Sexual and Reproductive Health Education for Youth with Intellectual Disabilities: a Mixed Methods Study of Professionals' Practices and Needs.

We conducted formative research to inform the creation of innovative new tools and strategies to engage professionals in communicating with youth with intellectual disabilities about sexual health. The research was guided by a multidisciplinary network of experts and an advisory board of self-advocates with intellectual disabilities and caregivers that make up Project SHINE: the Sexual Health Innovation Network for Equitable Education. A cross-sectional mixed-methods study utilized survey data from 632 disability support professionals who provide services to youth ages 16-24 with intellectual disabilities (ID). We then conducted focus groups with 36 professionals to obtain more in-depth information related to organizational support needs and suitable contexts, methods, and tools for sexuality education. Participants included licensed/credentialed direct service professionals (social workers, nurses, teachers), non-licensed direct service providers (case managers, supportive care specialists, residential care line staff), and program administrators. Quantitative and qualitative data analyses triangulated the findings across four content areas: attitudes about providing sexual health information to youth with ID, preparedness to communicate about sexuality, current communication practices, and professional needs in the field for new teaching tools and methods. We discuss how findings can be used to guide the creation and successful implementation of innovative new sexual health learning tools for youth with intellectual disabilities.

Sexual violence experiences among black gay, bisexual, and other men who have sex with men and transgender women in South African townships: contributing factors and implications for health.

This study examined experiences with sexual violence among Black African gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) in townships surrounding Pretoria, South Africa. Of 81 GBMSM and TGWs interviewed, 17 reported to have experienced sexual violence perpetrated by other men. Qualitative analysis of interviews revealed the social and relational context of these experiences as well as their psychological and health consequences. The described context included single- and multiple-perpetrator attacks in private and public spaces, bias-motivated attacks, and violence from known partners. Several participants reported refusing propositions for sex as a reason for being victimized. HIV-positive individuals were overrepresented among survivors compared to the sample as a whole. Following victimization, participants described feelings of pain, fear, anger and self-blame. The results demonstrate the need for interventions designed to (a) prevent sexual violence against GBMSM and TGW in this population, and (b) reduce the negative psychological and health outcomes of sexual victimization. The discussion also highlights the need to examine more closely the link between experiences of sexual violence and risk for HIV infection.

Gender Nonconformity and Peer Victimization: Sex and Sexual Attraction Differences by Age.

Among 2,185 Dutch adolescents (ages 11 to 18), we assessed whether the association among gender nonconformity, homophobic name-calling, and other general peer victimization differs for boys and girls and for youth with and without same-sex attraction (SSA). We also examined whether sex and sexual attraction differences in the association between gender nonconformity and both types of peer victimization are dependent upon adolescents' age. Data were collected in the academic year 2011-2012. Results showed that gender nonconformity was positively associated with homophobic name-calling and general peer victimization. These associations were stronger for boys compared with girls and were also stronger with increasing levels of SSA. Sex differences in the relationship between gender nonconformity and general peer victimization were significant for early and middle adolescents but not for late adolescents. Sexual attraction differences in the relationship between gender nonconformity and both types of peer victimization were significant for early and middle adolescents but not for late adolescents. These results emphasize that key educational messages that address sexual and gender diversity should be delivered during childhood before early adolescence.

Sexuality Disclosure Among Black South African MSM and Responses by Family.

Although South Africa protects sexual orientation in its Constitution, homosexuality is socioculturally contested and unaccepted. This lack of acceptance may impact the coming-out process of men who have sex with men (MSM). This study explored diverse factors that influenced whether Black South African MSM disclosed their sexual practices and identities to their families, how their families responded, and how family responses affected them. In-depth interviews were conducted with 81 Black MSM from four Tshwane townships about their sexual and gender identities, sexual practices, social networks, and familial relationships. Interview transcripts were analyzed with ATLAS.ti using a priori codes and inductive coding. Most participants disclosed their sexual identities to at least one person in their families or assumed their families knew despite no explicit disclosure about their sexual identity; a significant minority had not disclosed. Families of those who disclosed were either supportive, in denial, confused, or unsupportive in their responses. Whether or not family was supportive, silence around the participants' same-sex sexualities was prevalent within families. Family responses affected how participants perceived their sexuality and their confidence. Further studies are required to better understand the underlying processes of coming out for Black South African MSM and how these processes impact health outcomes and social well-being.

