Mental health disparities affecting sexual and gender minority (SGM) persons are well documented and indicate a substantially greater burden of mental disorders and suicide among SGM as compared to their heterosexual, cisgender peers across the life course. The Institutes of Medicine (IOM) identified substantial gaps in research on these health disparities among SGM persons, particularly in the context of sustained stigma. Additionally, as highlighted in NIH’s 2021-2025 SGM Research Office Strategic Plan, limited data exists on SGM persons residing in rural contexts; though where data are available, they suggest higher rates of mental disorders for SGM outside of, as opposed to residing within, urban centers. Technology-delivered interventions addressing depression are being increasingly explored among the general population and hold promise for use among rural SGM communities, but they must take into account both the substantial heterogeneity of rural SGM persons and pervasive experiences of SGM-related stigma, discrimination, and trauma to be effective. This research team from the Department of Mental Health and Key Populations Program at Johns Hopkins University and the Programs, Research, & Innovation in Sexual Minority Health at Emory University will use online approaches to enroll 2000 SGM (500 each cisgender female and male sexual minorities, and 500 each transfeminine and transmasculine persons) from rural counties and small cities across the US to follow for 12 months with repeated questionnaires to: 1) determine whether classes of stigma, discrimination, and traumatic experiences vary across rural SGM subgroups and whether these exposure classes are associated with increased prevalent depression and suicide ideation or attempt; 2) determine whether these exposure classes are associated with incident depression or suicidal ideation or attempt across rural SGM groups; and, 3) compare the relative acceptability of various technology-delivered interventions for depression and suicide prevention tailored to address rural SGM persons’ experiences of stigma, discrimination, and trauma. This study will produce the first comprehensive investigation of rural SGM adults’ experiences of distal minority stressors and their relationship to prevalent mental health outcomes, as well as by what pathways they may predict incident depression, suicidal ideation and attempts. The study will also provide substantive evidence-based recommendations for the development or adaptation of technology- delivered interventions to address mental health among heterogenous rural SGM communities, and in so doing is responsive to NIH’s Notice of Special Interest on the Health of SGM Populations (NOT-MD-19-001).

Sexual and Gender Minorities (SGM) living in rural areas and small cities in the United States are disproportionately affected by depression and suicide, yet little research has explored how pervasive and persistent experiences of SGM-related stigma, discrimination and trauma (i.e., distal minority stressors) may be associated with depression, suicide ideation, and suicide attempts among diverse rural SGM sub- populations. We will use online approaches to enroll 2000 rural SGM (500 each: cisgender sexual minority female, cisgender sexual minority male, transfeminine, and transmasculine persons) participants from across the US and administer repeat measures over 12 months to determine whether: classes of stigma, discrimination, and traumatic experiences vary across SGM subgroups; these exposures are associated with increased prevalent/incident depression, suicidal ideation, and suicide attempts; and if identity, psychological, and proximal minority stress related factors mediate and/or moderate these associations. Building on these findings, we will compare the relative acceptability of various technology-delivered intervention components for depression and suicide prevention that can be targeted to diverse rural SGM communities and their heterogenous experiences of distal minority stressors.