Healthcare satisfaction at the intersections of sexual orientation and race/ethnicity.

OBJECTIVES: Existing scholarship has consistently demonstrated disparities in healthcare experience based on sexual identity. However, relatively little research has considered intersections with race/ethnicity, despite that intersection with other characteristics may complicate healthcare experiences and satisfaction among sexual minorities. This study aims to address such a gap by examining healthcare satisfaction across the intersections of sexual and racial/ethnic identity. DESIGN: Utilizing data on U.S. adults included in the 2013-2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 372,766), we investigate levels of satisfaction with care among a range of groups simultaneously embodying two identities. RESULTS: Findings from ordered logistic regression models show that among adults who identify as heterosexual, the odds of reporting high satisfaction with care are lower among Blacks, Asians, and Native Americans. Among sexual minority adults, the likelihood of reporting high satisfaction with care is consistently lower among Native American gay and lesbian adults compared to gays and lesbians of other race/ethnicity or Native American and White heterosexuals, indicating heightened vulnerability to poorer healthcare experience among this multiple minority group. CONCLUSION: While levels of satisfaction with care tend to be generally high across groups, future research should endeavor to investigate the driving factors that lower the odds of high healthcare satisfaction among those with intersecting minority identities.

Racial, Ethnic, and Gender Disparities in Awareness of Preexposure Prophylaxis Among HIV-Negative Heterosexually Active Adults at Increased Risk for HIV Infection - 23 Urban Areas, United States, 2019.

In 2019, heterosexual sex accounted for 23% of new HIV diagnoses in the United States and six dependent areas (1). Although preexposure prophylaxis (PrEP) can safely reduce the risk for HIV infection among heterosexual persons, this group is underrepresented in PrEP research (2). CDC analyzed National HIV Behavioral Surveillance (NHBS) data to describe PrEP awareness among heterosexually active adults in cities with high HIV prevalence. Overall, although 32.3% of heterosexually active adults who were eligible were aware of PrEP, <1% used PrEP. Racial, ethnic, and gender disparities were identified, with the lowest awareness of PrEP among residents of Puerto Rico (5.8%) and Hispanic or Latino (Hispanic) men (19.5%) and women (17.6%). Previous studies have found that heterosexual adults are interested in taking PrEP when they are aware of it (3); tailoring PrEP messaging, including Spanish-language messaging, to heterosexual adults, might increase PrEP awareness and mitigate disparities in use.

Racial preferences in sexual attraction among White heterosexual and gay men: Evidence from sexual arousal patterns and negative racial attitudes.

Racial preferences in sexual attraction are highly visible and controversial. They may also negatively impact those who are excluded. It is unclear whether these preferences are merely self-attributed or extend to patterns of experienced sexual arousal. Furthermore, some argue that racial preferences in sexual attraction reflect idiosyncratic personal preferences, while others argue that they are more systematically motivated and reflect broader negative attitudes toward particular races. In two studies, we examined these issues by measuring the sexual arousal patterns and negative racial attitudes of 78 White men in relation to their racial preferences in sexual attraction to White versus Black people. For both White heterosexual men (n = 40; Study 1) and White gay men (n = 38; Study 2), greater racial preferences in sexual attraction to White versus Black people of their preferred gender were associated with more subjective and genital arousal by erotic stimuli featuring White versus Black people of their preferred gender, and with more explicit and implicit negative attitudes toward Black people. Findings suggest that racial preferences in sexual attraction are reflected in patterns of sexual arousal, and they might also be systematically motivated by negative attitudes toward particular races.

Evidence for HIV transmission across key populations: a longitudinal analysis of HIV and AIDS rates among Black people who inject drugs and Black heterosexuals in 84 large U.S. metropolitan areas, 2008-2016.

PURPOSE: To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008-2016. METHODS: We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables. RESULTS: At MSA level, baseline (standardized ß = 0.12) Black PWID AIDS rates and change in these rates over time (standardized ß = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable. CONCLUSIONS: Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations.

Changes in Racial and Ethnic Disparities in Estimated Diagnosis Rates of Heterosexually Acquired HIV Infection Among Heterosexual Males in the United States, 2014-2018.

