Gender(ed) science: How the institutionalization of gender continues to shape the conduct and content of women's health research.

Gender refers to the socially constructed roles, behaviors, and attributes that a particular society considers appropriate for men and women based on assumptions about biological sex. It also operates as a major social organizing principle that confers unequal power, status, and resources to men and women, with direct consequences for health. Historic patriarchal and misogynistic beliefs and values are reinforced through social institutions, including health science, which reify gender inequities. This commentary examines two key domains in which the social organization and institutionalization of gender in scientific research affect the conduct of women's health research and, by extension, women's health outcomes. These domains are: 1) decisions about which topics are prioritized, researched, and funded and 2) the dissemination of research findings. Using the National Institutes of Health (NIH) as a case study to illustrate broader patterns in scientific research, we present evidence of gender-based inequities in what is prioritized, deemed fundable, and disseminated, and how this affects knowledge production and attention to women's health. We highlight efforts and progress made by the NIH and call for additional attention to further address gender-based inequities and their impact on women's health research. We conclude with a call for critical social science analyses-ideally supported by the NIH-of the social organization of health science research to identify points of intervention for redressing deep-seated obstacles to advancing research on women's health.

Structural heteropatriarchy and maternal cardiovascular morbidities.

The United States has some of the poorest maternal health outcomes of any developed nation. Existing research on maternal cardiovascular morbidities has focused predominantly on individual- and clinic-level drivers, but we know little about community- and structural-level factors that shape these outcomes. We use a composite measure of "structural heteropatriarchy" which includes measures of structural sexism and structural LGB-stigma to examine the relationship between structural heteropatriarchy and three cardiovascular-related maternal morbidities using the National Longitudinal Study of Adolescent to Adult Health (n = 3928). Results using multivariate regressions show that structural heteropatriarchy is associated with increased risk of reporting maternal morbidities. Our findings provide further evidence that sexuality- and gender-based stigma operate together to shape health disparities, including maternal health.

Differences in medically assisted reproduction use by sexual identity and partnership: a prospective cohort of cisgender women.

