Gay fathers' motivations for and feelings about surrogacy as a path to parenthood.

Study question: Why do gay men choose to start their families through surrogacy? Summary answer: Most fathers chose surrogacy because they considered adoption to be a less desirable and/or accessible path to parenthood. What is known already: Little is known of gay fathers' motivations to use surrogacy as a path to parenthood over and above other forms of family building, such as adoption, and no studies have examined fathers' satisfaction with the surrogacy process. Study design size, duration: This study used a cross-sectional design as part of a larger investigation of parent-child relationships and child adjustment in 40 gay father surrogacy families. Multiple strategies (e.g. surrogacy agencies, social events and snowballing) were used to recruit as diverse a sample as possible. Data were obtained from 74 fathers (in 6 families only 1 father was available for interview). Participants/materials, setting, method: Semi-structured interviews, lasting ~1 h, were conducted in the family home (65%) or over Skype (35%) with 74 gay fathers (35 genetic fathers, 32 non-genetic fathers and 7 fathers who did not know or did not disclose who the genetic father was), when the children were 3-9 years old. Main results and the role of chance: Genetic and non-genetic fathers were just as likely to want to become parents and had similar motivations for choosing surrogacy as a path to parenthood. Most fathers (N = 55, 74%) were satisfied with surrogacy and were satisfied (N = 31. 42%) or had neutral feelings (N = 21, 28%) about their choice of who would be the genetic father. Most fathers received supportive reactions to their decision to use surrogacy from both families of origin (e.g. parents, siblings) (N = 47, 64%) and from friends (N = 63, 85%). Limitations, reasons for caution: Although diverse recruitment strategies were used, data were obtained from a volunteer sample. Therefore, the possibility that fathers who had a positive surrogacy experience may have been more likely to participate in the study, and therefore introduce bias, cannot be ruled out. Due to the high average annual income of the fathers in the study, findings may not generalize to gay fathers with lower incomes. Wider implications of the findings: It is often assumed that parents' primary motivation for using ART is to have a genetic connection to the child. This study revealed that whilst genetic fatherhood was important for some gay fathers in surrogacy families, it was not important for all. This information will be of use to surrogacy agencies and organizations supporting men who are considering the different routes to parenthood. Study funding/competing interest(s): This work was funded by the Wellcome Trust [097857/Z/11/Z] and the Jacob's Foundation. None of the authors has any conflict of interest to declare. Trial registration number: N/A.

It's not just what you say: relationships of HIV dislosure and risk reduction among MSM in the post-HAART era.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study - the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study.

This study aimed to understand whether and how highly active antiretroviral treatment (HAART) affects views and patterns of disclosure and how disclosure interacts with treatment decisions. One hundred and fifty-two HIV-positive adults (52 MSM, 56 women and 44 IDU men) from four US cities participated in two to three-hour, semi-structured interviews in 1998-99. Results indicate that HAART interacts with and shapes HIV disclosure issues in several ways. Medications may 'out' people living with HIV. Thus, in different settings (e.g. work, prisons, drug rehabs and public situations), some try to hide medications or modify dosing schedules, which can contribute to non-adherence, and affect sexual behaviours. Disclosure of HIV and/or HAART may also result in antagonism from others who hold negative attitudes and beliefs about HAART, potentially impeding adherence. Observable side effects of medications can also 'out' individuals. Conversely, medications may improve appearance, delaying or impeding disclosure. Some wait until they are on HAART and look 'well' before disclosing; some who look healthy as a result of medication deny being HIV-positive. Alternatively, HIV disclosure can lead to support that facilitates initiation of, and adherence to, treatment. HIV disclosure and adherence can shape one another in critical ways. Yet these interactions have been under-studied and need to be further examined. Interventions and studies concerning each of these domains have generally been separate, but need to be integrated, and the importance of relationships between these two areas needs to be recognized.

A gender-specific HIV/STD risk reduction intervention for women in a health care setting: short- and long-term results of a randomized clinical trial.