BACKGROUND: Diagnoses of HIV infection among male adults and adolescents ≥13 years with infection attributed to heterosexual contact decreased from 2014 through 2018. Racial disparities exist; HIV diagnoses are higher among Black/African American men compared with men of other races/ethnicities. In 2018, Black/African American males accounted for 61% of diagnosed HIV infections attributed to heterosexual contact among males. SETTING: We used national HIV surveillance data from Atlas Plus to obtain the annual case counts of new HIV diagnoses in males with infection attributed to heterosexual contact and population size for years 2014 through 2018 for males (United States excluding territories) by the racial/ethnic group. METHODS: We used an adjusted population denominator to calculate rates of diagnoses of HIV infection acquired through heterosexual contact per 100,000 males and 12 absolute and relative measures of disparity to calculate racial/ethnic disparity changes from 2014 to 2018. RESULTS: Results from all disparity measures indicate that disparities decreased in 2018, compared with 2014. The decreases ranged from 18.8% to 34.6% among the 4 absolute disparity measures and from 5.3% to 22.7% among the 8 relative disparity measures. CONCLUSIONS: Despite the decrease, disparities remain. Tailored, effective strategies and interventions are needed to address the social and structural factors associated with HIV risk among heterosexual Black men and to promote continued progress toward reducing disparities.

Methodological strategies to engage young black and Latino heterosexual couples in sexual and reproductive health research.

BACKGROUND: Approaches that move beyond individuals and target couples may be an effective strategy for reducing sexual and reproductive health (SRH) disparities among adolescents and young adults (AYA). However, few researchers have attempted to recruit couples due to feasibility and methodological issues. This study aims to enhance implementation and methodological approaches to successfully engage heterosexual Black and Latino adolescent and young adult (AYA) couples in sexual reproductive health (SRH) research. METHODS: We developed a four-step approach to systematically engage AYA couples in a qualitative study examining factors that influence uptake of combination HIV prevention methods: 1) understanding barriers and facilitators to engaging AYA couples, (2) identifying AYAs living in geographic areas of HIV vulnerability, (3) recruiting and screening AYA couples, and (4) scheduling and completion of the interview session. RESULTS: Black and Latino youth aged 16 to 24 and their opposite sex romantic were recruited in the South Bronx, New York from September 2017-May 2018. Three hundred and seventy-two men and women completed screening procedures to determine eligibility for the index participant; 125 were eligible and enrolled into the study. Forty-nine nominated partners (NPs) participated in screening procedures and enrolled into the study. A total of 49 couples enrolled into the study; 23 couples completed study activities. CONCLUSIONS: Developing a systematic recruitment plan aided in successfully engaging Black and Latino heterosexual youth. Nevertheless, barriers to study enrollment remained including locating eligible IPs and screening of the NP. Targeting both young men and women was an effective recruitment strategy. Moreover, dyadic strategies that allow for simultaneous interaction with both couple members may be a beneficial strategy to couples' study enrollment and completion of study activities.

Developmental Trends in Sexual Attraction Among Puerto Rican Early Adolescents in Two Contexts.

Sexual attraction (SA), the earliest stage of sexual orientation, is scarcely studied. This prospective study examined, over 3 years, prevalence, changes in SA, and the role of context, among 946 Puerto Rican youth, aged 11-13 years at initial assessment in the South Bronx (SBx), New York City, and Puerto Rico (PR). Overall, 98.1% of boys and 95.3% of girls reported opposite-sex only SA at some point, whereas 13.8% of girls and 12.0% of boys reported any-same SA. Opposite-sex only SA increased over time, whereas other SAs decreased except for any same-sex SA among SBx girls. Girls in the SBx and younger youth in PR reported more any same-sex SA. Context and culture may play a role in the developmental trajectories of adolescents' SA.

"I have HIV but I'm not the HIV" - the experiences of heterosexual Chinese men living with HIV in Singapore.

As HIV is widely acknowledged as a stigmatized chronic condition which impacts the self, it is important to study the experiences of people living with HIV in relation to their selves and identities. According to extant literature on HIV and identity, the incorporation of an HIV identity is essential to adapting to the diagnosis. However, most of the participants in this study reject HIV as an identity. Using qualitative in-depth interviews, this paper explores the experiences of twelve heterosexual Chinese men living with HIV in Singapore. This paper is anchored by identity concepts from identity theory to examine the impact of HIV on self and identities and how various identities are reworked in the face of a stigmatized chronic medical condition. Thematic analysis shows varying impact of HIV on self, the role of normative identities and the location of HIV in their lives. The findings shed light on the importance of normative identities and the manner in which participants locate HIV in their lives.

