Trial Outcomes & Findings for Development and Preliminary Trial of a Brief, Portable Health Intervention for Rural Sexual Minority Emerging Adults (NCT NCT03751020)

Last Updated: 2020-08-28

Results Overview

Depression will be measured using the Center for Epidemiological Studies -- Depression Scale (CESD). An overall depression score is computed as the sum of 20 items, with items 3, 11, 14, and 16 reversed. In cases with internally missing data (items not answered), the sums are computed after imputation of the missing values: # items on scale / # actually answered, multiplied by the sum obtained from the answered items. A range of 0-60, with higher scores indicating more depressive symptomatology during the past week.

Recruitment status

COMPLETED

Study phase

Target enrollment

108 participants

Primary outcome timeframe

Baseline, Post Intervention (day 5), and 3 Months.

Results posted on

2020-08-28

Participant Flow

Participants were specifically recruited through tailored advertising on geo-targeted websites; bulletin boards and listservs of local colleges; in-person announcement and flyers at local businesses, community events, and the gay-straight alliances of area schools. Participants completed a brief online survey to confirm eligibility.

Participants completed a brief online survey to confirm eligibility, defined as: age 18 -29; identifying as sexual minority; currently living in one of the eligible counties; and having daily personal Internet access. Participants emailed a photo of an identification card(e.g. a driver's license), as proof of age. 108 people were randomized.

Participant milestones

Participant milestones
Measure	Control Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Overall Study STARTED	36	36	36
Overall Study Post Intervention	33	33	30
Overall Study 3 Month Follow Up	27	32	26
Overall Study COMPLETED	27	32	26
Overall Study NOT COMPLETED	9	4	10

Reasons for withdrawal

Reasons for withdrawal
Measure	Control Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Overall Study Withdrawal by Subject	2	0	0
Overall Study Lost to Follow-up	7	4	10

Baseline Characteristics

Development and Preliminary Trial of a Brief, Portable Health Intervention for Rural Sexual Minority Emerging Adults

