Submission

Sexual & gender minorities, especially MSM, face higher substance use & stigma, impacting health. Substance policies affect MSM: criminalization increases stigma & reduces healthcare; harm reduction mitigates risks, compounding with lack of same-sex marriage recognition & worsened drug use. Criminalization jeopardizes LGBT well-being, limiting access to optimal lives, healthcare & services, possibly a distal stress exacerbating drug use & other minority stressors. This project uses harmonized multi-country data to study same-sex marriage policy effects on sexual & mental health. Multilevel regression assesses policy-health links, considering individual & country factors like policy acceptance & GDPI scores. 10 data repositories harmonized. Descriptive analysis ranks countries by policy index & dose-dependent effects on sexual health & substance use. Multilevel analysis infers how stigmatizing policies widen LGBT health disparities worldwide & cross-level compounding effects.

Research Aims: To determine the effect of same-sex marriage policy on sexual and mental health using harmonized data from multiple countries.

Methods:

• Data Structure: Hierarchical, with individuals nested within countries or provinces. Analyses will use a random effect multilevel regression model with level-2 variables modeled as random effects.
• Level 2 Exposure Variables:
  • Same-Sex Marriage Acceptance: Proportions reported by Pew Research, harmonized with Generalist Repository Ecosystem Initiative (GREI) repositories datasets (e.g., Harvard Dataverse, OSF, Mendeley Data). Includes the year of acceptance closest to data collection and change scores from 2002-2019.
  • Global Drug Policy Index (GDPI): Scores and ranks countries’ drug policies based on alignment with UN principles. Includes 75 indicators across five dimensions. Scores range from 1 to 100, with higher scores indicating better alignment. Norway scores highest at 74/100, median score is 48/100.
• Level 1 Variables:
  • Exposure Variables: 
    • Basic socio-demographic variables (age, education, income, partnership status, homelessness, cohabitation, occupation/employment status).
  • Outcome Variables:
    • Sexual Health: HIV testing frequencies, STI diagnosis, HBV/HCV status, HIV seropositivity, antiretroviral drug use, viral suppression, number of sexual partners, condom use.
    • Substance Use: Alcohol drinking, binge drinking, chemsex drug use, injection drug use, severity of substance use, problematic drug use patterns.

Data Sources and Harmonization:

• Data from 10 GERI datasets will be harmonized to create a pooled dataset with consistent variable definitions across countries and survey years.

Statistical Analysis:

• We will examine descriptive statistics by ranking combined categories of same-sex marriage, drug policy index by sociodemographics and outcome variables 
• A random effect multilevel regression model will be used to assess the association between same-sex marriage policy and health outcomes, controlling for individual-level socio-demographic variables.
• The model will also investigate the moderating effect of drug policy scores on the relationship between same-sex marriage acceptance and health outcomes.
• Sensitivity analyses will be conducted to ensure robustness, including alternative variable definitions and additional covariates.
• All analyses will be performed using R, with a significance level set at 0.05. Missing data will be handled using multiple imputation techniques if appropriate.

Ethical Considerations:

• The study will use de-identified data from GERI repositories without direct participant contact. IRB approval will be obtained before data access and analysis.

Data Sharing and Dissemination Plan

1. Research Findings and Expected Outcomes This research will assess the impact of substance use policies on health outcomes among Asian men who have sex with men (MSM). Key findings will likely include associations between policy stringency and health outcomes, the role of stigma and social support, and recommendations for evidence-based policy interventions.
2. Dissemination of Findings Findings will be shared through:
   • Academic journals focusing on public health, LGBTQ+ health, HIV/AIDS, and substance use policy
   • Presentations at public health and policy conferences
   • Policy briefs for public health organizations, advocacy groups, and policymakers
   • Online platforms (social media, institutional websites) to engage a wider audience
   • Community engagement through webinars and discussion forums with LGBTQ+ advocacy groups
3. FAIR and CARE Principles The project will adhere to FAIR and CARE principles:
   • Findable: Datasets and results will be cataloged with metadata, DOIs, and indexed in open-access repositories
   • Accessible: Datasets, results, and publications will be stored in public repositories without restrictive access barriers
   • Interoperable: Datasets will follow standardized formats for seamless integration with other projects
   • Reusable: Clear data use agreements and metadata will enable future reuse while respecting ethical and legal constraints
   • Collective Benefit: Research aims to benefit Asian MSM by informing policies that reduce health disparities
   • Authority to Control: Conscious of community’s authority and engaging with LGBTQ+ organizations for culturally sensitive interpretations
   • Responsibility: Prioritizing participant data privacy and confidentiality
   • Ethics: Following ethical guidelines and obtaining IRB approval as necessary
4. Addressing Replicability and Reproducibility The project will prioritize replicability and reproducibility by:
   • Providing detailed methodology and publicly available code for statistical analysis
   • Sharing datasets in accessible repositories with clear documentation
   • Following transparent reporting guidelines (e.g., STROBE)
   • Using version control systems to track changes in data and analysis