Depression and anxiety among HIV-positive men who have sex with men and men who have sex with women in China.

China is experiencing an emerging HIV epidemic among men who have sex with men (MSM). Minority stress theory posits that marginalized populations experience additional stress, which influences experiences of psychological distress and health outcomes. This study aimed to understand psychological distress of MSM relative to men who have sex with women (MSW) in an urban Chinese setting. Cross-sectional survey data were collected from 162 HIV-positive Chinese men receiving HIV treatment at Beijing's Ditan Hospital. Multiple linear regression with imputation was used to identify correlates of psychological distress. Relative to MSW, MSM were younger, more educated, and less likely to be in a relationship or have children. While both groups reported clinically elevated levels of depression and anxiety, sexual behavior was not associated with either outcome. Higher endorsement of depression symptomology was associated with worse reported physical health (ß = -1.37, p < .05) and greater endorsement of maladaptive coping (ß = 2.39, p < .05), whereas higher endorsement of anxiety symptomology was associated with greater endorsement of adaptive coping (ß = 0.78, p < .05), diminished physical health (ß = -0.86, p < .05), and a high school or greater level of education (ß = 4.13, p < .05). These findings suggest that interventions targeting coping strategies may address psychological distress among HIV-positive Chinese men.

Following Their Lead? Connecting Mainstream Media Use to Black Women's Gender Beliefs and Sexual Agency.

Although media exposure has emerged as a significant predictor of consumers' sexual decision making, less is known about the mechanisms involved and about the dynamics of these relations for adults, in general, and for African American adults, in particular. To address these gaps, we used structural equation modeling (SEM) to test whether heterosexual Black women's endorsement of traditional gender and sexual roles mediates connections between their consumption of four mainstream media (music videos, reality TV programming, movies, and women's magazines) and three dimensions of their sexual well-being (sexual assertiveness, sexual inhibition, and sexual deception). We surveyed 594 heterosexual Black women aged 17 to 55 who were undergraduate and graduate students at two universities (one historically Black university and one predominantly White institution). Results confirmed expectations, such that greater media consumption was associated with greater support of traditional gender and sexual roles; in turn, endorsing these roles predicted lower levels of sexual assertiveness, greater sexual inhibition, and more frequent use of sexual dishonesty to retain a partner. We discuss implications of these findings for psychology and sexuality research and also for Black women's sexual relationships.

Heteronormative gatekeeping when enacting queer research in elementary schools: an autoethnographic perspective.

Using authoethnography, the authors analyze how queerphobia and cis/heterosexism shape their research process regarding (LGBTQ)-inclusive empirical work in elementary school spaces. With examples from their own experiences, they show how queerphobic gatekeeping affects site access, negotiations required during data collection, and dissemination of the results to others. The authors argue that, taken together, these forces complicate - if not outright prevent - empirical, school-based research with young children, thereby artificially constraining the knowledge base of the field related to LGBTQ-inclusive education. They offer these analyses as affirmations to those facing similar challenges and as education to those in positions of power to change perceptions of, support of, and responses to queer, school-based educational research.

Male Homosexual Preference: Femininity and the Older Brother Effect in Indonesia.

Male homosexual preference (MHP) is an evolutionary enigma because it is partially heritable and imposes a fertility cost. In occidental societies, homosexual men are feminized at various levels and they have more older brothers than heterosexual men. To evaluate whether femininity and the fraternal birth order (FBO) effect are universal features of MHP or not, we collected original data from homosexual men, heterosexual men, and heterosexual women from Java (Indonesia). Facial photographs were used to test whether homosexual faces are feminized when compared with heterosexual ones. We found that faces manipulated to resemble the average face of homosexual men are perceived as facially feminized, suggesting that homosexual men are facially feminized compared to heterosexual men, although a higher facial femininity was not captured by morphological analyses. Then, family data were used to detect differences in siblings' composition between homosexuals and heterosexuals. Homosexual men displayed a higher number of older brothers than heterosexual men, even when sibship size was controlled for, suggesting that the FBO effect exists in Indonesian populations. Independent of sexual orientation, men with older brothers seem more feminized than those without older brothers, consistent with the immune origin of the FBO effect. In conclusion, MHP in Indonesia is partially feminized and they have more older brothers. Such features are also associated with MHP in other cultural contexts, suggesting a cross-cultural effect of men homosexual preference. An evolutionary explanation is available for the feminizing effect, although the FBO effect remains unexplained even if proximal mechanisms start to be identified.