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.	Total n=108 Participants Total of all reporting groups
Age, Continuous	24.14 years STANDARD_DEVIATION 3.24 • n=5 Participants	23.47 years STANDARD_DEVIATION 2.88 • n=7 Participants	23.42 years STANDARD_DEVIATION 3.25 • n=5 Participants	23.68 years STANDARD_DEVIATION 3.11 • n=4 Participants
Sex/Gender, Customized Man	10 Participants n=5 Participants	12 Participants n=7 Participants	9 Participants n=5 Participants	31 Participants n=4 Participants
Sex/Gender, Customized Woman	20 Participants n=5 Participants	21 Participants n=7 Participants	19 Participants n=5 Participants	60 Participants n=4 Participants
Sex/Gender, Customized Transgender Man	1 Participants n=5 Participants	3 Participants n=7 Participants	3 Participants n=5 Participants	7 Participants n=4 Participants
Sex/Gender, Customized Transgender Woman	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Sex/Gender, Customized Gender Queer	4 Participants n=5 Participants	2 Participants n=7 Participants	4 Participants n=5 Participants	10 Participants n=4 Participants
Sex/Gender, Customized Gender Non-Conforming/Binary	3 Participants n=5 Participants	3 Participants n=7 Participants	4 Participants n=5 Participants	10 Participants n=4 Participants
Sex/Gender, Customized Two-spirit	0 Participants n=5 Participants	0 Participants n=7 Participants	1 Participants n=5 Participants	1 Participants n=4 Participants
Sex/Gender, Customized Other	2 Participants n=5 Participants	2 Participants n=7 Participants	1 Participants n=5 Participants	5 Participants n=4 Participants
Sex: Female, Male Female	25 Participants n=5 Participants	26 Participants n=7 Participants	26 Participants n=5 Participants	77 Participants n=4 Participants
Sex: Female, Male Male	11 Participants n=5 Participants	10 Participants n=7 Participants	10 Participants n=5 Participants	31 Participants n=4 Participants
Ethnicity (NIH/OMB) Hispanic or Latino	1 Participants n=5 Participants	0 Participants n=7 Participants	1 Participants n=5 Participants	2 Participants n=4 Participants
Ethnicity (NIH/OMB) Not Hispanic or Latino	35 Participants n=5 Participants	36 Participants n=7 Participants	35 Participants n=5 Participants	106 Participants n=4 Participants
Ethnicity (NIH/OMB) Unknown or Not Reported	0 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	0 Participants n=4 Participants
Race/Ethnicity, Customized American Indian /Alaskan Native	0 Participants n=5 Participants	2 Participants n=7 Participants	0 Participants n=5 Participants	2 Participants n=4 Participants
Race/Ethnicity, Customized Asian	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Race/Ethnicity, Customized Black/African American	2 Participants n=5 Participants	4 Participants n=7 Participants	4 Participants n=5 Participants	10 Participants n=4 Participants
Race/Ethnicity, Customized Native Hawaiian/Pacific Islander	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Race/Ethnicity, Customized White	33 Participants n=5 Participants	33 Participants n=7 Participants	34 Participants n=5 Participants	100 Participants n=4 Participants
Race/Ethnicity, Customized Other	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Region of Enrollment United States	36 participants n=5 Participants	36 participants n=7 Participants	36 participants n=5 Participants	108 participants n=4 Participants
Sexual Orientation Asexual	0 Participants n=5 Participants	1 Participants n=7 Participants	1 Participants n=5 Participants	2 Participants n=4 Participants
Sexual Orientation Bisexual	13 Participants n=5 Participants	9 Participants n=7 Participants	8 Participants n=5 Participants	30 Participants n=4 Participants
Sexual Orientation Gay	8 Participants n=5 Participants	9 Participants n=7 Participants	9 Participants n=5 Participants	26 Participants n=4 Participants
Sexual Orientation Lesbian	12 Participants n=5 Participants	9 Participants n=7 Participants	9 Participants n=5 Participants	30 Participants n=4 Participants
Sexual Orientation Pansexual	3 Participants n=5 Participants	6 Participants n=7 Participants	6 Participants n=5 Participants	15 Participants n=4 Participants
Sexual Orientation Questioning	0 Participants n=5 Participants	0 Participants n=7 Participants	1 Participants n=5 Participants	1 Participants n=4 Participants
Sexual Orientation Other	0 Participants n=5 Participants	2 Participants n=7 Participants	2 Participants n=5 Participants	4 Participants n=4 Participants
Education Level Less than College	18 Participants n=5 Participants	19 Participants n=7 Participants	21 Participants n=5 Participants	58 Participants n=4 Participants
Education Level College Degree	18 Participants n=5 Participants	17 Participants n=7 Participants	15 Participants n=5 Participants	50 Participants n=4 Participants
Employment Status Full-time	14 Participants n=5 Participants	13 Participants n=7 Participants	14 Participants n=5 Participants	41 Participants n=4 Participants
Employment Status Part-time	21 Participants n=5 Participants	13 Participants n=7 Participants	12 Participants n=5 Participants	46 Participants n=4 Participants
Employment Status Student	0 Participants n=5 Participants	5 Participants n=7 Participants	6 Participants n=5 Participants	11 Participants n=4 Participants
Employment Status Unemployed	1 Participants n=5 Participants	5 Participants n=7 Participants	4 Participants n=5 Participants	10 Participants n=4 Participants
Personal Income Less than $10,000	11 Participants n=5 Participants	17 Participants n=7 Participants	13 Participants n=5 Participants	41 Participants n=4 Participants
Personal Income More than $10,000	25 Participants n=5 Participants	19 Participants n=7 Participants	23 Participants n=5 Participants	67 Participants n=4 Participants
Family Class Background Poor	3 Participants n=5 Participants	7 Participants n=7 Participants	6 Participants n=5 Participants	16 Participants n=4 Participants
Family Class Background Working Class	12 Participants n=5 Participants	11 Participants n=7 Participants	13 Participants n=5 Participants	36 Participants n=4 Participants
Family Class Background Lower Middle Class	8 Participants n=5 Participants	4 Participants n=7 Participants	5 Participants n=5 Participants	17 Participants n=4 Participants
Family Class Background Middle Class	10 Participants n=5 Participants	11 Participants n=7 Participants	11 Participants n=5 Participants	32 Participants n=4 Participants
Family Class Background Upper Middle Class	3 Participants n=5 Participants	3 Participants n=7 Participants	1 Participants n=5 Participants	7 Participants n=4 Participants
Relationship Status Single	11 Participants n=5 Participants	10 Participants n=7 Participants	14 Participants n=5 Participants	35 Participants n=4 Participants
Relationship Status In a Relationship	25 Participants n=5 Participants	26 Participants n=7 Participants	22 Participants n=5 Participants	73 Participants n=4 Participants

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Depression. Baseline	24.75 units on a scale Standard Deviation 11.83	25.17 units on a scale Standard Deviation 12.07	29.06 units on a scale Standard Deviation 13.41
Change in Depression. Post-Intervention	21.03 units on a scale Standard Deviation 11.79	17.42 units on a scale Standard Deviation 11.46	21.73 units on a scale Standard Deviation 13.45
Change in Depression. 3 Months	23.44 units on a scale Standard Deviation 13.09	18.45 units on a scale Standard Deviation 10.97	22.92 units on a scale Standard Deviation 14.61