This study assessed the short- and long-term effect of a gender-specific group intervention for women on unsafe sexual encounters and strategies for protection against HIV/STD infection. Family planning clients (N = 360) from a high HIV seroprevalence area in New York City were randomized to an eight-session, a four-session or a control condition and followed at one, six and 12 months post-intervention. Using an intention-to-treat analysis, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls at one month (OR = 1.93, 95% confidence interval [CI] = 1.07, 3.48, p = 0.03) and at 12-month follow-up (OR = 1.65, 95% CI = 0.94, 2.90, p = 0.08). Relative to controls, women assigned to the eight-session condition reported during the previous month approximately three-and-a-half (p = 0.09) and five (p < 0.01) fewer unprotected sex occasions at one- and 12-month follow-up, respectively. Women in the eight-session group also reduced the number of sex occasions at both follow-ups, and had a greater odds of first time use of an alternative protective strategy (refusal, outercourse, mutual testing) at one-month follow-up. Results for the four-session group were in the expected direction but overall were inconclusive. Thus, gender-specific interventions of sufficient intensity can promote short- and long-term sexual risk reduction among women in a family planning setting.

Urban women's negotiation strategies for safer sex with their male partners.

Heterosexual transmission of HIV is growing at an increasing rate. One primary prevention strategy is to consistently use condoms. With the exception of female condoms, women do not "wear" condoms and therefore must negotiate condom use with their male partners. This present study examines the strategies women believe they would use in a safer sex negotiation with a male partner including (1) initiating negotiations, (2) resolving conflict, and (3) maintaining the intention to practice safer sex. The findings highlight the importance of understanding women's patterns of negotiation as well as their repertoire of negotiation skills prior to their exposure to behavioral interventions and prevention programs.

Prevention of sexual risk behavior for HIV infection with women.

This paper defines the components of gender-specific interventions for HIV infections for women, i.e. negotiation skills with male partners for condom use, integration of strategies against HIV and other STD infections and for contraception, the urgent need for female controlled methods, the importance of the inclusion of heterosexual men and an expansion to couples in prevention programs. This paper also presents a critical update in HIV prevention articles for women since the beginning of the AIDS epidemic through March 1996. All reviewed interventions were conducted in the U.S., Canada or Puerto Rico and described a psychological, behavioral, or educational component that addressed sexual risk reduction and included a behavioral evaluation. Manual and computer searches identified 47 studies that targeted women and provided a female-specific analysis of intervention effects. Overall, the findings demonstrate that HIV prevention programs can be effective in reducing risky sexual behavior among women. Program effectiveness varied by intervention type, session duration, and whether studies included women alone or both men and women. The most efficacious HIV prevention programs were specifically directed toward women, focused on relationship and negotiation skills, and involved multiple, sustained contacts. Evidence also indicated that community-level interventions hold promise. It is recommended that outcomes for women be expanded to include strategies beyond the male condom, such as refusing or avoiding unsafe sex or using the female condom.

A gender-specific intervention for at-risk women in the USA.

Women are the fastest growing group in the USA to become infected with HIV. Also, the mode of transmission is changing with heterosexual behaviour being the predominant source. As these changes occur, HIV infection becomes more common in women who have not typically been considered at high risk. This paper describes an intervention designed to decrease unsafe sexual encounters and to focus on a highly meaningful concern in the lives of these women: relationships with men. The sessions encouraged making decisions, choice, partner selection, sexual rights, refusal of any unwanted sex, female controlled methods and other elements of empowerment. An eight-session and a four-session curriculum were created to assess dose factors as well.

Gender verification of female athletes.

The International Olympic Committee (IOC) officially mandated gender verification for female athletes beginning in 1968 and continuing through 1998. The rationale was to prevent masquerading males and women with "unfair, male-like" physical advantage from competing in female-only events. Visual observation and gynecological examination had been tried on a trial basis for two years at some competitions leading up to the 1968 Olympic Games, but these invasive and demeaning processes were jettisoned in favor of laboratory-based genetic tests. Sex chromatin and more recently DNA analyses for Y-specific male material were then required of all female athletes immediately preceding IOC-sanctioned sporting events, and many other international and national competitions following the IOC model. On-site gender verification has since been found to be highly discriminatory, and the cause of emotional trauma and social stigmatization for many females with problems of intersex who have been screened out from competition. Despite compelling evidence for the lack of scientific merit for chromosome-based screening for gender, as well as its functional and ethical inconsistencies, the IOC persisted in its policy for 30 years. The coauthors of this manuscript have worked with some success to rescind this policy through educating athletes and sports governors regarding the psychological and physical nature of sexual differentiation, and the inequities of genetic sex testing. In 1990, the International Amateur Athletics Federation (IAAF) called for abandonment of required genetic screening of women athletes, and by 1992 had adopted a fairer, medically justifiable model for preventing only male "impostors" in international track and field. At the recent recommendation of the IOC Athletes Commission, the Executive Board of the IOC has finally recognized the medical and functional inconsistencies and undue costs of chromosome-based methods. In 1999, the IOC ratified the abandonment of on-site genetic screening of females at the next Olympic Games in Australia. This article reviews the history and rationales for fairness in female-only sports that have led to the rise and fall of on-site, chromosome-based gender verification at international sporting events.