Objectification of sexual minority women: Responses, consequences, and resistance.

This study investigates responses to, consequences of, and resistance against objectification from the perspectives of sexual minority women in the United States. Data from 5 focus groups with 33 sexual minority women were analyzed using thematic analysis. Results revealed 13 themes and 49 subthemes. First, sexual minority women's responses to objectification included those described in prior research with heterosexual women, as well as novel responses not routinely assessed in prior research (e.g., critical examination), and the complex co-occurrence of responses (e.g., indignation and internalization). Second, participants identified deleterious consequences that were consistent with prior theory and research as well as consequences that reflected resilience and growth from working through objectification. Finally, participants articulated personal, relational, and identity-related forms of resistance against objectification. Sexual and gender identity processes were interwoven with resistance. These results highlight how centering sexual minority women's experiences can both corroborate and advance prior understanding of responses to and consequences of objectification. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Exploring Social Determinants of Health as Predictors of Mortality During 2012-2016, Among Black Women with Diagnosed HIV Infection Attributed to Heterosexual Contact, United States.

BACKGROUND: In 2016, black women with HIV infection attributed to heterosexual contact accounted for 47% of all women living with diagnosed HIV, and 41% of deaths that occurred among women with diagnosed HIV in the USA that year. Social determinants of health have been found to be associated with mortality risk among people with HIV. We analyzed the role social determinants of health may have on risk of mortality among black women with HIV attributed to heterosexual contact. METHODS: Data from the Center for Disease Control and Prevention's National HIV Surveillance System were merged at the county level with three social determinants of health (SDH) variables from the U.S. Census Bureau's American Community Survey for black women aged ≥ 18 years with HIV infection attributed to heterosexual contact that had been diagnosed by 2011. SDH variables were categorized into four empirically derived quartiles, with the highest quartile in each category serving as the reference variable. For black women whose deaths occurred during 2012-2016, mortality rate ratios (MRR) were calculated using age-stratified multivariate logistic regressions to evaluate associations between SDH variables and all-cause mortality risk. RESULTS: Risk of mortality was lower for black women aged 18-34 years and 35-54 years who lived in counties with the lowest quartile of poverty (adjusted mortality rate ratio aMRR = 0.56, 95% confidence interval CI [0.39-0.83], and aMRR = 0.67, 95% CI [0.58-0.78], respectively) compared to those who lived in counties with the highest quartile of poverty (reference group). Compared to black women who lived in counties with the highest quartile of health insurance coverage (reference group), the mortality risk was lower for black women aged 18-34 years and black women aged 35-54 who lived in counties with the lowest 2 quartiles of health insurance coverage. Unemployment status was not associated with mortality risk. CONCLUSIONS: This ecological analysis found poverty and lack of health insurance to be predictors of mortality, suggesting a need for increased prevention, care, and policy efforts targeting black women with HIV who live in environments characterized by increased poverty and lack of health insurance.

Hidden in plain sight: Making a case for heterosexual Black college women being identified as a high-risk population for HIV infection.

OBJECTIVE: Black emerging adult women (ages 18-25 years) are among the fastest growing demographics of HIV infection, second only to men who have sex with men. Black women account for nine of 10 new HIV cases, whereas 84% of these cases are reported to be from heterosexual contact with infected male partners. Heterosexual Black college women (BCW) have been nearly ignored in the HIV literature despite having shared (e.g., risky alcohol use, multiple and concurrent sex partnerships, and inconsistent condom use) and unique (e.g., segregating dating practices and high sexually transmitted infection rates) risk factors when compared with broader college student demographics. METHOD: This conceptual paper uses a multiple risk factor framework to underscore shared and unique risk factors that may work to increase the potential HIV infection risk burden in this understudied population. CONCLUSIONS: Prevention and intervention implications and recommendations for future research that have potential to impact the ways in which colleges, universities, and researchers engage this population are presented. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Potential drivers of HIV acquisition in African-American women related to mass incarceration: an agent-based modelling study.