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Psychological Distress will be measured using the Brief Symptom Inventory (BSI). The BSI consists of 18 items scored 0-4. Items are averaged to yield a final score of 0-4. The higher the score, the greater the psychological distress.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Psychological Distress. Baseline	2.31 units on a scale Standard Deviation 0.85	2.22 units on a scale Standard Deviation 0.73	2.63 units on a scale Standard Deviation 0.86
Change in Psychological Distress. Post-Intervention	1.84 units on a scale Standard Deviation 0.77	1.82 units on a scale Standard Deviation 0.67	2.08 units on a scale Standard Deviation 0.86
Change in Psychological Distress. 3 Months	2.14 units on a scale Standard Deviation 0.92	1.77 units on a scale Standard Deviation 0.65	2.35 units on a scale Standard Deviation 0.80

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Anxiety will be measured using the Beck Anxiety Inventory (BAI). The BAI total score is reported, which is the sum of all 21 items; with no subscales. The range of scores is 0-63, with higher scores indicating higher anxiety.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Anxiety. Baseline	21.72 units on a scale Standard Deviation 14.14	20.28 units on a scale Standard Deviation 12.29	26.94 units on a scale Standard Deviation 13.91
Change in Anxiety. Post-Intervention	14.73 units on a scale Standard Deviation 13.43	13.54 units on a scale Standard Deviation 10.91	19.47 units on a scale Standard Deviation 13.16
Change in Anxiety. 3 Months	18.26 units on a scale Standard Deviation 13.19	13.03 units on a scale Standard Deviation 10.55	19.73 units on a scale Standard Deviation 10.78

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Suicidal ideation will be measured using the Suicidal Ideation Attributes Scale (SIDAS) . Total SIDAS scores are calculated as the sum of the five items, with controllability reverse scored (10=0, 9=1, …, 0=10). Total scores range from 0 to 50.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Suicidality - Suicidal Ideation. Baseline	6.05 units on a scale Standard Deviation 9.81	4.19 units on a scale Standard Deviation 6.92	9.42 units on a scale Standard Deviation 11.21
Change in Suicidality - Suicidal Ideation. Post-Intervention	2.36 units on a scale Standard Deviation 4.08	1.21 units on a scale Standard Deviation 3.57	2.70 units on a scale Standard Deviation 6.24
Change in Suicidality - Suicidal Ideation. 3 Months	4.63 units on a scale Standard Deviation 8.19	3.87 units on a scale Standard Deviation 7.40	5.31 units on a scale Standard Deviation 7.54

PRIMARY outcome

Timeframe: Baseline, Post Intervention, 3 Months

Population: Data were analyzed intention to treat.

Alcohol use in participants will be assessed using the Alcohol Use Disorders Identification (AUDIT) instrument. The AUDIT consists of 10 items. Each of the questions has a set of responses to choose from, and each response has a score ranging from 0 to 4. All response scores should be added and recorded as "Total". Total scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. (A cut-off score of 10 will provide greater specificity but at the expense of sensitivity.) The score range is 0-40. Higher scores indicate greater hazardous drinking.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Alcohol Use. Baseline	5.08 units on a scale Standard Deviation 3.77	4.25 units on a scale Standard Deviation 4.29	5.97 units on a scale Standard Deviation 6.00
Change in Alcohol Use. Post-Intervention	4.67 units on a scale Standard Deviation 4.00	3.70 units on a scale Standard Deviation 4.33	3.73 units on a scale Standard Deviation 4.35
Change in Alcohol Use. 3 Months	5.26 units on a scale Standard Deviation 4.62	2.91 units on a scale Standard Deviation 3.76	5.58 units on a scale Standard Deviation 5.98

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

The Short Inventory of Problems-Modified for Drug Use (SIP-DU) is a 15-item scale that asks respondents to rate each item on a dichotomous scale ("No" = 0, "Yes" = 1). Total score reported, which is the sum of all items; no subscales: Range 0-15, higher scores indicate greater problems with drug use.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Drug Use. Baseline	0.39 units on a scale Standard Deviation 0.99	0.31 units on a scale Standard Deviation 0.98	1.47 units on a scale Standard Deviation 2.99
Change in Drug Use. Post-Intervention	0.36 units on a scale Standard Deviation 1.03	0.67 units on a scale Standard Deviation 2.53	0.57 units on a scale Standard Deviation 1.70
Change in Drug Use. 3 Months	0.33 units on a scale Standard Deviation 0.83	0.84 units on a scale Standard Deviation 2.89	1.58 units on a scale Standard Deviation 3.56

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Suicidal intent will be assessed using a single item that asks: Within the last 3 months/past week, have you seriously considered attempting suicide? \[yes/no\] Number of participants who reported suicidal intent is reported. Originally titled "Change in Suicidality - Suicidal Thoughts".