Contributions to relevant scientific disciplines:

Sexual and gender minorities, particularly (MSM, experience higher rates of substance use, especially alcohol, marijuana, methamphetamine, and chemsex drugs like methamphetamine, mephedrone, and GHB. The intersecting stigmatization of these groups leads to long-term mental, sexual, and physical health consequences, affecting their social functioning and relegating them to marginalized statuses. Substance use policies significantly shape health outcomes for MSM. Criminalizing substance use increases stigma and reduces healthcare access, worsening disparities. Meanwhile, harm reduction policies, such as needle exchanges and supervised injection sites, help mitigate health risks like HIV. Access to treatment and mental health services is also influenced by policy. Furthermore, the lack of legal recognition of same-sex relationships can destabilize intimate partnerships, often marked by drug use, as Amelia M. Stanton notes: “This is how we come to know what relationships are. It’s how we know each other.” Nearly three-fourths (74.7%;) of those who reported using methamphetamine at baseline were persistent users at 12 months in the US. Persistent methamphetamine users accounted for one-third of all observed HIV seroconversions.This research will contribute to public health and health equity by examining the impact of substance use policies on health outcomes among global populations of sexual minorities. It will enhance understanding of the interplay between substance use, HIV, mental health, and policy environments, informing future research and policy development focused on equity.

Impact on diagnosis, treatment, and/or prevention:

The study's findings can inform and improve public health interventions and policies aimed at reducing substance use and associated health risks among MSM. It may lead to the development of targeted prevention programs addressing the specific needs of Asian MSM, reducing HIV transmission rates and improving mental health outcomes. The research can also inform healthcare providers about creating supportive environments that encourage MSM to seek regular healthcare and substance use treatment, ultimately reducing health disparities.

• Charted by the Florida State University’s Board of Governor, The Center of Population Sciences of Health Equity was founded by Drs. Wong and Millender. Its mission is to conduct innovative population science and policy research.
• Our team is a diverse mix of disciplinary and methodological expertise, committed to improving health equity among regions experiencing the worst health outcomes from stigmatizing policies.  
• Prof. Frankie Wong (PhD, Social Psych) specializes in community-engaged substance use and HIV-related research, and established NIH-funded multisite research globally.
• Prof. Eugenia Millender (PhD, Psych Nursing) specializes in mental health equity research among indigenous and vulnerable populations as a sequelae of stress, trauma and gene-environment interaction.
• Doug Cheung (ScM, Epidemiology) specializes in substance use, mental health, and sexual risk behaviors among global sexual minority populations.
• Liying Wang (PhD, Clinical Psych) combines clinical, community and digital health approaches to address mental health disparities.
• Rasheda Haughbrook (PhD, Development Psych) specializes in the quantitative analyses of  behavioral genetics and environmental influences on mental health outcomes.
• Umed Ibragimov (MD/PhD, Public Health) specializes in substance use, HIV, and structural determinants of health with advanced modeling techniques.
• Artur Queiroz (PhD, Nursing) specializes in HIV prevention and the impact of chemsex on sexual health among LGBT subpopulations.

Data Quality: Ensure timely access to high-quality secondary data from national health surveys, public health records, and GREI. Proper data cleaning, harmonization, and management of missing data.

Statistical Rigor: Apply advanced methods like multilevel logistic regression and spline regression. Control confounding variables and conduct sensitivity analyses. Use GREI's tools for data integration compatibility.

Interdisciplinary Approach: Leverage expertise in public health, epidemiology, psychology, and LGBTQ+ health. Regular meetings and collaboration tools for smooth communication.

Ethical Considerations: Protect participant privacy through de-identified datasets and IRB approvals. Ensure cultural sensitivity for Asian MSM by collaborating with LGBTQ+ organizations.

Timeline: Structure phases with clear milestones. Develop contingency plans for potential delays.

Supporting documents: Include dataset identifiers, tools, workflows, and relevant references.