BACKGROUND: The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community. METHODS: We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women. RESULTS: Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact. CONCLUSION: The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

Willingness to Take PrEP for HIV Prevention: The Combined Effects of Race/Ethnicity and Provider Trust.

Blacks and Hispanics/Latinos are disproportionately burdened by HIV compared to non-Hispanic Whites, as evidenced by higher HIV incidence, prevalence, and deaths attributable to AIDS. Increasing the use of novel prevention techniques such as Truvada for pre-exposure prophylaxis (PrEP) could greatly help in reducing these disparities by lowering HIV incidence among these higher risk groups. Trust in providers, which may differ by race and ethnicity, may influence willingness to take PrEP. This study explores the moderating effect of race/ethnicity on trust in one's primary care provider (PCP) on PrEP willingness. This study found a significant association between PCP trust and PrEP willingness, with those with greater trust having 3.24 times the adjusted odds of being willing to try PrEP. Results regarding the effects of race and ethnicity on these outcomes, however, were inconclusive. Results indicate the importance of fostering trust between PrEP-prescribing PCPs and their patients.

"I don't care about you as a person": Sexual minority women objectified.

This study investigates sexual minority women's experiences of objectification in the United States. Data from 5 focus groups with 33 sexual minority women were analyzed using thematic analysis (Braun & Clarke, 2006, 2012). Results revealed 6 themes and 34 subthemes grouped into "manifestations of objectification: general and explicit intersections," "immediate context of relational and situational characteristics," and "broader context of oppression and privilege along gender and sexualities." First, sexual minority women's experiences of objectification included both general manifestations described in prior research with heterosexual women and manifestations of objectification that reflected intersections of systems of inequality based on sexual orientation, gender identity, race, ethnicity, culture, and age. Second, participants identified novel relational and situational characteristics of objectification. Finally, participants included experiences of stereotyping, discrimination, and dehumanization in their conceptualizations of objectification, connecting their experiences of objectification with broader dynamics of power related to gender and sexuality. Centralizing sexual minority women's experiences, this study produced a fuller understanding of objectification experiences in general and of sexual minority women's experiences in particular. (PsycINFO Database Record

Psychometric Properties of the Spanish Version of the Sexual Inhibition/Sexual Excitation Scales for Men.

The dual control model (DCM) postulates the involvement of relatively independent inhibitory and excitatory systems, which together provide a "double control" over sexual response and associated behavior (Janssen & Bancroft, 2007). Based on this model, the Sexual Inhibition and Sexual Excitation Scales assess the propensity for sexual excitation and sexual inhibition. This research focused on analyzing some psychometric properties of this questionnaire and developing a Spanish version in men. The sample consisted of 823 heterosexual men of ages ranging from 18 to 74 years. Confirmatory factor analysis generated a version of the scale that consisted of 34 items (11 items with the worst factor loadings were eliminated) distributed in four factors (one sexual excitation factor and three sexual inhibition factors). This is consistent with the DCM of sexual response. The four factors demonstrated good reliability coefficients except for sexual inhibition due to the threat of performance consequences, which was found to have a low internal consistency. Consequently, this is something that will be addressed in future studies. The four factors were found to have good test-retest reliability. The measures of the Sexual Inhibition and Sexual Excitation Scales had good validity properties and a coherent relationship with sexual sensation seeking and erotophilia.

Assessing the Theory of Gender and Power: HIV Risk Among Heterosexual Minority Dyads.

This study drew on the Theory of Gender and Power (TGP) as a framework to assess power inequalities within heterosexual dyads and their effects on women. Structural equation modeling was used to better understand the relationship between structural and interpersonal power and HIV sexual risk within African American and Latina women's heterosexual dyads. The main outcome variable was women's sexual HIV risk in the dyad and was created using women's reports of condomless sex with their main male partners and partners' reports of their HIV risk behaviors. Theoretical associations developed a priori yielded a well-fitting model that explained almost a quarter of the variance in women's sexual HIV risk in main partner dyads. Women's and partner structural power were indirectly associated with women's sexual HIV risk through substance use and interpersonal power. Interpersonal power was directly associated with risk. In addition, this study found that not identifying as heterosexual was directly and indirectly associated with women's heterosexual sex risk. This study provides further support for the utility of the TGP and the relevance of gender-related power dynamics for HIV prevention among heterosexually-active women.