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Suicidal Intent Baseline	4 Participants	4 Participants	9 Participants
Suicidal Intent Post-Intervention	0 Participants	0 Participants	1 Participants
Suicidal Intent 3 Months	3 Participants	1 Participants	2 Participants

PRIMARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Suicide attempts will be assessed using a single item that asks: Within the last past 3 months/past week, have you actually attempted suicide? \[yes/no\]. Reported are the number of participants who reported that they had attempted suicide. Original title: "Change in Suicidality: Suicide Attempts".

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Attempted Suicide Baseline	1 Participants	0 Participants	1 Participants
Attempted Suicide Post-Intervention	0 Participants	0 Participants	0 Participants
Attempted Suicide 3 Months	0 Participants	0 Participants	0 Participants

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Self injury behaviors will be assessed with the item that asks: How many times in the past 3 months/past week have you engaged in self-harm behavior (e.g., cutting, biting, burning, hitting self) with the intent of harming, but not killing, yourself? Reported are the frequency of self-harm behaviors/self-injury reported by participants. Original title: "Change in Self Injury".

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Self Injury. Baseline	0.61 self-harm behaviors Standard Deviation 1.50	1.36 self-harm behaviors Standard Deviation 5.11	0.94 self-harm behaviors Standard Deviation 2.11
Self Injury. Post-Intervention	0.12 self-harm behaviors Standard Deviation 0.48	0.21 self-harm behaviors Standard Deviation 1.22	0.07 self-harm behaviors Standard Deviation 0.25
Self Injury. 3 Months	0.26 self-harm behaviors Standard Deviation 0.71	0.97 self-harm behaviors Standard Deviation 4.45	1.27 self-harm behaviors Standard Deviation 3.97

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Rumination will be assessed using the Ruminative Response Scale - Brooding Subscale (RRS). This scale is modified from the original measure where only items 5, 10, 13, 15 and 16 are used. Each item is scored by respondents on a scale of 1 to 4. To get the overall score, the 5 items are summed; total scores range from 5-20, with higher scores indicating greater brooding and rumination (related to depression) in an individual.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Rumination Baseline	12.39 units on a scale Standard Deviation 3.68	12.97 units on a scale Standard Deviation 3.48	13.03 units on a scale Standard Deviation 3.55
Rumination Post-Intervention	11.58 units on a scale Standard Deviation 3.57	11.67 units on a scale Standard Deviation 3.48	12.10 units on a scale Standard Deviation 4.41
Rumination 3 Months	11.44 units on a scale Standard Deviation 4.86	10.81 units on a scale Standard Deviation 3.81	11.81 units on a scale Standard Deviation 3.62

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed intention to treat.

Perceived social support is measured using the Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS is a 12 item instrument that uses a scale 1-7 to rate each item. The scoring is done by taking the average of the items- therefore a score of 7 indicates the highest level of perceived social support.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Perceived Support Baseline	5.11 units on a scale Standard Deviation 1.30	5.35 units on a scale Standard Deviation 0.94	4.89 units on a scale Standard Deviation 1.40
Perceived Support Post-Intervention	5.10 units on a scale Standard Deviation 1.08	5.34 units on a scale Standard Deviation 0.93	5.03 units on a scale Standard Deviation 1.44
Perceived Support 3 Months	5.12 units on a scale Standard Deviation 1.39	5.53 units on a scale Standard Deviation 1.01	5.09 units on a scale Standard Deviation 1.65

SECONDARY outcome

Timeframe: Baseline, Post Intervention, 3 Months

Population: Data analyzed as intention to treat.

Hopelessness will be measured using the Beck Hopelessness Scale (BHS). The BHS is a 20-item dichotomous scale ("No" = 0, "Yes" = 1). Items 1, 3, 5, 6, 8, 10, 13, 15 and 19 are reverse-scored. The total score is out of 20, where 20 would be the highest score and considered a negative indicator of hopelessness.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Hopelessness Baseline	7.00 units on a scale Standard Deviation 6.08	5.14 units on a scale Standard Deviation 4.28	7.44 units on a scale Standard Deviation 6.07
Hopelessness Post-Intervention	6.93 units on a scale Standard Deviation 6.31	4.88 units on a scale Standard Deviation 4.87	7.80 units on a scale Standard Deviation 6.51
Hopelessness 3 Months	5.85 units on a scale Standard Deviation 5.80	5.19 units on a scale Standard Deviation 5.07	7.77 units on a scale Standard Deviation 7.00

