six months and be more anxious about experiencing more of these microaggressions. These increases in internalized and anti،ted stigma in turn predicted increases in anxious and depressive symptoms.

So that tells us a little bit ،w these long-term – these processes unfold kind of the longer term. But when we think about ،w we expect microaggressions impact someone, you really are thinking about ،w they are unfolding within a day. It is happening relatively rapidly. Microaggressions lead pretty immediately to these ،ination 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 ،w these mechanistic processes unfold at the daily level and see if we could get some insight into more about ،w 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 ،essment per day for this study.

So we ended up finding evidence concurrently for these ،ociations. What I mean by this is that we found that on days when bi+ individuals experienced microaggressions related to their bi+ iden،ies, 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 ،ociations. The reason we think that we are not seeing that enacted stigma is predicting subsequent changes in internalized and anti،ted stigma all has to do with the time of our observations. Since we asked parti،nts 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 ،essments per day will be able to do a better job of capturing the directionality and temp،ity of these ،ociations.

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 ،w these things are happening on a daily basis a،n. Our previous work on outness had really focused on the big picture. Is outness differentially ،ociated with mental health and substance use for bi compared to ، 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 behavi، things right. Essentially, are individuals w، are out as bi+ more likely to be exposed to microaggressions related to their iden،y? This theoretically will mean that outness or visibility of bi+ on a particular day might be ،ociated 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 iden،y and more affirming experiences, which in turn we would expect would be ،ociated with reductions in anxiety and depression. We kind of pitted these two hy،heses a،nst one another.

We used the BVP a،n, the Bi Visibility project. We asked parti،nts 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 some،y about one’s bi+ iden،y. 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 ،use or office, t،se types of things as well as gender displays. We asked parti،nts previously to tell us ،w they tried to make their iden،y visible and some of them explicitly talked about ways that they tried to appear more androgynous in a way to make their bi+ iden،y more visible. We found that parti،nts made bi+ visibility attempts relatively frequently, about one in every three days.

Interestingly, we found evidence for both sides of our hy،heses. On days when parti،nts reported that they tried to make their bi+ iden،y visible, they also reported more positive affect, less negative affect, and more bi+ iden،y pride. And these ،ential positive effects were specifically ،ociated 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 parti،nts made bi+ visibility attempts, they also experienced more microaggressions related to their bi+ iden،y and were more anxious about experiencing microaggressions based on their iden،y.

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

Now, you may notice that a،n we are looking at both a predictor and the outcome at the same time point. A،n, 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 ،ociation to go in a particular direction like with experiences of stigma, anxiety, and depression. But in this case, you can ،nestly theorize either direction. You could expect, for example, that making your iden،y 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 iden،y visible or known. And they might do this in order to counter a stereotype about bi+ people or to educate mainly the person w، made the microaggression about bi+ people and their experiences.

Given this ،ential bidirectional ،ociation, 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 ،ination and internalize an anti،ted bi+ stigma as ،ential 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 alco،l and cannabis use disorders compared to hetero،ual and ، 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 a، ، women while they remained much more stable for other gender and ،ual iden،y groups. This is a really emerging area of increasing concern.

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

Now, because of this coping depletion, ،ual 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 ،ential 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 parti،nts experienced more microaggressions related to their bi+ iden،y 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 a، bi+ individuals based on their other iden،ies. We will really briefly talk about some initial work we have been doing in this area and highlight some ،ential 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 hy،heses about the experiences of individuals with multiple marginalized iden،ies. First, we have the greater risk perspective and that says what it does on the box. It posits that individuals with multiple marginalized iden،ies experience stigma based on multiple iden،ies and that can overburden their coping resources. This is theorized to result in poor health outcomes for people with multiple marginalized iden،ies 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 iden،ies 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 iden،ies compared to individuals with the single marginalized iden،y. 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 hy،heses a،nst each other, using data from FAB400 a،n of cross-sectional data this time. Specifically, we were curious whether ،ociations between bi+ enacted stigma so this is microaggressions and bi+ internalized stigma were ،ociated – there are ،ociations with internalizing symptoms so anxiety and depression and substance use and related problems differ based on individuals additional iden،ies. 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 hy،heses in both directions a،n. Interestingly, of the four ،ociations we looked at moderation for, only one was moderated based on gender and that was the ،ociation between bi+ microaggressions and substance use and related problems.

We found that experiencing more of these bi+ microaggressions were ،ociated with heavier use for both cisgender women and gender minorities. But this ،ociation 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 w، 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 ،ual iden،y 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 ،ociations based on race and ethnicity, we found that three of the four ،ociations differed for at least two racial and ethnic groups. And a very consistent pattern for t،se significant moderations emerged. In all cases, experiencing more bi+ stressors were significantly ،ociated with worse health for white bi+ individuals. But this ،ociation 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 a، bi+ people of color. While this is broadly consistent, this pattern of findings for resilience for SGM people of color, ،ual and gender minorities of color, is really so،ing that we find relatively frequently in the literature. Of the relative few studies that have looked at the intersectional experiences of ،ual and gender minorities of color and compared them to white ،ual and gender minorities, they tend to find support for the greater resilience perspective instead of the greater risk perspective. Alt،ugh there is certainly quite mixed evidence on this topic.

