Suggestions for improving healthcare for transgender and gender diverse people in the United States.

Introduction: Transgender and gender diverse (TGD) individuals face disproportionate barriers to accessing affirming healthcare, ranging from individual practitioners' biases to financial constraints and societal-level cisnormativity. Method: This study identified suggestions for improving healthcare from 420 TGD individuals in the United States. Participants responded to an open-ended question about their suggestions for improving healthcare for TGD people. These responses were then coded using thematic analysis, resulting in 22 specific codes under 6 themes. Results: Results indicated a need for eliminating cisnormativity, taking a holistic approach with clients, adjusting conceptual frameworks for care, eliminating accessibility barriers, promoting affirmative interactions with TGD clients, and providing TGD-affirmative training for providers. Notably, these suggestions spanned from the broader, cultural level regarding general understandings of TGD people and gender to micro-level interactions. Conclusions: This study provides important tools for improving TGD care via a reduction of barriers and an increase in competency and affirmation.

Genome-Wide Linkage Study Meta-Analysis of Male Sexual Orientation.

Male sexual orientation is a scientifically and socially important trait shown by family and twin studies to be influenced by environmental and complex genetic factors. Individual genome-wide linkage studies (GWLS) have been conducted, but not jointly analyzed. Two main datasets account for > 90% of the published GWLS concordant sibling pairs on the trait and are jointly analyzed here: MGSOSO (Molecular Genetic Study of Sexual Orientation; 409 concordant sibling pairs in 384 families, Sanders et al. (2015)) and Hamer (155 concordant sibling pairs in 145 families, Mustanski et al. (2005)). We conducted multipoint linkage analyses with Merlin on the datasets separately since they were genotyped differently, integrated genetic marker positions, and combined the resultant LOD (logarithm of the odds) scores at each 1 cM grid position. We continue to find the strongest linkage support at pericentromeric chromosome 8 and chromosome Xq28. We also incorporated the remaining published GWLS dataset (on 55 families) by using meta-analytic approaches on published summary statistics. The meta-analysis has maximized the positional information from GWLS of currently available family resources and can help prioritize findings from genome-wide association studies (GWAS) and other approaches. Although increasing evidence highlights genetic contributions to male sexual orientation, our current understanding of contributory loci is still limited, consistent with the complexity of the trait. Further increasing genetic knowledge about male sexual orientation, especially via large GWAS, should help advance our understanding of the biology of this important trait.

Exploring Cross-Sectional Predictors of Suicide Ideation, Attempt, and Risk in a Large Online Sample of Transgender and Gender Nonconforming Youth and Young Adults.

PURPOSE: Rates of suicide ideation and attempt appear to be particularly high in the transgender and gender nonconforming (TGNC) population, yet little is known about which factors are the most salient contributors for TGNC young people and how these contributors vary across suicide-related outcomes. METHODS: Within the largest sample of TGNC young people to date (N = 1896; ages 14-30), we examined the contribution of demographics (age, assigned sex, gender identity, sexual orientation identity, race/ethnicity, and socioeconomic status), minority stress (gender-related affirmation, gender-related self-concept, victimization, and gender-affirming medical treatment desire/access), social support (from family and friends), and depressive symptoms in the cross-sectional prediction of three suicide-related outcomes: past-year attempt, past-year ideation, and a composite measure of suicide risk. RESULTS: Each set of factors explained significant variance in each outcome; however, only several predictors remained significant in each of the full models. Gender-related victimization and depressive symptoms were independent predictors for all three outcomes. Additional predictors varied across outcome. Age, male identity, sexual orientation-based victimization, and friend support were associated with suicide attempt. Age, queer identity, gender-related self-concept negativity, and family support were associated with suicide ideation, and pansexual identity and gender-related self-concept negativity were associated with positive suicide risk screen. CONCLUSION: Prevention and intervention efforts aimed at building support and positive self-concept, decreasing victimization, and treating depression are likely to partially reduce suicide ideation and attempt in TGNC adolescents and young adults. Comprehensive interventions with younger adolescents are particularly critical.

Evaluating the Paper-to-Screen Translation of Participant-Aided Sociograms with High-Risk Participants.