STUDY QUESTION: Does medically assisted reproduction (MAR) use among cisgender women differ among those with same-sex partners or lesbian/bisexual identities compared to peers with different-sex partners or heterosexual identities? SUMMARY ANSWER: Women with same-sex partners or lesbian/bisexual identities are more likely to utilize any MAR but are no more likely to use ART (i.e. IVF, reciprocal IVF, embryo transfer, unspecified ART, ICSI, and gamete or zygote intrafallopian transfer) compared to non-ART MAR (i.e. IUI, ovulation induction, and intravaginal or intracervical insemination) than their different-sex partnered and completely heterosexual peers. WHAT IS KNOWN ALREADY: Sexual minority women (SMW) form families in myriad ways, including through fostering, adoption, genetic, and/or biological routes. Emerging evidence suggests this population increasingly wants to form genetic and/or biological families, yet little is known about their family formation processes and conception needs. STUDY DESIGN, SIZE, DURATION: The Growing Up Today Study is a US-based prospective cohort (n = 27 805). Participants were 9-17 years of age at enrollment (1996 and 2004). Biennial follow-up is ongoing, with data collected through 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cisgender women who met the following criteria were included in this sample: endorsed ever being pregnant; attempted a pregnancy in 2019 or 2021; and endorsed either a male- or female-sex partner OR responded to questions regarding their sexual identity during their conception window. The main outcome was any MAR use including ART (i.e. procedures involving micromanipulation of gametes) and non-ART MAR (i.e. nonmanipulation of gametes). Secondary outcomes included specific MAR procedures, time to conception, and trends across time. We assessed differences in any MAR use using weighted modified Poisson generalized estimating equations. MAIN RESULTS AND THE ROLE OF CHANCE: Among 3519 participants, there were 6935 pregnancies/pregnancy attempts and 19.4% involved MAR. A total of 47 pregnancies or pregnancy attempts were among the same-sex partnered participants, while 91 were among bisexual participants and 37 among lesbian participants. Participants with same-sex, compared to different-sex partners were almost five times as likely to use MAR (risk ratio [95% CI]: 4.78 [4.06, 5.61]). Compared to completely heterosexual participants, there was greater MAR use among lesbian (4.00 [3.10, 5.16]) and bisexual (2.22 [1.60, 3.07]) participants compared to no MAR use; mostly heterosexual participants were also more likely to use ART (1.42 [1.11, 1.82]) compared to non-ART MAR. Among first pregnancies conceived using MAR, conception pathways differed by partnership and sexual identity groups; differences were largest for IUI, intravaginal insemination, and timed intercourse with ovulation induction. From 2002 to 2021, MAR use increased proportionally to total pregnancies/pregnancy attempts; ART use was increasingly common in later years among same-sex partnered and lesbian participants. LIMITATIONS, REASONS FOR CAUTION: Our results are limited by the small number of SMW, the homogenous sample of mostly White, educated participants, the potential misclassification of MAR use when creating conception pathways unique to SMW, and the questionnaire's skip logic, which excluded certain participants from receiving MAR questions. WIDER IMPLICATIONS OF THE FINDINGS: Previous studies on SMW family formation have primarily focused on clinical outcomes from ART procedures and perinatal outcomes by conception method, and have been almost exclusively limited to European, clinical samples that relied on partnership data only. Despite the small sample of SMW within a nonrepresentative study, this is the first study to our knowledge to use a nonclinical sample of cisgender women from across the USA to elucidate family formation pathways by partnership as well as sexual identity, including pathways that may be unique to SMW. This was made possible by our innovative approach to MAR categorization within a large, prospective dataset that collected detailed sexual orientation data. Specifically, lesbian, bisexual, and same-sex partnered participants used both ART and non-ART MAR at similar frequencies compared to heterosexual and different-sex partnered participants. This may signal differential access to conception pathways owing to structural barriers, emerging conception trends as family formation among SMW has increased, and a need for conception support beyond specialized providers and fertility clinics. STUDY FUNDING/COMPETING INTEREST(S): The research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH), under award number R01MD015256. Additionally, KRSS is supported by NCI grant T32CA009001, AKH by the NCI T32CA057711, PC by the NHLBI T32HL098048, BM by the Stanford Maternal Child Health Research Institute Clinical Trainee Support Grant and the Diversity Fellowship from the American Society for Reproductive Medicine Research Institute, BGE by NICHD R01HD091405, and SM by the Thomas O. Pyle Fellowship through the Harvard Pilgrim Health Care Foundation and Harvard University, NHLBI T32HL098048, NIMH R01MH112384, and the William T. Grant Foundation grant number 187958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The first author recently had a leadership role in the not-for-profit program, The Lesbian Health Fund, a research fund focused on improving the health and wellbeing of LGBTQ+ women and girls. The fund did not have any role in this study and the author's relationship with the fund did not bias the findings of this manuscript. TRIAL REGISTRATION NUMBER: N/A.

Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses.

Importance: Extensive evidence documents health disparities for lesbian, gay, and bisexual (LGB) women, including worse physical, mental, and behavioral health than heterosexual women. These factors have been linked to premature mortality, yet few studies have investigated premature mortality disparities among LGB women and whether they differ by lesbian or bisexual identity. Objective: To examine differences in mortality by sexual orientation. Design, Setting, and Participants: This prospective cohort study examined differences in time to mortality across sexual orientation, adjusting for birth cohort. Participants were female nurses born between 1945 and 1964, initially recruited in the US in 1989 for the Nurses' Health Study II, and followed up through April 2022. Exposures: Sexual orientation (lesbian, bisexual, or heterosexual) assessed in 1995. Main Outcome and Measure: Time to all-cause mortality from assessment of exposure analyzed using accelerated failure time models. Results: Among 116 149 eligible participants, 90 833 (78%) had valid sexual orientation data. Of these 90 833 participants, 89 821 (98.9%) identified as heterosexual, 694 (0.8%) identified as lesbian, and 318 (0.4%) identified as bisexual. Of the 4227 deaths reported, the majority were among heterosexual participants (n = 4146; cumulative mortality of 4.6%), followed by lesbian participants (n = 49; cumulative mortality of 7.0%) and bisexual participants (n = 32; cumulative mortality of 10.1%). Compared with heterosexual participants, LGB participants had earlier mortality (adjusted acceleration factor, 0.74 [95% CI, 0.64-0.84]). These differences were greatest among bisexual participants (adjusted acceleration factor, 0.63 [95% CI, 0.51-0.78]) followed by lesbian participants (adjusted acceleration factor, 0.80 [95% CI, 0.68-0.95]). Conclusions and Relevance: In an otherwise largely homogeneous sample of female nurses, participants identifying as lesbian or bisexual had markedly earlier mortality during the study period compared with heterosexual women. These differences in mortality timing highlight the urgency of addressing modifiable risks and upstream social forces that propagate and perpetuate disparities.

