PROJECT SUMMARY PA-21-048 Ruth L. Kirschstein National Research Service Award Individual Postdoctoral Fellowship, NOT-MD- 19-001 (Notice of Special Interest in Research on the Health of Sexual and Gender Minority (SGM) Populations): The coronavirus disease 2019 (COVID-19) pandemic has had a profound negative impact on population mental health in the United States, especially for marginalized populations such as sexual minorities (SMs). Emerging research suggests that this disparity is driven by minority stress processes (e.g., stigma) and structural vulnerabilities (e.g., institutional oppression) that systematically expose SMs to more pandemic-related stressors and exacerbate their effects. However, critical knowledge gaps remain regarding the intersectional distribution and upstream (i.e., social and structural) determinants of COVID-19-related disparities in mental health. To address these gaps, the current project will draw on minority stress, intersectionality, and ecosocial frameworks to examine how multiple dimensions of social identity/position and upstream pandemic-related stressors have jointly impacted population mental health for SMs over the course of the pandemic. Leveraging unprecedented data from the COVID-19 Pandemic Sub-Study (a population-based longitudinal cohort study embedded within the Nurses’ Health Study 2 & 3 and the Growing Up Today Study with N>57,000) and novel analytic methods from social, spatial, and legal epidemiology, the project aims are to: 1) estimate the time-varying prevalence of mental health symptoms (i.e., depressive, anxiety, and eating disorder symptomology) over the first year of the COVID-19 pandemic across groups jointly defined by sexual orientation, gender, and race/ethnicity; 2) evaluate whether the prevalence patterns observed in Aim 1 are related to the spatiotemporal distribution characteristics of COVID-19 morbidity and mortality (e.g., county-level mortality rate); and 3) evaluate whether the prevalence patterns observed in Aim 1 are related to the broader pandemic policy environment (e.g., lockdowns/stay-at- home orders, with or without concomitant economic relief efforts). These aims are consistent with the stated priorities in the NIH FY 2021–25 Strategic Plan to Advance Research on the Health & Well-Being of Sexual & Gender Minorities, and importantly, are of urgent relevance to public health. Ultimately, the proposed project will provide a more nuanced and contextualized understanding of SM mental health during the ongoing COVID-19 pandemic, with the intent of generating knowledge that can inform the development and implementation of much- needed mental health equity efforts. A tailored mentored training plan accompanies this proposal and outlines the steps required to advance the Applicant’s career as an independent investigator with expertise in conducting methodologically-rigorous and theoretically-informed SM mental health disparities research.

PROJECT NARRATIVE The coronavirus disease 2019 (COVID-19) pandemic has had a profound negative impact on population mental health in the United States, especially for marginalized populations such as sexual minorities (SMs). SMs with diverse sexual orientation, gender, and racial/ethnic identities may be differentially impacted due to unique structural vulnerabilities, although few studies have explored this. The goal of this project is thus to examine the intersectional distribution and upstream determinants of SM mental health disparities over the course of the COVID-19 pandemic using an unprecedented data source and advanced epidemiologic methods, with the goal of generating knowledge to inform mental health equity efforts for COVID-19 relief and beyond.