Our research team conducted 100 interviews of youth aged 18 to 24 between May 2017 and April 2018, with written informed consent obtained before each interview. Our survey questionnaire was composed of the Government Performance and Results Act survey for adolescents, supplemented with validated measures for substance use, anxiety, depression, PTSD, adverse childhood experiences, and quality of life. Based on consultations with frontline service delivery staff at Larkin Street, it was considered most effective for the interviewer to sit with the participant while they were completing the questionnaire in order to answer any questions the participant might have. If the participant preferred to complete the questionnaire in private, the research team member left the interview room. All participants who initiated the survey were provided with a $30 gift card to thank them for participating in the survey. Participation in the questionnaire had no bearing on individuals’ ability to obtain services at Larkin Street. All of the above stages of data collection were approved by the University of California, San Francisco’s Institutional Review Board .Demographics. Participants reported on age, race, ethnicity, and highest level of education attained . To determine sexual orientation and gender identity, participants also reported on sex assigned at birth, gender identity, and sexual orientation in multiple-choice and open-field format. Options for gender identity included “male”, “female”, and “other”, which allowed participants to write answers into an open-field option. Options for sexual orientation included “straight or heterosexual”, “bisexual”, “gay or lesbian”, and “unsure”. Government Performance and Results ActQuestionnaire. Per federal mandate, all Substance Abuse and Mental Health Services Administration grantees are required to collect and report performance data using the GPRA questionnaire. Data collection for GPRA includes measures on demographics, substance use, and HIV infection.
To assess HIV status,weed trimming tray participants were asked if they have ever been tested for HIV and to estimate the date of their last HIV test and to self-identify their HIV status. Of note, concomitant testing was not performed to confirm self-reported serostatus. National Institute on Drug Abuse-Modified Alcohol, Smoking, and Substance Involvement Screening Test V2.0 . The NIDA-Modified ASSIST V2.0 is a screening test for individuals who may have been, or are currently, at risk of developing a substance use disorder. The ASSIST questionnaire assesses for use of tobacco, alcohol, cannabis, cocaine, stimulants, sedatives, hallucinogens, inhalants, opioids, and other drugs. Individuals are asked to report whether or not they have ever used each substance in their lifetime, and then how frequently they used each substance within the past three months. For each substance used in the past 3 months, the respondent then answers five additional questions to measure harmful use associated with each substance. Q3 asks about compulsion , Q4 asks about health, social, financial, or legal complications associated with substance use, Q5 asks whether participants have failed to fill responsibilities of a usual role due to use of that substance, Q6 asks whether close contacts have expressed concern about their substance use, and Q7 asks about prior failed attempts to cut down on substance use. Based on responses to these latter questions measuring harmful use, a Substance Involvement score can be calculated that correlates to the overall health risk level associated with use of each specific substance. An SI score of 0 to 3 is considered low risk of harmful use, 4 to 26 equates to moderate risk, and 27+ indicates high risk of harmful use. The tool is intended to help clinicians assess the level of health-related risks associated with an individual’s substance use habits. The NIDA ASSIST has been validated for use in both adolescents and adults, including individuals who use a number of substances and exhibit varying degrees of use across different substances.Center for Epidemiologic Studies-Depression . The CES-D is a 20-item validated measure that asks participants to describe symptoms that have been associated with depression over the past week. Scores range from 0 to 60, with higher scores indicating greater depressive symptoms.
A score greater than 15 indicates increased risk for clinical depression. PTSD Checklist for DSM-5 . The PCL-5 is a 20-item validated measure that screens for the presence of symptoms of post-traumatic stress disorder . Participants are asked to consider “a very stressful experience” and answer questions about symptoms of PTSD over the past month specifically in response to the stressful experience. Scores range from 0 to 80, with higher scores indicating more severe symptoms of PTSD. A PCL-5 cut-off score of 33 can be used to screen for symptoms consistent with clinical PTSD. Generalized Anxiety Disorder instrument . Participants are asked to respond to questions regarding different symptoms of anxiety over the past 2 weeks. A total score of 10 or above on a scale of 0 to 21 indicates symptoms of moderate anxiety, with increasing scores indicating greater functional impairment due to clinical symptoms.The research team conducted a total of 103 interviews; three participants were unable to complete the entirety of the questionnaire and their data was excluded from analysis. Our analysis defined homelessness as living in a supervised publicly- or privately-operated shelter designated to provide temporary living arrangement or living within a primary nighttime residence that is a public or private place not designed for as a regular sleeping accommodation including car parks, abandoned buildings, bus or train stations, airports, and camping grounds. Participants who identified as gay, lesbian, bisexual, unsure, or self-identified in write-in responses as “pansexual”, “transgender”, and “non-gender” were categorized as SGM youth in data analysis. Pearson’s Chi-square analysis, Fisher’s Exact Test, and independent t-tests were used to test associations between study participant demographics and anxiety, depression, PTSD, and SGM status. One-tailed independent t-tests were used to test associations between mean ASSIST scores by substance and SGM status, with the hypothesis that SGM youth would exhibit higher levels of substance use and associated risks than heterosexual cisgender participants.