Structural stigma and alcohol use among sexual and gender minority adults: A systematic review.

Background: Sexual and gender minority (SGM) people are more likely than their cisgender, heterosexual counterparts to report negative alcohol-related outcomes. Although the association between individual- and interpersonal-level minority stressors and negative alcohol-related outcomes among SGM people is well-established, structural-level minority stressors are understudied. This systematic review examined structural-level stigma and alcohol-related outcomes among SGM people to inform future research, interventions, and policy. Methods: We used five electronic databases to search for studies published between January 2010 and May 2022 that examined associations between structural stigma and alcohol use among SGM adults in the United States. Peer-reviewed, quantitative studies available in English were included. We conducted quality appraisal using the Joanna Briggs Institute checklist. Results: The final sample included 11 studies. Overall, there was moderate to strong support for a positive association between structural stigma and negative alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Structural stigma was most commonly measured as a state-level index. Alcohol measures were heterogeneous. Multilevel stigma and resiliency factors were understudied. Conclusions: Addressing structural stigma is critical in reducing negative alcohol-related outcomes and inequities among SGM people. Research is needed that includes probability samples, longitudinal designs, and samples that reflect the diversity of SGM people. Future studies should examine the influence of multilevel stigma and resiliency factors on alcohol-related outcomes.

Associations of adult roles and minority stressors with trajectories of alcohol dependence symptoms throughout adulthood among sexual minority women.

OBJECTIVE: In the present study, we sought to identify trajectories of symptoms of potential alcohol dependence (AD) among adult sexual minority women (SMW). Theoretical correlates were examined in relation to the empirically identified trajectories. METHOD: Data were collected at three time points between 2000 and 2012 from SMW drinkers (n = 434) enrolled in a longitudinal study (M Age = 37.49 at baseline, SD = 11.55). Using an accelerated-cohort longitudinal design, latent growth curve mixture models identified homogeneous patterns of any past-year symptoms of potential AD. Correlates of trajectories included alcohol-related developmental risk factors, adult roles, and exposure to minority stressors. RESULTS: Three trajectories were identified that captured risk of symptoms of potential AD over time, reflecting: (a) relatively consistent, low risk over time; (b) deceleration in risk throughout adulthood; (c) relatively persistent, high risk over time. Consistent with prior work, SMW drinkers who reported higher levels of perceived stigma or masculinity showed persistently high risk of reporting at least one past-year symptom of potential AD. CONCLUSIONS: Most SMW drinkers report deceleration in risk of AD symptoms over time. Findings have implications for prevention and intervention efforts tailored to SMW drinkers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sexual Orientation-Related Nondiscrimination Laws and Maternal Hypertension Among Black and White U.S. Women.

