"I wouldn't have felt so alone": The sexual health education experiences of transgender and gender diverse youth living in the southeastern United States.

BACKGROUND: Transgender and gender diverse youth experience multiple disproportionate adverse sexual health outcomes. Sexual health education teaches knowledge, attitudes, and skills for promoting sexual health, including reducing risk for sexually transmitted infection, HIV acquisition, and unintended pregnancy. Provision of sexual health education may be protective, but research remains scarce. METHODS: We conducted a multi-stage thematic analysis of 33 in-depth interviews among transgender and gender diverse youth (ages 15-24) living in the southeastern United States on their sexual health education experiences. RESULTS: Our study participants described school-based sexual health education as unhelpful due to a lack of relevant information, inadequately prepared teachers, and a perceived negative tone toward sexuality. They reported relying on online sources of sexual health information, finding relevant content and community despite some limitations. Participants desired content and pedagogy that expands beyond binary and white-centric presentations of sexuality and gender and sought resources that provide relevant, accurate, and judgment-free information while holding positive framing around sexuality and gender. CONCLUSION: There is much work needed to improve the breadth, quality, and relevance of school-based sexual health education. Sexual health education can improve by strengthening critical media literacy skills of youth; raising staff cultural competency on gender, race, and sexual identity through training and supports; using culturally relevant and inclusive curricula; and partnering with community-based organizations. Transgender and gender diverse youth would benefit from sexual health education from multiple sources which is queer-friendly, affirms their existence, and provides information on gender, race, and sexuality in positive and expansive ways.

Sexual and Reproductive Health Outcomes of Violence Against Women and Girls in Lower-Income Countries: A Review of Reviews.

Gender-based violence (GBV) against women and girls is pervasive and has negative consequences for sexual and reproductive health (SRH). In this systematic review of reviews, we aimed to synthesize research about the SRH outcomes of GBV for adolescent girls and young women in low- and middle-income countries (LMICs). GBV exposures were child abuse, female genital mutilation/cutting, child marriage, intimate partner violence (IPV), and non-partner sexual violence. PsycINFO, PubMed, and Scopus searches were supplemented with expert consultations, reference-list searches, and targeted organizational website searches. Reviews had to contain samples of girls and young women ages 10-24, although inclusion criteria were expanded post-hoc to capture adolescent-adult combined samples. Twenty-seven reviews were quality-rated. Study-level data were extracted from the 10 highest quality reviews (62 unique studies, 100 samples). Reviews were mostly from Africa and Asia and published between 2011 and 2015. We found consistent associations between GBV and number of sexual partners, gynecological conditions (e.g., sexually transmitted infections [STIs]), unwanted/unplanned pregnancy, and abortion. Some types of IPV also were associated with greater use of contraception/STI prevention. Addressing GBV is essential to improve SRH for girls and women in LMICs.

"We Deserve Care and we Deserve Competent Care": Qualitative Perspectives on Health Care from Transgender Youth in the Southeast United States.

PURPOSE: Transgender populations experience health inequities that underscore the importance of ensuring access to high quality care. We thematically summarize the health care experiences of transgender youth living in the southeast United States to identify potential barriers and facilitators to health care. DESIGN AND METHODS: Transgender youth recruited from community settings in an urban area of the southeast United States participated in individual interviews (n = 33) and focus groups (n = 9) about protective factors. We conducted a thematic analysis of data from 42 participants who described their experiences seeking and receiving health care. RESULTS: Participants reported a wide range of gender identities. The individual interview sample was majority Black (54.5%) and the mean age was 21.7 years and focus group participants were all white and the mean age was 16.8 years. Participants described numerous barriers to health care, including limited availability of gender affirming care, logistical challenges, such as gatekeeping and cost, concerns about confidentiality in relation to sexual behavior and gender identity, and inadequate cultural competency among providers regarding gender-affirming care. Facilitators included intake procedures collecting chosen pronouns and names and consistent use of them by providers, and open communication, including active listening. CONCLUSIONS: Findings underscore the need for a multi-component approach to ensure both transgender- and youth-friendly care. PRACTICE IMPLICATIONS: Providers and office staff may benefit from transgender cultural competency trainings. In addition, clinic protocols relating to confidentiality and chosen name and pronoun use may help facilitate access to and receipt of quality care.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt.