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

LGB identity will be measured using the 'LGB Identity Centrality' instrument.The measure consists of 4 items that are rated on a scale of 1-7. The summed scores have a range of 4-28 and the higher score would indicate a stong agreement (positive) with the centrality of one's LGB identity.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Lesbian, Gay, Bisexual (LGB) Identity Baseline	22.44 units on a scale Standard Deviation 6.08	18.47 units on a scale Standard Deviation 5.36	20.11 units on a scale Standard Deviation 5.67
Lesbian, Gay, Bisexual (LGB) Identity Post-Intervention	19.91 units on a scale Standard Deviation 5.17	17.33 units on a scale Standard Deviation 5.95	18.27 units on a scale Standard Deviation 7.08
Lesbian, Gay, Bisexual (LGB) Identity 3 Months	20.74 units on a scale Standard Deviation 4.92	17.00 units on a scale Standard Deviation 5.81	18.27 units on a scale Standard Deviation 7.48

SECONDARY outcome

Timeframe: 1 and 4 months post baseline.

Population: Data were analyzed as intention to treat.

Participants will provide 50-100 hair strands (at least 2 cm in length) to be used to determine levels of stress based on the cortisol levels found in the analyses of the hair provided.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Cortisol 1 Month	10.12 pg/mg Standard Deviation 12.20	8.28 pg/mg Standard Deviation 10.96	10.91 pg/mg Standard Deviation 15.85
Change in Cortisol 4 Months	10.37 pg/mg Standard Deviation 10.18	6.18 pg/mg Standard Deviation 5.49	12.21 pg/mg Standard Deviation 28.72

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Stress will be assessed using the Perceived Stress Scale (PSS). Participants were asked to respond to the 14-item version. Participants respond to each item on a 0-4 scale and scores are obtained by reversing responses to the 7 positively stated items (items 4,5,6,7,9,10, \& 13), and then summing across all scale items. Range = 0-56. Higher scores indicating higher perceived stress.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Stress Baseline	30.25 units on a scale Standard Deviation 8.62	29.53 units on a scale Standard Deviation 8.40	31.61 units on a scale Standard Deviation 9.51
Change in Stress Post-Intervention	27.03 units on a scale Standard Deviation 9.96	24.70 units on a scale Standard Deviation 9.67	26.73 units on a scale Standard Deviation 8.58
Change in Stress 3 Months	28.41 units on a scale Standard Deviation 10.66	25.88 units on a scale Standard Deviation 7.77	28.69 units on a scale Standard Deviation 9.01

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Impulsiveness Total Score Baseline	53.75 units on a scale Standard Deviation 11.92	51.03 units on a scale Standard Deviation 11.31	54.31 units on a scale Standard Deviation 4.11
Change in Impulsiveness Total Score Post-Intervention	52.35 units on a scale Standard Deviation 10.50	52.76 units on a scale Standard Deviation 12.34	54.06 units on a scale Standard Deviation 11.36
Change in Impulsiveness Total Score 3 Months	53.39 units on a scale Standard Deviation 11.38	54.14 units on a scale Standard Deviation 11.43	53.58 units on a scale Standard Deviation 9.37

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Impulsiveness will be assessed using the Barratt Impulsiveness Scale (BIS). The BIS is a 30 item questionnaire that uses a 1-4 rating scale per item. The 30-item self-report questionnaire, can yield a total score, as well as three factors: attentional (6, 5, 9, 11, 20, 24, 26, 28; motor (2, 3, 4, 16, 17, 19, 21, 22, 23, 25, 30); non-planning (1, 7, 8, 10, 12, 13, 14, 15, 18, 27, 29). The attentional scale has a range of 8-32, the greater the value, the greater the level of attentional impulsiveness.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Impulsiveness- Attentional Baseline	16.36 units on a scale Standard Deviation 4.98	16.44 units on a scale Standard Deviation 4.59	16.33 units on a scale Standard Deviation 4.11
Change in Impulsiveness- Attentional Post-Intervention	15.79 units on a scale Standard Deviation 4.69	15.64 units on a scale Standard Deviation 4.62	16.70 units on a scale Standard Deviation 4.19
Change in Impulsiveness- Attentional 3 Months	15.43 units on a scale Standard Deviation 4.33	15.75 units on a scale Standard Deviation 4.19	16.69 units on a scale Standard Deviation 5.53

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Impulsiveness will be assessed using the Barratt Impulsiveness Scale (BIS-11). The BIS-11 is a 30 item questionnaire that uses a 1-4 rating scale per item. The 30-item self-report questionnaire, can yield a total score, as well as three factors: attentional (6, 5, 9, 11, 20, 24, 26, 28; motor (2, 3, 4, 16, 17, 19, 21, 22, 23, 25, 30); non-planning (1, 7, 8, 10, 12, 13, 14, 15, 18, 27, 29). The motor scale has a range of 11-44, the greater the value, the greater the level of motor impulsiveness.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Impulsiveness- Motor Baseline	20.78 units on a scale Standard Deviation 4.33	20.78 units on a scale Standard Deviation 4.00	21.39 units on a scale Standard Deviation 4.14
Change in Impulsiveness- Motor Post-Intervention	15.71 units on a scale Standard Deviation 5.01	20.52 units on a scale Standard Deviation 3.94	21.23 units on a scale Standard Deviation 4.16
Change in Impulsiveness- Motor 3 Months	21.96 units on a scale Standard Deviation 5.17	21.23 units on a scale Standard Deviation 4.18	20.27 units on a scale Standard Deviation 3.11