Background: Black women and sexual minority women are more likely to report adverse maternal health. Little research has investigated maternal health disparities at the intersection of race/ethnicity and sexual orientation or the mechanisms that contribute to these disparities. Materials and Methods: We analyzed data from the National Longitudinal Study of Adolescent to Adult Health. Our sample was restricted to Black and White women who had at least one live birth and were followed-up in Wave V of the data (n = 3,396). We used multivariable logistic regression to analyze the associations between race, sexual orientation identity, and a four-item state-level index of sexual orientation-related nondiscrimination laws. Results: We found that higher numbers of state-level sexual orientation-related nondiscrimination laws were associated with lower risk of maternal hypertension among U.S. women overall (odds ratio [OR] = 0.82, 95% confidence interval [CI] 0.73-0.93), and Black women had a higher risk of maternal hypertension relative to White women (OR = 1.32, 95% CI 1.00-1.79). Interactions between race, sexual orientation identity, and sexual orientation-related policies show that, regardless of sexual orientation identity, sexual orientation-related nondiscrimination laws were associated with a lower risk of maternal hypertension among White mothers (OR = 0.80, 95% CI 0.70-0.92). However, among Black women, these laws were associated with a lower risk of maternal hypertension among lesbian and bisexual women (OR = 0.18, 95% CI 0.05-0.68) only. Conclusions: Laws that prevent discrimination related to sexual orientation in various societal domains may play an important role in improving maternal health outcomes among White women in general and Black lesbian and bisexual women in particular.

Adverse pregnancy and birth outcomes in sexual minority women from the National Survey of Family Growth.

BACKGROUND: Few studies have examined how multiple marginalized identities are associated with adverse pregnancy and birth outcomes, especially for Black and Hispanic sexual minority women. Sexual minorities are people who identify as lesbian, gay, bisexual or transgender (LGBT). The purpose of this study was to examine differences in adverse pregnancy (i.e., miscarriage) and birth outcomes (i.e., preterm birth, low birthweight, and stillbirth) in a national sample of women by race and ethnicity, and sexual minority status (LGBT identification and same-sex sexual behavior). METHODS: We conducted a cross-sectional analysis of the National Survey of Family Growth (NSFG). The unit of analysis was pregnancy, not participants. In this study, we examined pregnancies to participants who identified as heterosexual, lesbian, and bisexual, by race and Hispanic ethnicity. We also studied sexual behaviors to categorize participants as women who have sex with women (WSW) and women who have sex with men (WSM). Outcomes included preterm birth, low birthweight, miscarriage, and stillbirth. We employed logistic and linear regression analyses for analyses using STATA. RESULTS: We studied 53,751 pregnancies, and 9% of these occurred in people who identified as heterosexual, but had engaged in sexual activity with a female partner (heterosexual-WSW), 7% in those identifying as bisexual, and 1% to women who identified as lesbian. Pregnancies ended in preterm birth (10.7%) and low birthweight (9.0%), stillbirths (2-4%), and miscarriages (17-21%) in sexual minority women. We observed that pregnancies reported by Hispanic lesbian women had a higher birthweight (ß = 10.71, SE = 4.1, p-value = 0.01) compared to infants born to Hispanic heterosexual-WSM. Pregnancies to lesbian women were significantly more likely to end in stillbirth (aRR = 3.58, 95% CI 1.30,9.79) compared to heterosexual-WSM. No significant differences were noted in risk of adverse birth outcomes by sexual orientation for NH Black or Hispanic women. CONCLUSION: In this sample, preterm births were less likely to occur among heterosexual-WSW than in heterosexual-WSM. Pregnancies to lesbians and bisexual women were more likely to end in miscarriage or stillbirth than heterosexual WSM. Lesbian Hispanic women reported higher birthweights compared to heterosexual-WSM Hispanic women. More research should be done to further understand these findings.

Mothers' Sexual Identity and Children's Health.