Longitudinal changes in sexual risk behavior among HIV+ and HIV- male injecting drug users.

UNLABELLED: Injecting drug users (IDUs) play a prominent role in the transmission of human immunodeficiency virus (HIV), particularly in urban areas such as New York City, where they comprise nearly half of all adult acquired immunodeficiency syndrome (AIDS) cases. Intervention studies have demonstrated that IDUs are responsive to safer sex messages, but sexual behavior appears to be more resistant to change than drug use behavior. This multidisciplinary study (without an intervention component) assesses changes in sexual risk behavior as a function of time, HIV status, and disease progression in a cohort of HIV+ and HIV- male IDUs (N = 144) for 4 years. RESULTS: For HIV+ and HIV- men, there were increases in abstinence and monogamy, with decreases in the frequency of unprotected vaginal/anal sex and sexual risk index scores. With the exception of monogamy, HIV+ men reported lower levels of risk. Although there was also a decline in substance use, this accounted for only some of the decline in sexual risk behavior. Among the HIV+ men, a CD4 level below 200 was associated with more abstinence and monogamy. HIV-related medical symptoms were associated with increased abstinence, less unprotected sex, and lower sexual risk index scores. Lower neuropsychological memory test scores were associated with increased abstinence and lower sexual risk index scores. Neurological impairment and depression were not associated with sexual risk behavior. CONCLUSION: IDU men in New York City have modified their sexual behavior toward safer practices. Lower levels of risk are found among HIV+ men, particularly those with more progressed HIV illness. Nevertheless, a substantial amount of sexual risk behavior remained in this cohort, indicating the continued need for education and intervention.

Heterosexual men's attitudes toward the female condom.

This article addresses heterosexual men's familiarity with the female condom and their attitudes toward this barrier method. Qualitative interviews were conducted with 71 ethnically diverse and heterosexually active men who were recruited in sexually transmitted disease (STD) clinics or through word of mouth in communities with high HIV/STD seroprevalence in New York City during fall 1994 to fall 1995. Only one man reported previous experience with the female condom. The large majority of men had no or limited knowledge of the female condom. Men's reactions to learning about this method ranged from positive to negative, although most men reported willingness to have sex with a partner who wanted to use the female condom. Positive reactions included: endorsement of a woman-controlled condom and her right to use it, the potential for enhancing one's sexual pleasure, and an eagerness to have a new sexual experience. Negative reactions centered on the "strangeness" and "bigness" of the female condom, concerns about prevention efficacy, and concerns about reductions in sexual pleasure. Our findings highlight the need for HIV prevention programs that target heterosexual men and promote the use of the female condom.

PIP: Clinical trials suggest that the female condom is highly effective in preventing the transmission of HIV/STDs if used properly. Qualitative interviews were conducted with 71 ethnically, educationally, and occupationally diverse and heterosexually active men aged 18-38 years recruited in STD clinics or through word of mouth in New York City communities with high HIV/STD seroprevalence during fall 1994 to fall 1995. 50.7% of the men were Black, 25.4% were Hispanic, and 16.9% were White. The men's median annual income was $12,600, and about two thirds were currently involved in some type of steady relationship. Only 1 man reported ever using the female condom, while most men had either no or limited knowledge of the female condom. Men's reactions to learning about the method ranged from positive to negative, although most men reported a willingness to have sex with a partner who wanted to use the female condom. Positive reactions to the condom included the endorsement of a woman-controlled condom and her right to use it, the potential for enhancing one's sexual pleasure, and an eagerness to have a new sexual experience, while negative reactions focused upon the strangeness and large size of the female condom, and concerns about prevention efficacy and reductions in sexual pleasure. These findings point to the need for HIV prevention programs which target heterosexual men and promote the use of the female condom.