While much social network data exists online, key network metrics for high-risk populations must still be captured through self-report. This practice has suffered from numerous limitations in workflow and response burden. However, advances in technology, network drawing libraries and databases are making interactive network drawing increasingly feasible. We describe the translation of an analog-based technique for capturing personal networks into a digital framework termed netCanvas that addresses many existing shortcomings such as: 1) complex data entry; 2) extensive interviewer intervention and field setup; 3) difficulties in data reuse; and 4) a lack of dynamic visualizations. We test this implementation within a health behavior study of a high-risk and difficult-to-reach population. We provide a within-subjects comparison between paper and touchscreens. We assert that touchscreen-based social network capture is now a viable alternative for highly sensitive data and social network data entry tasks.

Separating Family-Level and Direct Exposure Effects of Smoking During Pregnancy on Offspring Externalizing Symptoms: Bridging the Behavior Genetic and Behavior Teratologic Divide.

Maternal smoking during pregnancy (MSDP) has been robustly associated with externalizing problems and their developmental precursors in offspring in studies using behavioral teratologic designs (Wakschlag et al., Am J Public Health 92(6):966-974, 2002; Espy et al., Dev Psychol 47(1):153-169, 2011). In contrast, the use of behavior genetic approaches has shown that the effects commonly attributed to MSDP can be explained by family-level variables (D'Onofrio et al., Dev Psychopathol 20(01):139-164, 2008). Reconciling these conflicting findings requires integration of these study designs. We utilize longitudinal data on a preschool proband and his/her sibling from the Midwest Infant Development Study-Preschool (MIDS-P) to test for teratologic and family level effects of MSDP. We find considerable variation in prenatal smoking patterns both within and across pregnancies within families, indicating that binary smoking measures are not sufficiently capturing exposure. Structural equation models indicate that both conduct disorder and oppositional defiant disorder symptoms showed unique effects of MSDP over and above family level effects. Blending high quality exposure measurement with a within-family design suggests that it is premature to foreclose the possibility of a teratologic effect of MSDP on externalizing problems. Implications and recommendations for future studies are discussed.

Evaluation of respondent-driven sampling in a study of urban young men who have sex with men.

Evidence suggests that respondent-driven sampling (RDS) is an efficient approach to sampling among varied populations of adult men who have sex with men (MSM) both in the USA and abroad, although no studies have yet evaluated its performance among younger MSM, a population with a steep rise in HIV infection in recent years. Young MSM (YMSM) may differ in terms of their connectedness to other YMSM (e.g., due to evolving sexual identity, internalization of sexual minority stigma, and lack of disclosure to others) and mobility (e.g., due to parental monitoring) which may inhibit the sampling process. The aims of this study were to evaluate the efficiency and effectiveness of RDS-based sampling among young urban MSM and to identify factors associated with recruitment success. We hypothesized that demographic, social, behavioral, and network factors, including racial/ethnic minority status, homelessness (i.e., as an indicator of socioeconomic marginalization), HIV-positive status, substance use problems, gay community connectedness, and network size would be positively related to recruitment productivity, while sexual minority stigmatization, environmental barriers (e.g., parental monitoring), and meeting sex partners on the internet (i.e., virtual venue) would be negatively related to recruitment productivity. Between December 2009 and February 2013, we used RDS to recruit a sample of 450 YMSM, ages 16-20. Findings suggest that the use of RDS for sampling among YMSM is challenging and may not be feasible based on the slow pace of recruitment and low recruitment productivity. A large number of seeds (38 % of the sample, n = 172) had to be added to the sample to maintain a reasonable pace of recruitment, which makes use of the sample for RDS-based population estimates questionable. In addition, the prevalence of short recruitment chains and segmentation in patterns of recruitment by race/ethnicity further hamper the network recruitment process. Thus, RDS was not particularly efficient in terms of the rate of recruitment or effective in generating a representative sample. Hypotheses regarding factors associated with recruitment success were supported for network size and internalized stigma (but not other factors), suggesting that participants with larger network sizes or high levels of internalized stigma may have more and less success recruiting others, respectively.

Do dopamine gene variants and prenatal smoking interactively predict youth externalizing behavior?