Sexual minority women face a plethora of structural, socioeconomic, and interpersonal disadvantages and stressors. Research has established negative associations between women's sexual minority identities and both their own health and their infants' birth outcomes. Yet a separate body of scholarship has documented similarities in the development and well-being of children living with same-sex couples relative to those living with similarly situated different-sex couples. This study sought to reconcile these literatures by examining the association between maternal sexual identity and child health at ages 5-18 using a US sample from the full population of children of sexual minority women, including those who identify as mostly heterosexual, bisexual, or lesbian, regardless of partner sex or gender. Analyses using data from the National Longitudinal Study of Adolescent to Adult Health (N=8,978) followed women longitudinally and examined several measures of their children's health, including general health and specific developmental and physical health conditions. Analyses found that children of mostly heterosexual and bisexual women experienced health disadvantages relative to children of heterosexual women, whereas the few children of lesbian women in our sample evidenced a mixture of advantages and disadvantages. These findings underscore that to understand sexual orientation disparities and the intergenerational transmission of health, it is important to incorporate broad measurement of sexual orientation that can capture variation in family forms and in sexual minority identities.

Examining Differences in Alcohol and Smoking Behaviors between Parenting and Nonparenting Lesbian Women.

BACKGROUND: The transition to parenthood is a significant life event that has implications for health behaviors and health. Few studies have examined alcohol use and smoking by parenthood status (nonparent vs. parent) among women who identify as lesbian. METHODS: This study used data from two longitudinal studies, the Chicago Health and Life Experiences of Women Study (n = 135) and the U.S. National Longitudinal Lesbian Family Study (n = 116), to compare problem drinking and cigarette smoking trajectories among lesbian-identified women by parenthood status. We used mixed models to investigate differences in problem drinking and cigarette smoking in three waves of data in each study. RESULTS: Lesbian parents reported significantly less problem drinking, but not cigarette smoking, than nonparent lesbian women. When considering the interaction between parental status and time, problem drinking was significantly higher among nonparents than parents at each time interval. CONCLUSIONS: Parenthood was associated with positive changes in drinking among lesbian women; however, more research is needed to understand how to support smoking cessation among parenting lesbian women.

Gender self-concept and hazardous drinking among sexual minority women: Results from the Chicago health and life experiences of women (CHLEW) study.

OBJECTIVE: Sexual minority women (SMW; e.g., lesbian, bisexual) report substantially higher rates of hazardous drinking (HD) than heterosexual women.Yet, few studies have examined sub-group differences. In this study, we investigated the relationship between gender self-concept and HD among SMW. Research consistently shows a link between heavier drinking and masculinity. SMW are more likely than heterosexual women to be gender nonconforming, and masculinity among SMW is associated with increased minority stress, a key HD risk factor. METHODS: We used Wave 3 data from the Chicago Health and Life Experiences of Women study, a longitudinal study of SMW (N = 598), which assessed participants' self-perceived levels of masculinity and femininity and their perception of how masculine/feminine others viewed them. Using multivariable logistic regression, we examined the association between gender self-concept and past 12-month heavy episodic drinking (HED), drinking-related problems, and alcohol dependence. RESULTS: Controlling for demographics and minority stress, greater masculinity (both self-perceived and perceptions by others) was associated with higher odds of HED and alcohol dependence. Masculinity as perceived by others was associated with higher odds of drinking-related problems. Neither femininity measure was associated with HD. Additionally, minority stress (i.e., discrimination, stigma, internalized stigma) did not account for the relationship between gender self-concept and HD. CONCLUSIONS/IMPORTANCE: In this sample, masculinity, particularly SMW's beliefs that others viewed them as masculine, was associated with HD. This association was not attributable to differences in minority stress and may be related to differences in gendered drinking norms, which could be targeted in intervention studies.

State-Level Regulations Regarding the Protection of Sexual Minorities and Birth Outcomes: Results From a Population-Based Cohort Study.

