Background: Recent research has established that sexual and gender minority (SGM) adolescents under 18 use geosocial networking (GSN) apps despite policies barring minors. SGM adolescent app users tend to have more sexual partners than those who do not, use condoms less reliably, and report having older partners. As such, GSN apps may expose SGM adolescents to legal- and sexual health-related risk. However, almost no scholarship exists which examines the unique ways in which this population navigates issues of trustworthiness and safety in GSN spaces. Methods: Data were collected in a larger online survey study about SGM adolescent GSN application use and sexual health in 2018. Open-ended questions asked 239 SGM adolescents assigned male at birth aged 15-18 (M = 16.92, SD = 0.96; 32% youth of color; 77% gay; 7% gender minority) about their perceptions of safety or lack thereof when using GSN apps for gay, bisexual, and queer men. We also examined perceptions of trustworthiness and untrustworthiness of other users. Data were coded and analyzed thematically using Dedoose. Results: We identified 12 themes related to safety and 18 related to trustworthiness. A sense of safety while using GSN apps was most often associated with a sense of control over disclosure of personal information (33% of answers regarding safety) and control over who one meets in real life or continues to engage on the app (30%). Most endorsed using the following safety precautions while chatting: limited disclosure of personal information (74.1%), using Snapchat to verify identity (65.7%), and finding other users on social media (77%). Telling a close friend about the meeting (42.7%) and meeting in public (45.6%) were the most commonly endorsed safety precautions for in-person meetings. Trustworthiness of other users was primarily ascertained through behavioral/interactional qualities (e.g., conversation length; 45%). Likewise, untrustworthiness was often founded on interactional/behavioral qualities (61%). Characteristics of other users (e.g., age; 14%) and refusal to verify one’s identity (19%) were less often endorsed. Most reported that profiles were untrustworthy if they: lack a face (71.1%), are much older (60.7%), or report not using condoms (61.9%). Nearly half (49.4%) reported that profiles endorsing drug use are untrustworthy. 42.3% endorsed overlooking untrustworthy traits if another user was perceived as attractive. Discussion: SGM adolescent app users lack well-defined strategies for determining the trustworthiness of other users and for maintaining a sense of safety during interactions with them. While most strategies center on verifying other users’ identities and/or disclosures, limiting one’s own was the most endorsed safety strategy. Trustworthy judgments were less defined than untrustworthy, and centered on appraisals of interactions rather than direct appraisals of others. Adolescents may “weed out” certain users based on certain criteria, but lack a similar framework for gauging the trustworthiness of those with whom they continue to interact. Virtually no participants mentioned the legal implications of underage sexting or public sexual encounters. Future interventions should shore up these gaps in adolescent knowledge, as they present unique opportunities to empower youth in decreasing their exposure to sexual risk.

The LGBTQ population remains disproportionately affected by HIV, and LGBTQ adolescents represent a particularly high-risk and vulnerable group. CDC recommends universal HIV screening over age 13, which has been implemented in adult healthcare settings. Although adolescents account for most undiagnosed HIV infections in the US, most pediatric providers perform targeted testing in high-risk patients only. We aim to 1) identify young adults diagnosed with HIV through adult ED-based opt-out screening and 2) describe visits made by these individuals to the pediatric ED (PED) in the 10-years prior to diagnosis. This was a retrospective chart review of young adults diagnosed with HIV through adult ED-based opt-out screening (2013-17). Patients were identified through laboratory results and were included if they had a positive HIV screen. CD4 count at diagnosis was used to determine the likely time period of infection. For this conservative estimate, patients with a CD4 of at least 500 were assumed to have been infected for less than one year, and it was assumed that CD4 declined by 60 each year thereafter. Records of PED visits in the 10-years prior to diagnosis were reviewed. There were 194 patients (mean age 22 years; 89% male). Of the 134 patients with available CD4, 28% had stage-3 HIV at diagnosis. Thirty-eight patients had a total of 109 PED visits in the preceding 10 years (mean 5.2 yrs between most recent PED visit and HIV diagnosis). The most common reasons for PED visit were injury (22%) and non-GU/GYN infectious symptoms (18%). Sexual history was documented in 12% of PED visits, and in 4 cases the gender of the sexual partner(s) was documented. One male patient disclosed having male sexual partners, the other 3 patients reported heterosexual relations. An STI test was sent in 6% of PED visits. Two patients had HIV testing in the PED, one test was positive; the patient was referred for outpatient care and did not follow-up. Ten patients had 26 PED visits during the likely period of HIV infection; sexual history was documented in 7 of these visits and STI testing was sent in 2, including the one positive HIV test. The one male patient who disclosed having sex with male partners was presumed to be HIV positive at a visit when STI testing was sent at his request, an HIV test was not included during that visit. Young adults diagnosed with HIV through adult ED-based opt-out screening often present with late-stage HIV. Many of these patients have had visits in the PED, where HIV risk factors, including sexual history and orientation, are infrequently documented and HIV testing is rare. Adolescents with asymptomatic HIV will likely go unrecognized in the PED; LGBTQ youth are particularly vulnerable and may be unwilling to disclose risk factors that would otherwise lead providers to suspect HIV. Implementation of CDC recommended universal screening in this setting has the potential to reduce stigma and may save lives with earlier diagnosis.