Sexual risk behavior changes among HIV+ and HIV-female injecting drug users over 4 years.

This paper examines the sexual risk behavior of female injecting drug users who participated in a 4 year longitudinal study. Both HIV+ and HIV- women showed increases in monogamy, decreases in the frequency of unprotected vaginal/anal sex, and decreases in a risk index score throughout the study. HIV+ women had fewer occasions of unprotected sex than HIV-. However, a substantial proportion of the sample continued to engage in unprotected sex. Among the HIV+ women, depressed mood was significantly related to abstinence and to fewer occasions of unprotected sex, but CD4, medical symptoms, neurological impairment, and memory test performance were not associated with sexual risk behavior.

Remission of substance use disorders: gay men in the first decade of AIDS.

OBJECTIVE: Participants in a 5-year prospective study of HIV-seropositive and seronegative gay men demonstrated a significant decline in the rate (from lifetime to current) of alcohol and other DSM-III-R psychoactive substance use disorders. The goal of the current study was to identify factors associated with the cessation of problematic substance use, to observe rates of relapse over 4 years, and to describe factors associated with relapse and no relapse. METHOD: A volunteer community sample of self-identified gay men (N = 56) were administered a semi-structured interview and several self-report measures by trained mental health clinicians, twice annually over a 5-year period. RESULTS: Retrospective and prospective data revealed a significant decline in substance use and problems associated with use in the decade of the 1980s. This change occurred, for the most part, without formal treatment. Numerous motivating factors were associated with this change, which included a fear of AIDS, a change in attitudes in the gay community, changes in other risk-taking behaviours and concerns about self-image. A variety of informal methods were employed. Most notable was "avoiding situations associated with substance use." CONCLUSIONS: Changes in substance abuse/dependence occurred in the context of health concerns, caring for oneself and "cleaning up one's act." Having a concern about "self-image," avoiding situations associated with drug use and not using "drug substitution" as a method of quitting were important factors for maintaining successful change.

Families affected by pediatric acquired immunodeficiency syndrome: sources of stress and coping.

This study explores stress and coping among inner-city, ethnically diverse families with human immunodeficiency virus (HIV)-infected children. Caregivers, siblings, and HIV-infected children from 25 families responded to a semistructured interview on the psychosocial impact of HIV. Families were primarily African-American and Latino and from low socioeconomic-status backgrounds. Approximately one third of the children lived with an HIV-positive birth parent, one third with a grandmother, and one third in foster or adoptive care. The majority of caregivers were single mothers who confronted major life events and who were overextended with caregiving responsibilities. Compared with uninfected caregivers, HIV-infected parents reported more isolation and fewer financial and support resources. All children were particularly vulnerable to separations and loss, with uninfected siblings reporting anger and burden from caregiving tasks. Although some families had coping resources, many families might benefit from family-focused mental health services, particularly those that reduce isolation, promote family functioning and provide respite care.

Psychiatric morbidity in school-age children with congenital human immunodeficiency virus infection: a pilot study.

This study examined the relationship between human immunodeficiency virus (HIV) infection and psychiatric morbidity within the context of prenatal drug exposure. Twenty-six HIV-infected, 14 seroreverted, and 20 control (non-HIV-exposed) children were studied; the sample consisted of nonreferred children living in foster placement who had been exposed to maternal drug addiction. Each child received a psychiatric diagnostic evaluation which included completion by the caretaker of a structured diagnostic interview and a behavior checklist on the child as well as a child self-report on a pictorial interview. Age, ethnicity, and IQ were controlled in the analyses because of group differences. There were high rates of behavioral and psychiatric morbidity, especially with respect to disruptive behavior disorders, in this sample of school-age children with HIV infection, but similarly high rates were found in the seroreverted and non-HIV-exposed children. There was some suggestion that the HIV-infected children were experiencing higher levels of subjective distress than either the nonexposed or seroreverted children. The possible relevance of drug exposure to the behavioral outcomes observed here is discussed, as well as the importance of using age-appropriate materials to elicit subjective distress in HIV-infected school-age children. Clinical implications and directions for further research are discussed.