OBJECTIVE: We leverage state-level variability in social policies that confer legal protections for sexual minorities (e.g., employment nondiscrimination acts) and examine their association with birth outcomes among sexual minority women. METHODS: We link measures of structural protections (i.e., social policies) to a prospective, population-based cohort of US adults-the National Longitudinal Study of Adolescent to Adult Health ( n = 7913 total singleton births, n = 274 singleton births to bisexual women, n = 53 singleton births to lesbian women)-which includes measurement of key risk factors for birth outcomes over the life course. RESULTS: Lesbian, gay, bisexual (LGB) policy protections were associated with better birth outcomes for lesbian women. For example, among lesbian women, the predicted birth weight for infants in states with no policy protections was 3.01 kg (95% confidence interval = 2.71-3.30) but was 3.71 kg (95% confidence interval = 3.46-3.96) in states with three or four policy protections. In negative control analyses, there was no association between LGB policy protections and birth outcomes among the nonstigmatized group (i.e., heterosexual women), providing evidence of specificity. Furthermore, in states with the most LGB policy protections, lesbian women were at lower risk for preterm births and had infants with higher birth weights than heterosexual and bisexual women. These associations remained robust after adjusting for 13 risk factors, including demographics, prior and current indicators of socioeconomic status, preconception and perinatal risk factors, and neighborhood characteristics. CONCLUSIONS: These results provide novel evidence that sexual orientation-related policy protections, measured at the state level, are associated with a decreased risk for adverse birth outcomes among lesbian women.

Sexual Orientation Disparities in Experiences of Male-Perpetrated Intimate Partner Violence: A Focus on the Preconception and Perinatal Period.

INTRODUCTION: Compared with their heterosexual counterparts, sexual minority women (SMW), especially those with male partners, are at increased risk for intimate partner violence (IPV). IPV has been linked to a variety of adverse maternal, infant, and child health outcomes. However, to date, no research has examined SMW's experiences of IPV in the context of pregnancy. This study explored whether SMW were more likely than exclusively heterosexual women with only male sexual partners (WSM) to report a variety of forms of IPV perpetrated by their male partner before or during pregnancy. METHODS: Data are from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Our sample size ranged from 10,081 to 10,328 pregnancies, matched with their male pregnancy partner, reported by 3,828 to 3,873 women. RESULTS: Logistic regression results indicated that compared with heterosexual-WSM, mostly heterosexual women and heterosexual-women who have sex with women (WSW) were more likely to report any IPV, mostly heterosexual women were more likely to report an IPV-related injury, and heterosexual-WSW were more likely to report sexual assault. CONCLUSIONS: Results suggest that mostly heterosexual and heterosexual-WSW are at increased risk of experiencing multiple forms of IPV with their male pregnancy partners, highlighting the need for additional screening and prevention efforts to reduce IPV and its negative sequelae.

Sexual Fluidity and Psychological Distress: What Happens When Young Women's Sexual Identities Change?

The sexual identities of young women today are less binary and more fluid than ever before. Several theoretical perspectives imply that this fluidity could be accompanied by distress. To examine this, we analyzed four waves of data from Australian women born 1989 to 1995 (n = 11,527). We found no evidence of a universal association between sexual identity change and psychological distress. Instead, psychological distress was elevated when women changed their identity away from the heterosexual norm and lowered when they changed their identity toward it. Social stress partly attenuated these associations. In addition, women unsure of their identity at multiple assessment points reported significantly greater psychological distress in the final assessment than women who were never unsure. Our findings suggest that greater support should be offered to women who are questioning their sexual identity or developing a minority identity.

Sex, poverty, and public health: Connections between sexual wellbeing and economic resources among US reproductive health clients.

OBJECTIVE: To document associations between socioeconomics and indicators of sexual wellbeing. METHODS: We obtained our data from the HER Salt Lake Initiative, a large, longitudinal cohort study of family planning clients in the United States who accessed free contraceptive services between March 2016 and March 2017. Baseline socioeconomic measures included Federal Poverty Level, receipt of public assistance, and difficulty paying for housing, food, and other necessities. Sexual wellbeing measures assessed sexual functioning and satisfaction, frequency of orgasm, and current sex-life rating. Among participants who had been sexually active in the last month (N = 2581), we used chi-square tests to examine bivariate associations between sexual and socioeconomic measures. RESULTS: We found strong and consistent relationships between sexual wellbeing and economic resources: those reporting more socioeconomic constraints also reported fewer signs of sexual flourishing. CONCLUSIONS: Financial scarcity appears to constrain sexual wellbeing. To support positive sexual health, the public health field must continue to focus on economic reform, poverty reduction, and dismantling of structural classism as critical aspects of helping people achieve their full health and wellbeing potential. ClinialTrials.gov Identifier: NCT02734199.