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Impulsiveness will be assessed using the Barratt Impulsiveness Scale (BIS-11). The BIS-11 is a 30 item questionnaire that uses a 1-4 rating scale per item. The 30-item self-report questionnaire, can yield a total score, as well as three factors: attentional (6, 5, 9, 11, 20, 24, 26, 28; motor (2, 3, 4, 16, 17, 19, 21, 22, 23, 25, 30); non-planning (1, 7, 8, 10, 12, 13, 14, 15, 18, 27, 29). The non-planning scale has a range of 11-44, the greater the value, the greater the level of non-planning impulsiveness.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Impulsiveness- Non-Planning Baseline	17.00 units on a scale Standard Deviation 5.20	16.80 units on a scale Standard Deviation 5.59	16.58 units on a scale Standard Deviation 5.18
Change in Impulsiveness- Non-Planning Post-Intervention	15.71 units on a scale Standard Deviation 5.01	16.61 units on a scale Standard Deviation 6.58	16.13 units on a scale Standard Deviation 5.31
Change in Impulsiveness- Non-Planning 3 Months	16.00 units on a scale Standard Deviation 4.74	17.16 units on a scale Standard Deviation 6.06	16.62 units on a scale Standard Deviation 4.98

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: This outcome measure was never collected.

Risk taking impulse will be assessed using the Columbia Card Task. Participants are presented with 32 face-down cards. Some of these cards are "gain cards" (which add either +10 or +30 points to the participant's total score) and some of these cards are "loss cards" (which subtract either -250 or -750 points from the participant's total score). On each trial, the participant may turn over as many cards as desired until a loss card is encountered or the participant chooses to not turn over any more cards. As a participant turns over more cards, the probability of encountering a loss card increases. Therefore, turning over more cards constitutes greater risk taking.

Outcome measures

Outcome data not reported

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

To assess rejection as a form of minority stress, the Gay-Related Rejection Sensitivity Scale (GRRS) will be used.The Gay-related rejection sensitivity scale was adapted for this study to be gender-inclusive and has 12 items. Scale range 1-36, where higher scores indicate greater rejection sensitivity based on one's sexual orientation (worse outcome).

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Minority Stress (Rejection) 3 Months	12.17 units on a scale Standard Deviation 8.16	9.31 units on a scale Standard Deviation 7.60	12.33 units on a scale Standard Deviation 5.65
Change in Minority Stress (Rejection) Baseline	14.47 units on a scale Standard Deviation 7.35	12.33 units on a scale Standard Deviation 6.11	14.94 units on a scale Standard Deviation 7.43
Change in Minority Stress (Rejection) Post-Intervention	12.92 units on a scale Standard Deviation 8.23	10.95 units on a scale Standard Deviation 6.51	12.99 units on a scale Standard Deviation 6.41

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzes as intention to treat.

The participant's perception of their parent's attitudes towards their sexual orientation are assessed using the Parental Attitudes Toward Child's Sexual Orientation. This tool has 4 items- 2 that deal with mother/parent 1/closest female guardian, 2 that deal with father/parent 2/closest male guardian. The second item for each parent asks about their attitude towards the respondent's sexual orientation on a scale from 1 (completely tolerant and accepting) to 7 (completely hostile and rejecting). Scores for maternal and paternal attitude should be averaged for each participant. The score has a range from 1-7, where higher scores indicate greater rejection from parents (worse outcome).

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Parental Attitudes Baseline	2.85 units on a scale Standard Deviation 1.50	2.59 units on a scale Standard Deviation 1.52	2.61 units on a scale Standard Deviation 1.46
Change in Parental Attitudes Post-Intervention	2.71 units on a scale Standard Deviation 1.21	2.60 units on a scale Standard Deviation 1.47	2.36 units on a scale Standard Deviation 1.28
Change in Parental Attitudes 3 Months	2.75 units on a scale Standard Deviation 1.46	2.63 units on a scale Standard Deviation 1.36	2.68 units on a scale Standard Deviation 1.48