Background: Adolescent sexual minority males (ASMM; < 18 years old) have an increased risk acquiring HIV in the United States (US). ASMM also experience disproportionately high rates of sexually transmitted infections (STIs), which raise HIV risk. Despite increased risk, and CDC recommendations for regular HIV and STI testing, few ASMM have ever tested for HIV or STIs. Barriers to HIV/STI testing among adolescents include concerns about confidentiality, the perceived need for guardian consent, or concerns about notification of guardians. Although state laws aim to reduce these barriers by permitting minors to consent to HIV/STI testing and treatment, there is a dearth of research assessing how these laws relate to testing behavior. To begin to address this gap, we investigated whether minor consent laws for HIV/STI testing and treatment are related to testing behavior among ASMM. Methods: In June-July 2017, sexually active ASMM (N = 127; ages 14-17) across the US completed an online sexual health survey. State laws at the time of the survey along with age and state of residence were used to code participants’ legal capacity to consent to HIV testing/treatment and STI testing/treatment without guardian permission. Bivariate analyses assessed differences in legal capacity to consent, testing behaviors, and beliefs about guardian permission for testing. Factors independently associated with ever testing for HIV were established using multivariable logistic regression. Results: Average age was 16 years old (SD = 1.0). Half (51%) identified as racial/ethnic minorities. Participants lived in 32 states (West: 33%, South: 32%, Midwest: 19%; Northeast: 16%). Most (85%) had not disclosed their sexual activity to their guardians. One-third (n=40) reported male-male condomless anal sex. Most participants had legal capacity to independently consent (HIV testing: 79%; HIV testing/treatment: 65%; STI testing/treatment: 97%). Few had ever tested (HIV: 15%; STIs: 18%). A substantial proportion of those who tested in the past year believed that guardian permission was required or were uncertain about this (HIV: 9/16, 56%; STIs: 8/18, 44%). Capacity to consent to HIV testing was not associated with ever testing for HIV (AOR = 0.3, 95% CI = 0.1, 1.1). Participants who had not disclosed their sexual activity to their guardians were 70% less likely (AOR = 0.3, 95% CI = 0.1, 0.9) to have ever tested for HIV. Discussion: Although most ASMM have the legal right to consent independently to HIV/STI testing and treatment, (a) few reported testing and (b) most of those who tested were unaware that guardian permission was not required. Further, even though legal capacity to consent to HIV testing was not associated with testing behavior, youth who had not disclosed their sexual activity to their guardians were significantly less likely to have tested. These results suggest that confidentiality remains a concern for these youth despite the laws that are in place to protect them. Taking steps to mitigate confidentiality concerns is necessary to curtail the increasing rates of HIV and STIs among ASMM.