Measuring the Sexual Acceptability of Contraception: Psychometric Examination and Development of a Valid and Reliable Prospective Instrument.

BACKGROUND: People's sexual experiences have a strong association with contraceptive satisfaction and continuation, but no measures exist to specifically assess contraceptive-related sexual acceptability. AIM: This study developed and examined the psychometric properties of reliability, separation, and item fit of a new Contraceptive Sexual Acceptability (CSA) instrument. METHODS: Enrolled participants initiating a new contraceptive method from the HER Salt Lake longitudinal cohort study contributed baseline survey responses for scale development. The study included the Female Sexual Function Index, the New Sexual Satisfaction Scale, measures of physical and mood-related side effects, and self-reported perceptions of contraception's sexual impacts. Items from these measures' served as the basis for analyses. We analyzed responses using descriptive techniques and modeled using exploratory factor (EFA) and bifactor analyses (BFA). The Masters' Partial Credit Rasch method modeled reliability, separation, and item fit statistics. Here we evaluate (i) the reproducibility of relative measure location on the modeled linear latent variable, (ii) the number of statistically unique performance levels that can be distinguished by the measure, and (iii) the discrepancy between item responses and expectations of the model. Psychometric findings and theoretical models informed item reduction and final scale development. OUTCOMES: We developed a 10-item Contraceptive Sexual Acceptability scale that exceeded the thresholds and sufficiently covered domains for use in contraceptive research and clinical settings. RESULTS: Starting with data on 39-items from 4,387 individuals, we identified 10-items that best measured the CSA latent construct. The Rasch model included a total of 5 calibrations. We reduced items based on bifactor analysis and surpassed unidimensionality thresholds (OH = 0.84, ECV = 0.74) set a priori. The final items included questions with scaled responses about pleasure and orgasm (orgasm quality, orgasm frequency, giving partner pleasure), physical (arousal and function) and psychological (emotional connection, surrender) components, general questions of satisfaction and frequency, and a measure of perceived impact of contraception on sexual experiences in the previous 4 weeks. CLINICAL IMPLICATIONS: The 10-item CSA instrument covers physical and psychological aspects of contraceptive sexual acceptability and can be used in clinical settings. STRENGTHS & LIMITATIONS: The unidimensional CSA instrument offers a brief, yet comprehensive assessment of sexual acceptability. Given the limited diversity of the sample, implementation of this scale in contraceptive research and clinical interactions should be evaluated and validated in more diverse settings. CONCLUSION: Attuning to sexual acceptability could ultimately help contraceptive clients find methods that better meet their needs and preferences. Sanders JN, Kean J, Zhang C, et al. Measuring the Sexual Acceptability of Contraception: Psychometric Examination and Development of a Valid and Reliable Prospective Instrument. J Sex Med 2022;19:507-520.

Sexual Functioning, Satisfaction, and Well-Being Among Contraceptive Users: A Three-Month Assessment From the HER Salt Lake Contraceptive Initiative.

Few large, longitudinal studies document multiple contraceptive methods' effects on sexual functioning, satisfaction, and well-being. We leveraged data from the HER Salt Lake Contraceptive Initiative, a prospective cohort study with patient surveys at baseline, one month, and three months. Surveys assessed bleeding changes, contraceptive-related side effects, sexual functioning and satisfaction, and perceptions of methods' impact on sexual well-being. Individuals in the final sample (N = 2,157) initiated either combined oral contraceptives, levonorgestrel intrauterine devices (IUDs), copper IUDs, implants, injectables, or vaginal rings. Across methods, participants exhibited minimal changes in sexual function (Female Sexual Function Index-6 scores) or satisfaction (New Scale of Sexual Satisfaction scores) over three months. However, many perceived contraception-related changes to sexual well-being. Half (51%) reported their new method had made their sex life better; 15% reported it had made their sex life worse. Sexual improvements were associated with decreased vaginal bleeding, fewer side effects, and IUD use. Negative sexual impacts were associated with physical side effects (e.g., bloating and breast tenderness), increased bleeding, and vaginal ring use. In conclusion, contraceptive users did not experience major changes in sexual functioning or satisfaction over three months, but they did report subjective sexual changes, mostly positive, due to their method.