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Participants openness about one's sexual orientation will be assessed using the Outness Inventory (OI). A respondent is asked to rate how open they are with various people in society (from family to strangers) on an 11 item questionnaire. The scale for responding is 0-7- where 7 indicates that a person is completely open with their sexual orientation status. The scale score is obtained by averaging the 11 items for a score range of 0-7, where higher scores indicate more openness about respondents' sexual orientation in different domains of their lives/different people. 0 indicates that an item does not apply/ there is no such group of people/person in the respondents' life. A score of 7 would indicate that one is completely open or "out" with respect to sexual orientation.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Outness Baseline	4.46 units on a scale Standard Deviation 1.56	5.32 units on a scale Standard Deviation 1.43	5.05 units on a scale Standard Deviation 1.40
Change in Outness Post-Intervention	4.55 units on a scale Standard Deviation 1.66	5.13 units on a scale Standard Deviation 1.39	4.94 units on a scale Standard Deviation 1.21
Change in Outness 3 Months	4.95 units on a scale Standard Deviation 1.49	5.16 units on a scale Standard Deviation 1.49	5.01 units on a scale Standard Deviation 1.33

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Internalized homophobia in participants will be assessed using the Internalized Homophobia Scale (IHS). The IHS score is obtained by averaging the scores across the 9 items (rather than summing). Range is 1-4, with higher scores indicating higher internalized stigma related to one's sexual orientation.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Internalized Homophobia Baseline	1.42 units on a scale Standard Deviation 0.57	1.38 units on a scale Standard Deviation 0.50	1.58 units on a scale Standard Deviation 0.65
Change in Internalized Homophobia Post-Intervention	1.27 units on a scale Standard Deviation 0.64	1.27 units on a scale Standard Deviation 0.53	1.56 units on a scale Standard Deviation 0.58
Change in Internalized Homophobia 3 Months	1.29 units on a scale Standard Deviation 0.63	1.39 units on a scale Standard Deviation 0.57	1.52 units on a scale Standard Deviation 0.58

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Everyday discrimination experienced by participants will be measured using the Everyday Discrimination - Sexual Orientation (EDSO) Part 1. Part 1 is a 9 item inventory where respondents rate statements on a scale of 1-6. The scale has a summed total score ranging from 9-54, higher scores indicate higher discrimination. The higher the score, the greater the feeling that one is discriminated against for one's sexual orientation.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Discrimination - 9 Items (Part 1) Baseline	19.75 units on a scale Standard Deviation 10.63	19.22 units on a scale Standard Deviation 7.26	21.14 units on a scale Standard Deviation 8.72
Change in Discrimination - 9 Items (Part 1) Post Intervention	18.61 units on a scale Standard Deviation 9.47	17.88 units on a scale Standard Deviation 7.27	20.47 units on a scale Standard Deviation 9.42
Change in Discrimination - 9 Items (Part 1) 3 Months	17.81 units on a scale Standard Deviation 9.22	16.87 units on a scale Standard Deviation 7.49	17.81 units on a scale Standard Deviation 8.64

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Everyday discrimination experienced by participants will be measured using the Everyday Discrimination - Sexual Orientation (EDSO) Part 2. Part 2 is a 2 item inventory where respondents rate statements on a scale of 0-3. The lower the score, the less the feeling that one is discriminated against overall for one's sexual orientation. Item 1: Overall, how much has discrimination based on your sexual orientation interfered with you having a full and productive life?

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Discrimination - Item 1 (Part 2) Baseline	0.78 units on a scale Standard Deviation 0.76	0.89 units on a scale Standard Deviation 0.82	1.19 units on a scale Standard Deviation 0.98
Change in Discrimination - Item 1 (Part 2) Post Intervention	0.67 units on a scale Standard Deviation 0.66	1.00 units on a scale Standard Deviation 0.79	0.97 units on a scale Standard Deviation 0.89
Change in Discrimination - Item 1 (Part 2) 3 Months	0.74 units on a scale Standard Deviation 0.81	0.87 units on a scale Standard Deviation 0.72	0.73 units on a scale Standard Deviation 0.87

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Everyday discrimination experienced by participants will be measured using the Everyday Discrimination - Sexual Orientation (EDSO) Part 2. Part 2 is a 2 item inventory where respondents rate statements on a scale of 0-3. The lower the score, the less the feeling that one is discriminated against overall for one's sexual orientation. Item 2: Overall, how much harder has your life been because of discrimination based on your sexual orientation?