Externalizing behaviors (encompassing antisocial, impulsive, and substance use behaviors) are pervasive and impairing across a multitude of settings and developmental contexts. These behaviors, though often investigated separately, are highly comorbid. Prenatal tobacco exposure in interaction with various genetic influences has predicted later externalizing behavior, and recent evidence supports investigating sex differences in these patterns. In the current study, we extend this work by (a) examining two functional genetic markers in the dopamine system: the transporter gene (DAT1) and the dopamine receptor D4 gene (DRD4) in interaction with prenatal tobacco exposure to predict a latent composite of externalizing behavior and (b) testing whether these patterns differ by sex of youth in a community sample of adolescents (n=176). The relatively small sample is partially offset by high quality, multi-method prospective measurement. We assessed prenatal tobacco exposure using prospective repeated cotinine-corrected reports and externalizing behaviors were assessed utilizing multiple measures across three waves. The interaction between DAT1 (but not DRD4) and prenatal tobacco exposure was statistically significant in boys, and patterns appeared to differ by sex. Risk for externalizing behaviors for exposed boys increased linearly as a function of the 10r DAT1 allele. For exposed girls, there was a trend such that DAT1 heterozygotes had a marginally higher risk than homozygotes. This pattern was not explained by passive gene-environment correlation. Elucidating sex-specific pathways through which early adverse exposures and genetic susceptibilities contribute to externalizing behavior can inform early targeted prevention efforts for those children at highest risk.

Prevalence of mental health disorders among low-income African American adolescents.

PURPOSE: Data on the prevalence of mental health disorders for low-income, urban African American adolescents are scarce. This study presents data about the burden of mental disorders for this understudied population. METHODS: Mental disorders were assessed using the Diagnostic Interview Schedule for Children (C-DISC), Youth Self-Report (YSR), and Child Behavior Checklist (CBCL) among a sample of adolescents and their caregivers from very impoverished neighborhoods in a Southern city. RESULTS: Based on the C-DISC, 3.8, 5.1 and 7.7% of adolescents met diagnostic criteria for major depression, post-traumatic stress disorder, and conduct disorder, respectively. There were significant differences among some of the mental health disorders based on adolescent and caregiver characteristics such as sex, school status, caregiver work status, and income level. We found a low prevalence of alcohol, marijuana, and substance abuse and dependence disorders. CONCLUSIONS: Information about the prevalence of mental health disorders in specific communities and populations can assist in addressing unmet needs, planning for services and treatment, and reducing health disparities.

The interplay between online and offline explorations of identity, relationships, and sex: a mixed-methods study with LGBT youth.

Although the Internet is commonly used by lesbian, gay, bisexual, and transgender (LGBT) youth to explore aspects of sexual health, little is known about how this usage relates to offline explorations and experiences. This study used a mixed-methods approach to investigate the interplay between online and offline explorations of multiple dimensions of sexual health, which include sexually transmitted infections, sexual identities, romantic relationships, and sexual behaviors. A diverse community sample of 32 LGBT youth (ages 16-24) completed semi-structured interviews, which were transcribed and then qualitatively coded to identify themes. Results indicated that, although many participants evaluated online sexual health resources with caution, they frequently used the Internet to compensate for perceived limitations in offline resources and relationships. Some participants turned to the Internet to find friends and romantic partners, citing the relative difficulty of establishing offline contact with LGBT peers. Further, participants perceived the Internet as an efficient way to discover offline LGBT events and services relevant to sexual health. These results suggest that LGBT youth are motivated to fill gaps in their offline sexual health resources (e.g., books and personal communications) with online information. The Internet is a setting that can be harnessed to provide support for the successful development of sexual health.

Sexual health information seeking online: a mixed-methods study among lesbian, gay, bisexual, and transgender young people.

The current study used a mixed-methods approach to investigate the positive and negative aspects of Internet use for sexual health information among lesbian, gay, bisexual, and transgender (LGBT) young people. A diverse community sample of 32 LGBT young people (aged 16-24 years) completed qualitative interviews focusing on how, where, and when LGBT young people use the Internet for sexual health information. Results indicate that although many participants seek facts and statistics about sexually transmitted infections (STIs) and HIV online, few conduct searches about broader aspects of sexual health. Participants reported that fear about becoming infected with STIs/HIV is a common motivator of searches and noted a number of reasons for not using online sexual health information, including stigma associated with being observed accessing LGBT or HIV information. Together, the results revealed not only significant interest in online sexual health information but also concerns about the perceived limitations of this promising method of sexual health promotion.

HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions.

Epidemiological studies have found that young men who have sex with men (YMSM) represent the majority of young people infected with HIV annually in the United States. Further, they are one of the few risk groups to show an increase in the rate of infections in recent years. In addition to these disparities in prevalence and infection rates, there is an inequity in prevention and intervention research on this population. The purpose of this article is to review the existing YMSM literature on HIV epidemiology, correlates of risk, and intervention research. The article concludes that promising future directions for basic research include a focus on multiple clustering health issues, processes that promote resiliency, the role of family influences, and the development of parsimonious models of risk. In terms of intervention research, the article suggests that promising future directions include Internet-based intervention delivery, integration of biomedical and behavioral approaches, and interventions that go beyond the individual level to address partnership, structural, community, and network factors.

Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths.

OBJECTIVES: We examined associations of race/ethnicity, gender, and sexual orientation with mental disorders among lesbian, gay, bisexual, and transgender (LGBT) youths. METHODS: We assessed mental disorders by administering a structured diagnostic interview to a community sample of 246 LGBT youths aged 16 to 20 years. Participants also completed the Brief Symptom Inventory 18 (BSI 18). RESULTS: One third of participants met criteria for any mental disorder, 17% for conduct disorder, 15% for major depression, and 9% for posttraumatic stress disorder. Anorexia and bulimia were rare. Lifetime suicide attempts were frequent (31%) but less so in the prior 12 months (7%). Few racial/ethnic and gender differences were statistically significant. Bisexually identified youths had lower prevalences of every diagnosis. The BSI 18 had high negative predictive power (90%) and low positive predictive power (25%) for major depression. CONCLUSIONS: LGBT youths had higher prevalences of mental disorder diagnoses than youths in national samples, but were similar to representative samples of urban, racial/ethnic minority youths. Suicide behaviors were similar to those among representative youth samples in the same geographic area. Questionnaires measuring psychological distress may overestimate depression prevalence among this population.

A network-individual-resource model for HIV prevention.

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

Fluctuating asymmetry and sexual orientation in men and women.

The present study measured handedness and bodily fluctuating asymmetry (FA), two markers of developmental instability, in 89 heterosexual and 78 gay men and women. Asymmetry in ear breadth, ear length, ankle breadth, second digit length, fourth digit length, and two composite indices were calculated for each participant and a modified Edinburgh Inventory was used to assess handedness. Results showed that, for men, there was a significant positive correlation between three measures of FA and sexual orientation scores (SOS). As ear breadth FA and two composite FA scores increased so did SOS on a modified Kinsey scale (where 0 indicated exclusive heterosexuality and 6 indicated exclusive homosexuality). No significant relationships were found between SOS and FA for women. Similarly, sexual orientation was not related to handedness for either sex. The theoretical implications of the present results are discussed.

Methamphetamine and young men who have sex with men: understanding patterns and correlates of use and the association with HIV-related sexual risk.

OBJECTIVE: To examine patterns, consequences, and correlates of methamphetamine use among adolescent and young adult men who have sex with men (YMSM). DESIGN: Descriptive, bivariate, and hierarchical regression analyses of cross-sectional data. SETTING: Howard Brown Health Center, a community-based facility in Chicago, Ill, from August 2004 to September 2005. PARTICIPANTS: Three hundred ten YMSM who completed an anonymous, computer-assisted survey. MAIN OUTCOME MEASURE: Methamphetamine use in the past year. RESULTS: Participants ranged in age from 16 to 24 years (mean age, 20.3 years); 30% were white and 70% were of other race/ethnicity (African American, 33%; Hispanic, 26%; Asian or Pacific Islander, 3%; and other, 8%). Participants reported many high-risk sexual and substance use behaviors. Thirteen percent used methamphetamine in the past year. Methamphetamine use was more common among human immunodeficiency virus-infected participants (odds ratio, 2.8; 95% confidence interval, 1.3-5.3) and varied by age and race/ethnicity; substantially higher prevalence was reported by older and non-African American YMSM (P<.001). Compared with other illicit substance users, methamphetamine users reported more memory difficulties, impairments in daily activities, and unintended risky sex resulting from substance use (all P<.01). Hierarchical regression identified sexual risk (unprotected intercourse and multiple partners), sexualized social context (eg, Internet sex, sex in a bathhouse or sex club, sex with older partners, and commercial sex), lower self-esteem, and psychological distress as correlated with methamphetamine use among participants (P<.05). CONCLUSIONS: A substantial percentage of YMSM in this sample used methamphetamine. Methamphetamine use is a public health problem with significant implications for the health and well-being of YMSM. Methamphetamine use was associated with human immunodeficiency virus-related risk, and patterns of use were predicted by demographic data, sexualized social contexts, and psychological variables.

Tip of the Iceberg: young men who have sex with men, the Internet, and HIV risk.