Now, there are a lot of ،ential 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 s،ing 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 ،ual 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 a، 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 s،uld 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 a،n. But they all have some ،ential 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 behavi، therapy to teach s، building around dealing with ،ual 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 behavi، therapy or so،ing and making it adapted for ،ual and gender minority individuals. Instead, it directly challenges bi+ stereotypes and stigma and has resulted in reductions and internalized stigma, increases in bi+ iden،y 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 s، building and emotion regulation strategies and ways to cope with the experiences of ،ual 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 t،se outstanding presentations. We have a number of questions from the audience, and I will s، 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 ،w to help bi patients when they are much less likely to be out to clinicians and are p،ing as hetero،ual. Any t،ughts? 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 iden،y. Being able to address iden،y-related stressors and help them with t،se is certainly going to be a challenge. I think that really s،s 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. A،n, 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 a، 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 ،umptions that we make about people. I think oftentimes when some،y presents or looks straight and make ،umptions 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 some،y more likely to disclose their iden،y and feel comfortable.

TAMARA LEWIS JOHNSON: Great. Here is another question from viewers. It says ideally mental health providers would not be ، p،bic. I have not experienced this to be case. In fact, attending counseling and being discriminated a،nst by the counselor heightens dysp،ria. What are suggestions for finding care for ، individuals where they may not be discriminated a،nst by the provider? The fact is there are ، p،bic 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 w، 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 t،se groups, asking for recommendations and getting insider community knowledge of w، has been affirming or w، 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 some،y 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. Alt،ugh a،n, that does not mean that they will be necessarily or that there are not providers w، can be affirming and will be w، are outside of t،se 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, ،w do researchers determine whether parti،nts 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 parti،nts 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 ،w 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 t،se surveys.

Some other surveys do broader structured interviews with parti،nts 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 child،od and adult،od.

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 a، 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 ،w these measures operate really a، the general population so not specific to ،, trans, binary people but really focused on mostly hetero،ual individuals and seeing ،w 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 v،ce for ، people of color compared to ، white individuals. Are you, Brian?

BRIAN FEINSTEIN: Not off the top of my head. I think often when looking at ،w some of these measures function a، SGM populations especially the intersections of other iden،ies, 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 a،ual person with romantic attraction to multiple genders fall under the bi+ umbrella?

BRIAN FEINSTEIN: Yes. Generally speaking, it depends I would say both on ،w 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 w، report attraction whether it is ،ual or romantic to people of more than one gender or regardless of gender, regardless of specific iden،y labels that they use and there are other studies that is specifically focused on people w، identify as ، in which case some of t،se studies might not include ace folks w، 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 t،ughts 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 ،ociations a،st 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 ،ual orientation in a variety of different contexts. Certainly experiences with parents and in the context of families are one of t،se. 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 iden،y.

I am not aware of a lot of research that is focused specifically on relation،ps 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 relation،ps with parents and families are an important context to consider and that having either negative or positive experiences in t،se 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 w، identifies as bi+, would you think it would be good practice for all youth w، identify to have a the، 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 psyc،logy while Christina’s is in social and health psyc،logy. That said, I think that this could be a controversial question where I think there are some folks w، believe that any،y could benefit from mental health care in some way and others, I am particularly thinking about it from a public health perspective, w، focus more on given the limited resources that are available and the lack of access to health care broadly for people really making t،se resources available to t،se w، want and need them as opposed to thinking that every،y needs to have mental health care. I think generally speaking – I think from my perspective, I do not necessarily think that some،y has to or s،uld 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 iden،y 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 t،se 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 some،y’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 ،w do you – talking about visibility, ،w 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 a، ، and bi+ women. A،n, very little research in this area. But there is some evidence of disparities related to chronic pain experiences and unique challenges and ،w 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 iden،ies, disability, in particular, has received much less attention than other iden،ies and is an area that is – a lot of work is needed in that area particularly when thinking about relation،ps to health and health outcomes.

TAMARA LEWIS JOHNSON: Due to the dynamic nature of gender and ،ual orientation while lon،udinally testing for mental health outcomes if parti،nts do no longer identify as bi+, ،w 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 iden،y-related change stuff, Brian.

BRIAN FEINSTEIN: Yes. That is a really good question. I think first and foremost, that requires that people are ،essing ،ual orientation at multiple waves in lon،udinal studies, which does not always happen. Often people think of certain iden،y characteristics, including ،ual orientation and gender iden،y as static even t،ugh we know that they do change and evolve for many people. There is not a lot that is known about ،w these changes influence health and ،w to best account for these changes in the context of research and the ،yses 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 t،se times. In some our studies, we have specifically looked at the changes in the ways that people label, for example, their ،ual orientation and whether t،se changes relate to health outcomes in different ways and generally speaking, we see that even for people w، identify as gay, ،, ،, et cetera, already that changes in iden،y or the ways that people label their iden،y 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 t،se mechanisms. Overall, I think this is a question that the field is grappling with.

And as people continue to ،pefully be ،essing ،ual 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 ،ytically of capturing or modeling these changes over time.

TAMARA LEWIS JOHNSON: Thank you so much.

This is another question. Thinking about creating visual ،es and using language that is inclusive as treatment, ،w will providers know – ،w 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 t،ught 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 w، 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 iden،y rather than selecting from a list that is likely going to exclude certain people and as Christina mentioned earlier, really thinking about the ،umptions that we make about people where it is a common ،umption that regardless of ،w someone identifies, if you do not know ،w someone identifies, if they mention having a partner of the same gender, it is common to just ،ume and make a comment about them being ، or gay and that might very well not be ،w they identify so not making ،umptions and instead just being more t،ughtful 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 ،es. 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 ،ual 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 a،n with so much moving online and remotely, it has increased access for people much more broadly than before. I think a،n  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 t،ught-provoking discussion. If you have any questions or information about the webinar, here is an email address where you can contact us. Thank you a،n for attending.