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Discrimination - Item 2 (Part 2) Post Intervention	1.00 units on a scale Standard Deviation 0.79	1.24 units on a scale Standard Deviation 0.87	1.30 units on a scale Standard Deviation 1.02
Change in Discrimination - Item 2 (Part 2) 3 Months	0.85 units on a scale Standard Deviation 0.72	1.06 units on a scale Standard Deviation 0.73	1.15 units on a scale Standard Deviation 0.97
Change in Discrimination - Item 2 (Part 2) Baseline	1.03 units on a scale Standard Deviation 0.81	1.42 units on a scale Standard Deviation 0.87	1.53 units on a scale Standard Deviation 0.91

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Feelings of victimization are captured using the LGBT Victimization Experiences measure. This questionnaire consists of 10 items. The LGBT victimization scale is rated on a 0 "Never" to 3 "3+ times" scale with a total score range 0-30. The total score reflects the amount of victimization one has experienced due to being known or thought to be LGBTQ. Higher scores indicate more negative experiences.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Victimization Baseline	1.47 units on a scale Standard Deviation 2.16	1.33 units on a scale Standard Deviation 2.05	2.56 units on a scale Standard Deviation 5.42
Change in Victimization Post-Intervention	0.30 units on a scale Standard Deviation 0.81	0.24 units on a scale Standard Deviation 0.56	0.67 units on a scale Standard Deviation 1.65
Change in Victimization 3 Months	0.81 units on a scale Standard Deviation 1.33	0.97 units on a scale Standard Deviation 2.47	1.08 units on a scale Standard Deviation 2.42

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Tolerance of one's sexual orientation through the lense of one's practiced religion is measured using a single question. Respondents use a 1-7 scale to rate the question "How tolerant is your religion toward your sexual orientation?"- where 7 indicates total rejection and hostility.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Religious Affiliation Baseline	2.70 units on a scale Standard Deviation 1.86	3.05 units on a scale Standard Deviation 1.84	2.78 units on a scale Standard Deviation 2.06
Change in Religious Affiliation Post Intervention	2.78 units on a scale Standard Deviation 1.57	2.79 units on a scale Standard Deviation 1.65	2.71 units on a scale Standard Deviation 1.94
Change in Religious Affiliation 3 Months	2.20 units on a scale Standard Deviation 1.47	2.56 units on a scale Standard Deviation 1.50	3.13 units on a scale Standard Deviation 1.96

SECONDARY outcome

Timeframe: Baseline, Post Intervention (day 5), and 3 Months.

Population: Data were analyzed as intention to treat.

Religious Strain Scale total score obtained by reverse scoring items 1-7 and then summing across the 20 items (range 0-60), higher scores indicate greater religious strain.

Outcome measures

Outcome measures
Measure	Control n=36 Participants Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. Control: Participants randomly assigned to the control condition will be asked to write about what they have done since waking up that morning for 20 minutes across 3 consecutive days. This control matches the time and activity of the EW and SA arms and has been implemented across dozens of EW and SA studies.	Expressive Writing (EW) n=36 Participants Expressive Writing (EW) prompts individuals to write about personally stressful events, potentially enabling cognitive processing of unresolved, psychological and physiological stressors. Expressive Writing (EW) Intervention: The EW intervention will utilize the procedures piloted earlier with gay and bisexual male college students in urban and rural regions of the US. In this condition, participants will be instructed to write for 20 minutes across three consecutive days in a free-form manner about the most stressful or traumatic LGB-related event that they have encountered.	Self-Affirmation (SA) n=36 Participants Self-Affirmation (SA) interventions prompt individuals to write advice to a (hypothetical) similarly stigmatized person regarding how best to cope with stigma-related stress. By affirming one's own stigmatized identity through the process of helping another similarly stigmatized person. Self-Affirmation (SA) Intervention: The SA intervention will ask participants to read a brief description, over the course of 3 consecutive days, of a (hypothetical) LGB youth who is facing minority stress. Each day's description will contain a different LGB youth facing a different stigma-related stressor derived from Phase 1 and 2 interviews. Participants will then be asked to write a letter for 20 minutes to advise the LGB youth how best to cope with minority stress drawing on their personal experiences.
Change in Religious Strain Baseline	29.08 units on a scale Standard Deviation 8.92	27.11 units on a scale Standard Deviation 10.01	32.75 units on a scale Standard Deviation 9.36
Change in Religious Strain Post Intervention	27.52 units on a scale Standard Deviation 9.52	26.52 units on a scale Standard Deviation 9.49	31.40 units on a scale Standard Deviation 10.62
Change in Religious Strain 3 Months	27.11 units on a scale Standard Deviation 9.63	25.44 units on a scale Standard Deviation 9.31	29.50 units on a scale Standard Deviation 9.61

Adverse Events

Control

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Expressive Writing (EW)

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Self-Affirmation (SA)

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Serious adverse events

Adverse event data not reported

Other adverse events

Adverse event data not reported

Additional Information

Dr. John Pachankis

Yale University School of Public Health (Social and Behavioral Sciences)

Phone: (203) 785-3710

Email: [email protected]

Results disclosure agreements

Principal investigator is a sponsor employee
Publication restrictions are in place