OBJECTIVES: We examined the prevalence of Internet use for meeting sexual partners (Internet partners) and HIV risk behaviors associated with this use among young men who have sex with men (aged 16-24 years). METHODS: A sample of 270 young men who have sex with men completed a computer-assisted survey. We used bivariate chi(2) analyses and hierarchical logistic regression to assess factors associated with Internet-facilitated sexual encounters. RESULTS: Using the Internet to meet sexual partners was common; 48% of our sample had sexual relations with a partner they met online. Of these, only 53% used condoms consistently, and 47% reported having sexual partners older (>4 years) than themselves. Regression analyses showed increased age, White race/ethnicity, history of unprotected anal intercourse, multiple anal intercourse partners, and engaging in sexual activity at a sex club or a bathhouse were associated with meeting sexual partners through the Internet. Only history of unprotected anal intercourse was associated with risky sexual behaviors with Internet partners (P<0.025). CONCLUSIONS: Young men who have sex with men and who seek partners online also engage in other behaviors that place them at risk for HIV and other sexually transmitted infections.

A genomewide scan of male sexual orientation.

This is the first report of a full genome scan of sexual orientation in men. A sample of 456 individuals from 146 families with two or more gay brothers was genotyped with 403 microsatellite markers at 10-cM intervals. Given that previously reported evidence of maternal loading of transmission of sexual orientation could indicate epigenetic factors acting on autosomal genes, maximum likelihood estimations (mlod) scores were calculated separated for maternal, paternal, and combined transmission. The highest mlod score was 3.45 at a position near D7S798 in 7q36 with approximately equivalent maternal and paternal contributions. The second highest mlod score of 1.96 was located near D8S505 in 8p12, again with equal maternal and paternal contributions. A maternal origin effect was found near marker D10S217 in 10q26, with a mlod score of 1.81 for maternal meioses and no paternal contribution. We did not find linkage to Xq28 in the full sample, but given the previously reported evidence of linkage in this region, we conducted supplemental analyses to clarify these findings. First, we re-analyzed our previously reported data and found a mlod of 6.47. We then re-analyzed our current data, after limiting the sample to those families previously reported, and found a mlod of 1.99. These Xq28 findings are discussed in detail. The results of this first genome screen for normal variation in the behavioral trait of sexual orientation in males should encourage efforts to replicate these findings in new samples with denser linkage maps in the suggested regions.

Genetic and environmental influences on pubertal development: longitudinal data from Finnish twins at ages 11 and 14.

To study sources of individual differences in pubertal development, the authors fit a sex-limitation common factor model to data reported, at ages 11 and 14 years, by 1,891 twin pairs on items that comprise the Pubertal Development Scale (PDS; A. C. Petersen, L. Crockett, M. Richards, & A. Boxer, 1988). The model divides variation into a general pubertal factor and item-specific variation and, in addition, decomposes it into constituent sources. In both boys and girls, genetic influences made the largest contribution to variance common to PDS items. Genetic and nonshared environmental factors accounted for variation specific to PDS items in boys, whereas for girls, common environmental influences were added for growth spurt and menarcheal status. For both common and item-specific variation, genetic effects were partially sex specific. Subsidiary analyses found accelerated maturation in both boys and girls who at age 14 were reared in father-absent homes.

A candidate gene study of CYP19 (aromatase) and male sexual orientation.

Aromatase cytochrome P450 (CYP19), which is necessary for the conversion of androgens to estrogens, plays an important role in the sexual differentiation of the brain. To investigate whether differences in the gene encoding the aromatase enzyme influence sexual orientation in men, we conducted linkage, association, and expression analyses in a large sample of homosexual brothers using microsatellite markers in and around CYP19. No linkage was detected, and a gene-specific relative risk of 1.5-fold could be excluded at a lod score of -2. Results of the TDT demonstrated no preferential transmission of any of the CYP19 alleles in this sample. Expression of aromatase mRNA by microarray analysis was not significantly different between heterosexual and homosexual men. These results suggest that variation in the gene for this subunit of the aromatase enzyme complex is not likely to be a major factor in the development of individual differences in male sexual orientation.

Genetic influences on the association between personality risk factors and alcohol use and abuse.

The authors assessed the association of 2 personality dimensions with use and abuse of alcohol in 1,320 twin pairs concordantly reporting nonabstinence at age 18.5 years. The 2 alcohol outcomes differentially relate to the 2 personality dimensions: Alcohol-related problems correlate more highly with social deviance than with excitement seeking (ES), and alcohol consumption correlates more highly with ES than with social deviance. Biometric models fit to the data identified similar patterns in genetic covariance, although differences were more evident in genetic correlations between social deviance and alcohol outcomes than in those for ES. Results suggest that genetic influences underlie the association of personality with alcohol use and subsequent problems and illustrate the utility of informative twin analyses in exploring links between genes, personality, and behavior disorder.