Psychosocial aspects of precocious puberty.

This paper will deal with the psychologic correlates of abnormal puberty and the implications for assessment and treatment. The main areas of adolescent behavior, equally relevant to the child who undergoes normal or abnormal puberty, are psychosexual development, psychopathology and mental functioning in terms of level of intelligence and cognitive strengths and weaknesses. Regarding psychosexual development, the important findings are that adolescents with precocious puberty tend to be somewhat earlier in starting their adolescent sex life, though they still remain within the normal range of current standards. The reports on psychopathology in children with precocious puberty on a short-term or long-term basis are based on clinical case reports and systematic studies and suggest that a history of precocious puberty may carry with it an increased risk of psychopathology. IQ and school achievement are typically not negatively affected in precocious puberty; in fact, there is a suggestion of the opposite. It may be that there is an advantage in intellectual development associated with early pubertal maturation, which may be temporary rather than long-term.

Gender verification in competitive sports.

The possibility that men might masquerade as women and be unfair competitors in women's sports is accepted as outrageous by athletes and the public alike. Since the 1930s, media reports have fuelled claims that individuals who once competed as female athletes subsequently appeared to be men. In most of these cases there was probably ambiguity of the external genitalia, possibly as a result of male pseudohermaphroditism. Nonetheless, beginning at the Rome Olympic Games in 1960, the International Amateur Athletics Federation (IAAF) began establishing rules of eligibility for women athletes. Initially, physical examination was used as a method for gender verification, but this plan was widely resented. Thus, sex chromatin testing (buccal smear) was introduced at the Mexico City Olympic Games in 1968. The principle was that genetic females (46,XX) show a single X-chromatic mass, whereas males (46,XY) do not. Unfortunately, sex chromatin analysis fell out of common diagnostic use by geneticists shortly after the International Olympic Committee (IOC) began its implementation for gender verification. The lack of laboratories routinely performing the test aggravated the problem of errors in interpretation by inexperienced workers, yielding false-positive and false-negative results. However, an even greater problem is that there exist phenotypic females with male sex chromatin patterns (e.g. androgen insensitivity, XY gonadal dysgenesis). These individuals have no athletic advantage as a result of their congenital abnormality and reasonably should not be excluded from competition. That is, only the chromosomal (genetic) sex is analysed by sex chromatin testing, not the anatomical or psychosocial status. For all the above reasons sex chromatin testing unfairly excludes many athletes. Although the IOC offered follow-up physical examinations that could have restored eligibility for those 'failing' sex chromatin tests, most affected athletes seemed to prefer to 'retire'. All these problems remain with the current laboratory based gender verification test, polymerase chain reaction based testing of the SRY gene, the main candidate for male sex determination. Thus, this 'advance' in fact still fails to address the fundamental inequities of laboratory based gender verification tests. The IAAF considered the issue in 1991 and 1992, and concluded that gender verification testing was not needed. This was thought to be especially true because of the current use of urine testing to exclude doping: voiding is observed by an official in order to verify that a sample from a given athlete has actually come from his or her urethra. That males could masquerade as females in these circumstances seems extraordinarily unlikely. Screening for gender is no longer undertaken at IAAF competitions.

Psychopathology and social functioning in men prenatally exposed to diethylstilbestrol (DES).

Previous research has suggested increased psychopathology in prenatally diethylstilbestrol (DES)-exposed persons. The current study compares the psychiatric histories and social functioning of 27 men with a history of high-dose prenatal DES exposure and their unexposed brothers. We expected DES subjects to show greater lifetime psychopathology and poorer social functioning than controls. Both groups showed high rates of lifetime depression, lifetime alcoholism, and current psychiatric symptoms in excess of community norms. The only diagnosis on which DES subjects exceeded their unexposed brothers was Major Depressive Disorder (MDD). DES-exposed men had almost twice the prevalence of at least one episode of MDD and had significantly more recurrent episodes. The relatively small number of subjects with concomitant lack of statistical power may have contributed to the difficulty obtaining significant effects.