A prospective analysis of the relationship between sexual acceptability and contraceptive satisfaction over time.

BACKGROUND: Contraceptives are used to prevent unwanted pregnancies and treat certain gynecologic conditions, but many women report non-use or inconsistent use because of method dissatisfaction. The sexual acceptability of contraception-how birth control methods affect users' sexual well-being-is likely an important component of contraceptive satisfaction but has yet to be systematically examined. OBJECTIVE: This study aimed to assess contraceptive satisfaction among new-start contraceptive users and examine whether sexual acceptability measures predict contraceptive satisfaction at 3 months while controlling for more commonly measured contraceptive side effects. STUDY DESIGN: This analysis used data derived from the baseline, 1-month, and 3-month surveys of the HER Salt Lake Contraceptive Initiative, a prospective cohort study of new contraceptive clients. From March 2016 to March 2017, enrolled participants received their desired contraceptive method at no cost and could switch or discontinue at any time (up to 3 years). This analysis included individuals who continued their new contraceptive method for at least 1 month and completed all relevant survey measures. We used ordered logistic regression modeling to predict contraceptive satisfaction at 3 months. Primary predictor variables included changes in sexual functioning (6-item Female Sexual Function Index), sexual satisfaction (New Sexual Satisfaction Scale), and perceived impact of the contraceptive method on sex life at 1 month. Covariates included vaginal bleeding changes, physical side effects, and mood-related side effects. RESULTS: Our analytical sample included 1879 individuals. At 3 months, 52.1% of participants were "completely satisfied" with their contraceptive method, 30.7% were "somewhat satisfied," 4.2% were "neither satisfied nor dissatisfied," 6.9% were "somewhat dissatisfied," and 6.2% were "completely dissatisfied." Compared with patients who said their contraceptive method made their sex life "a lot" worse at 1 month, patients whose method improved their sex life "a lot" had a 7.7 times increased odds of greater satisfaction at 3 months (95% confidence interval, 4.02-14.60; P<.0001) and patients whose method improved their sex life a "little" had a 5.88 times increased odds of greater satisfaction (confidence interval, 3.12-11.11; P<.001). To a much lesser degree, experiencing less or no bleeding was significantly associated with increased satisfaction, whereas worsening of physical side effects was linked to decreased satisfaction. The only other factors significantly associated with satisfaction were changes in bleeding and physical side effects. CONCLUSION: Our findings suggest that patients' sexual experiences of their contraceptive methods are important correlates of satisfaction. Clinicians may wish to underscore that sexual experiences of birth control methods matter and encourage patients to find a contraceptive method that works for them sexually.

Structural Heteropatriarchy and Birth Outcomes in the United States.

Emerging evidence links structural sexism and structural discrimination against lesbian, gay, and bisexual (LGB) populations to poor health outcomes, but studies have yet to examine the combined effects of these mutually reinforcing systems of inequality. Therefore, we developed a composite measure of structural heteropatriarchy-which includes state-level LGB policies, family planning policies, and indicators of structural sexism (e.g., women's political and economic position relative to men)-and examined its relationship to birth outcomes using data from Waves I to V of the National Longitudinal Study of Adolescent to Adult Health. Multivariate regression analyses demonstrated that higher levels of heteropatriarchy were associated with an increased risk of preterm birth and decreased birth weight, net of important covariates. There was no association between clinical low birth weight and heteropatriarchy, or interactions between heteropatriarchy and individuals' race, ethnicity or sexual identity, suggesting a negative effect of heteropatriarchy on birth outcomes for all pregnant people. This study demonstrates the importance of considering gender and sexuality as mutually reinforcing systems of oppression that impact population health. Future research should examine the impact of heteropatriarchy on additional health outcomes and in conjunction with other structural inequalities such as racism and transgender oppression.