All analyses were conducted using STATA Version 14.2.Of the 100 participants included in the analysis, the mean age was 21.7 years, with an age range from 18 to 24 years. Of these, 67% of participants identified as male, 28% as female, and 5% as another gender identity. 52% of participants identified as lesbian, gay, or bisexual. More than three-quarters of participants were people of color, including participants who identified as Black, American Indian or Alaska Native, Filipino, Pacific Islander, or Multiracial , which correlates closely to the overall demographics of youth served at Larkin Street . With regards to education, 91% of participants had completed at least a high school education. Overall, 23% of surveyed participants self-reported living with an HIV diagnosis, including 43% of surveyed SGM youth, compared to only 3% of their heterosexual cisgender peers .Data on current or recent substance use revealed that 35 SGM participants and 21 heterosexual cisgender participants had used at least one substance in the past three months. The four most commonly used substances among all 100 participants were cannabis , cocaine and crack cocaine , methamphetamine and hallucinogens . Of note, recent use within the past 3 months did not differ significantly by SGM status for any of the substance types surveyed . Using the NIDA-modified ASSIST tool, we also assessed whether service-seeking SGM youth reported higher risk levels for negative health outcomes from substance use. Across all nine substances surveyed, a significant difference in ASSIST SI scores by SGM status was only noted for methamphetamine use . Using the ASSIST tool, SGM participants reported higher mean health risk scores associated with methamphetamine use compared to heterosexual cisgender participants . For the eight other substances analyzed, no significant increase in health risks scores were observed among service-seeking SGM participants compared to heterosexual cisgender participants .In addition to assessing substance use, mental health measures were also analyzed by SGM identity. Overall,cannabis grow setup service-seeking SGM youth were noted to experience more severe symptoms of generalized anxiety compared to their heterosexual cisgender peers . On average, SGM youth scored 10.8 on the GAD-7 –a score which correlates to moderate clinical symptoms of anxiety–whereas heterosexual cisgender youth scored an average of 8.5, which correlates to mild symptoms of anxiety. Of note, nearly one-third of SGM youth had severe range anxiety symptoms, compared to only 16% of heterosexual cisgender youth . Notably, with respect to PTSD, no significant differences were found between PCL-5 scores for symptoms of PTSD between service-seeking SGM and heterosexual cisgender youth. However, high rates of PTSD symptoms were seen among participants overall, with 80% of participants with PCL-5 scores screening positive for symptoms of PTSD . Similarly, the CES-D depression screening tool revealed that 74% of participants scored at or above 16 , although similarly high rates were found among both SGM youth and their heterosexual cisgender peers . All mental health validated questionnaires demonstrated strong internal consistency among our study population, with Cronbach’s alpha values for the GAD-7, PCL-5, and CES-D of 0.90, 0.96, and 0.83, respectively.In our study, service-seeking SGM youth experiencing homelessness did not exhibit higher levels of recent substance use within the past three months compared to their heterosexual cisgender peers. Across all nine substances analyzed, SGM and heterosexual cisgender participants were equally likely to have reported use of the substance in question at least once within the past 3 months.
This finding differs from several existing studies which reported higher levels of substance use among SGM youth experiencing homelessness. Beyond strictly measuring frequency of recent use, our study also demonstrated that compared to heterosexual cisgender youth, service-seeking SGM youth reported comparable risk levels of harmful outcomes associated with substance use for all substances measured, with the exception of methamphetamine. In regards to methamphetamine use, our finding that SGM participants reported higher associated risk levels fits into the well-established body of literature describing the high prevalence and associated risks of methamphetamine among gay and bisexual men. Additionally, previous research has demonstrated that methamphetamine use disorder is uniquely difficult to treat, though contingency management programs provide the best evidence for efficacy. Thus, the increased risk specifically associated with methamphetamine use among SGM youth identified in our study may be an important indicator that SGM youth require more tailored interventions for substance use disorders compared to the general homeless youth population. It is unclear why our study did not find significant differences in frequency and harmful risks of substance use among SGM youth experiencing homelessness and their heterosexual cisgender counterparts, though several possibilities exist. One possible explanation is the relatively high availability of supportive services and communities for SGM youth in San Francisco. In a qualitative study of gay and transgender youth of color in San Francisco, participants described the Castro, a historically queer neighborhood of San Francisco, as a place “where they each spent time and sought safety, community, and identification”.Larkin Street, our partnering community organization, provides transitional housing in the Castro for clients who identify as LGBTQ, including housing specifically for transgender youth experiencing homelessness. While programs in other cities may similarly support the needs of youth experiencing homelessness, they may also be settings in which SGM youth experience discrimination. For example, homeless youth in Canada have reported experiences of discrimination due to their SGM status from both other clients and staff in emergency shelters. The relatively higher availability of SGM-friendly services for unstably housed youth in San Francisco, including our partnering organization Larkin Street Youth Services, may in turn have helped mitigate the underlying factors leading to higher prevalence and risk of substance use and mental health symptoms among SGM youth described in other studies, such as discrimination and stigma. For example, staff at Larkin Street create a welcoming environment for all youth by using SGM-supportive language and imagery on program materials. Additionally, all staff undergo LGBTQ cultural competency training, a core tenant of public health policy recommendations aimed at improving outcomes for SGM youth experiencing homelessness. Available resources at Larkin Street specifically for SGM youth include culturally competent case management, aforementioned housing in neighborhoods that are welcoming to LGBTQ+ residents, and SGM-specific services such as support with official name and gender changes, and providing material needs such as chest binders. Larkin Street also offers substance use interventions such as harm reduction supplies and support groups to help individuals manage the intersection of substance use, trauma, and PTSD.