Background Gender and sexual minority (GSM) adolescents are at the center of extensive social and legal debates in the United States. While they are more visible than ever, they face stark health disparities due to factors such as social stigma, abuse, and a lack of culturally competent health care services. Depression, suicide, substance misuse, violence, sexual health, and homelessness are among key health and social concerns for this group. Furthermore, health information targeting GSM adolescents is limited and often inaccurate. No studies to date have explored the specific health needs of GSM young people in Louisville, Kentucky. Methods Our multidisciplinary research team conducted a mixed-methods study on GSM adolescent health with residents of Louisville, Kentucky. The goals of this study were to (1) understand the health issues affecting local adolescents; (2) to determine the barriers to, and facilitators of, good health; and (3) develop an intervention to improve health policies and practices, enhancing their health experiences and outcomes. A sample of GSM adolescents, ages 13-18, were administered a survey covering demographics, health experiences, and adverse childhood experiences (ACEs). Participants then took part in focus groups on topics related to health and its social determinants. Interviews with adult stakeholders such as parents, educators, health care/mental health providers and social workers explored health beliefs, experiences, knowledge, and local priorities. Descriptive statistics and major themes arising from the inductive qualitative analysis are presented. Results Overall, adolescent participants (Pilot n=4; Study n=26) reported very negative experiences at school: 100% (26/26) had heard homophobic, biphobic, or transphobic remarks, 65.4% (17/26) experienced harassment, 61.5% (16/26) felt unsafe, and 26.9% (7/26) experienced physical violence in school. Their self-reported health was worse than expected, with 42.3% (11/26) reporting their general health as fair and 7.7% (2/26) rating their health as poor. Their mentally unhealthy days far outweighed their physically unhealthy days (Mean 18.68, Standard Deviation 8.18 vs. Mean 5.48, Standard Deviation 7.13) and their mean ACEs score was 3.77 (Standard Deviation 2.75). In the focus groups, the young people discussed mental health extensively, which this was heavily influenced by their sociocultural environment, in particular the behavior of their peers, family, and other adults. Barriers to physical well being, for example exclusionary policies and inhospitable environments, were also identified. Adult stakeholders (Pilot n=5; Study n=16) affirmed the focus group narratives, sharing concerns about mental health and social exclusion. Adult participants expressed a desire for more resources, inclusive environments, role models, and mental health support for youth. Discussion Mental health care and social inclusion are the most pressing needs of GSM adolescents in Louisville, KY. Addressing these issues will require collaboration between agencies. The results have implications for the development of health services and resources to meet the needs of GSM youth locally and nationally. Next steps include collaborating with the local health department and school system to develop a health communication campaign on GSM adolescent mental health. This campaign will be launched in fall 2019.

Adolescence is an important developmental period during which young people come to understand themselves as sexual actors, develop a sexual identity, and develop skills necessary for navigating sexuality development across the life-course. Existing sexuality research establishes that an awareness of one’s self as an agentic, sexual subject is required for engaging in meaningful sexual decision-making (Bryant & Shoefield, 2007; Fields, 2008; Garcia, 2012). Further, sexual agency is a fundamental component of positive sexuality development, one that is necessary for developing a positive sexual identity, navigating healthy sexual relationships, and negotiating consensual sexual experiences and the use of contraception (Arbeit, 2012, 2014, Fine1998; Tolman, 2002). Scholars across disciplines are drawing on sexual agency to understand sexual decision-making throughout the life-course, yet there are few studies that seek to understand how young people conceptualize sexual agency. Moreover, there are no studies that examine how non-female identified (i.e. cis-men, trans men), gender expansive (i.e. transgender, gender queer, gender non-conforming) and/or sexual minority (i.e. Lesbian, Gay, Bisexual, Queer) adolescents make sense of sexual agency. This qualitative study adopts an assets-based framework in examining sexual agency; moving beyond the pervasive victim narratives that have obscured adolescent sexual agency and further perpetuated the notion that adolescent sexuality is subject to risk and in need of intervention. Specifically, this empirical investigation examines sexual agency and sexual decision-making during adolescence utilizing phenomenology as a theoretical framework and community based participatory research as a methodological framework. I conducted three focus groups and 20 one-on-one semi-structured interviews with a diverse sample of adolescents (ages 16-21) from the Chicago-land area. Overall, the findings from my study reveal that the relational aspects of sexual agency, including but not limited to communicating desires, negotiating desires, negotiating boundaries, and negotiating safety, inform how young people engage in sexual relationships. The results of this study contribute to our understanding of sexual agency by moving a) beyond the individual, b) beyond the scope of penile-vaginal intercourse and c) beyond the scope of white, heterosexual women. In addition to the aforementioned contributions this study expands the literature on adolescent sexuality development by linking desire and negotiation, detailing how young people manage risk, and acknowledging the role of self-awareness and self-reflection. Findings also indicate that young people must contest and resist oppressive gendered norms and sexual scripts that impact their ability to exercise sexual agency and make informed decisions. Evidence reveals that oppressive gendered norms and sexual scripts are prevalent in the lives of study participants, communicated by parents, family members, teachers, and peers. Findings suggest that oppressive norms and scripts impact how youth participants explore their intersecting identities (e.g. Queer Latina, Gay Black Male), express their desires, and how they negotiate complex sexual experiences. By examining sexual agency beyond the scope of white heterosexual women, we can deepen our understanding of sexuality development and identify ways to support queer and gender expansive youth as they navigate complex sexual decision-making.