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the practice.

Community Influences on Female Genital Mutilation/Cutting: A Comparison of Four Francophone West African Countries.

Despite long-term efforts to encourage abandonment of female genital mutilation/cutting (FGMC), the practice remains widespread globally. FGMC is situated in specific social and historical contexts, and both prevalence and rates of decline vary widely across practicing countries. However, cross-national comparative research on the determinants of FGMC is sparse. This paper adds to the limited body of rigorous, theoretically grounded quantitative studies of FGMC and takes a step toward advancing cross-national comparative research. We apply an integrated theoretical framework that brings together norms-based and gender-based explanations of community-level influences on FGMC. We test this framework in four francophone West African countries, drawing on comparable nationally representative data from the Demographic and Health Surveys in Burkina Faso (2010), Côte d'Ivoire (2011-2012), Guinea (2012), and Mali (2012-2013). Results show that community-level FGMC norms and community-level gendered opportunities are associated with girls' risk of FGMC, but that the direct and moderating associations vary qualitatively across countries. Our findings highlight the contribution of context-specific social and institutional processes to the decline or persistence of FGMC.

Community Influences on Female Genital Mutilation/Cutting in Kenya: Norms, Opportunities, and Ethnic Diversity.

Female genital mutilation/cutting (FGMC) is a human rights violation with adverse health consequences. Although prevalence is declining, the practice persists in many countries, and the individual and contextual risk factors associated with FGMC remain poorly understood. We propose an integrated theory about contextual factors and test it using multilevel discrete-time hazard models in a nationally representative sample of 7,535 women with daughters who participated in the 2014 Kenya Demographic and Health Survey. A daughter's adjusted hazard of FGMC was lower if she had an uncut mother who disfavored FGMC, lived in a community that was more opposed to FGMC, and lived in a more ethnically diverse community. Unexpectedly, a daughter's adjusted FGMC hazard was higher if she lived in a community with more extrafamilial opportunities for women. Other measures of women's opportunities warrant consideration, and interventions to shift FGMC norms in more ethnically diverse communities show promise to accelerate abandonment.

The explanatory role of relationship power and control in domestic violence against women in Nicaragua: a feminist psychology analysis.

This study offers a feminist psychology analysis of various aspects of relationship power and control and their relative explanatory contribution to understanding physical, psychological, and sexual violence against women. Findings from structured interviews with 345 women from rural Nicaragua (M age = 44) overwhelmingly demonstrate that measures of power and control reflecting interpersonal relationship dynamics have the strongest predictive power for explaining violence when compared in multivariate analyses to several of the more commonly used measures. These findings have implications for future research and the evaluation of interventions designed to decrease levels of violence against women.

Sociocultural attitudes surrounding menstruation and alternative menstrual products: the explanatory role of self-objectification.

We extend objectification theory research to consider the relationship between self-objectification and attitudes toward an alternative menstrual product in a diverse sample of female undergraduates from the United States (N = 151). We use a survey design to investigate attitudes toward one's menstruation as a potential mechanism that may explain this relationship. Reactions to an alternative menstrual product were predominantly negative, supporting prior research on stigma and shame surrounding menstruation. Exploratory structural equation modeling revealed attitudes toward one's menstruation mediated the relationship between self-objectification and participants' reactions to an alternative menstrual product. Implications for women's health are discussed.

Sexual education, gender ideology, and youth sexual empowerment.

Sexual education plays an essential role in preventing unplanned pregnancy and the transmission of sexually transmitted infections (STIs). School-based sexual education programs, in particular, may be well positioned to address social factors that are empirically linked to negative sexual health outcomes, such as traditional social norms surrounding gender and sexuality. However, youth are seldom granted access to sexual education programs that explicitly address these issues. This study presents findings from a pretest-posttest survey of a sexual education program that did. It was designed for eighth graders (N=95) in the context of a school-community collaboration. The study assessed the links between several components of sexual empowerment, including gender ideology, sexual knowledge, and contraceptive beliefs. Findings link participation in the sexual education program to more progressive attitudes toward girls and women, less agreement with hegemonic masculinity ideology, and increases in sexual health and resource knowledge. Structural equation models suggest that traditional attitudes toward women were significantly related to hegemonic masculinity ideology among both boys and girls, which was in turn negatively related to safer contraceptive beliefs.