A PrEP Information and Self-Screening Tool for Women.

Although HIV pre-exposure prophylaxis (PrEP) is effective for women, studies show limited uptake among women to date. Barriers to women's PrEP uptake include their limited knowledge about PrEP and low perceived HIV risk. To address these barriers, we developed and pretested a printed palm card containing HIV prevention/PrEP information that addressed HIV prevention motivation with self-assessment questions about HIV risk. We conducted expert interviews (N = 8), focus groups with health, education, and social service providers (N = 13), and interviews with community women (N = 30) in New York City to assess attention to and acceptability of the card, comprehension of the information, and potential impact on prevention motivation. The card format and content were found to be acceptable and potentially motivational for preventive behaviors, as well as particularly relevant for women. Results of testing for language use, comprehension, and attention guided the final version of the card content.

Raising Awareness of Pre-Exposure Prophylaxis (PrEP) among Women in New York City: Community and Provider Perspectives.

This study explored the knowledge, attitudes, and perceived facilitators and barriers to adoption of HIV pre-exposure prophylaxis (PrEP) among black women and Latinas in the Bronx, NY. Data were collected in focus group discussions (FGDs) held separately with staff (n = 21) and black and Latina female clients aged 18 to 50 (n = 23) of four organizations providing health and social services. Participants were also asked to give feedback about four action messages regarding PrEP for a social marketing campaign. Transcripts were analyzed by two researchers using grounded theory. We found that the majority of clients (74%) and staff (57%) had not heard about PrEP before participating in the FGDs. Following brief educational messaging about PrEP, participants identified potential facilitators and barriers to PrEP uptake among women, and expressed enthusiasm for more widespread efforts to raise awareness about PrEP as an HIV prevention option. Participants preferred an action message that was brief, referred to PrEP as a pill, and did not mention condoms or STD testing. These findings demonstrate the need to raise awareness about PrEP among women and build the capacity of women-serving organizations to educate, screen, and refer or provide PrEP services.

A Clinical Home for Preexposure Prophylaxis: Diverse Health Care Providers' Perspectives on the "Purview Paradox".

BACKGROUND: One barrier to wider preexposure prophylaxis (PrEP) availability is uncertainty about the most appropriate providers and practice settings for offering PrEP. METHODS: The authors conducted in-depth interviews with 30 clinicians--primary care and HIV specialists--in the New York City (NYC) region to explore issues related to PrEP rollout, including who should provide it and in what settings. RESULTS: A diverse group favored offering PrEP in non-HIV specialty settings in order to reach high-risk HIV-negative individuals. Yet, for each clinical skill or ancillary service deemed important for providing PrEP--knowledge of the medications, ability to assess and counsel around sexual risk behavior, and ability to provide support for retention and medication adherence--participants were divided in whether they thought primary care providers/practices could achieve it. Five participants strongly favored providing PrEP in HIV care practices. CONCLUSION: Although there may be multiple "homes" for PrEP, implementation research is needed to identify the most effective delivery approaches.

Healing Our Women for Transgender Women: Adaptation, Acceptability, and Pilot Testing.

Healing Our Women (HOW) is a group-level HIV risk-reduction intervention developed to address the role of prior sexual victimization in HIV risk and protective behaviors among HIV-positive women of color. This article describes the process of adapting HOW for transgender women of color in New York City in accordance with CDC guidance for the adaptation of efficacious interventions. Twenty-one transgender women were enrolled in a study to evaluate the acceptability and fidelity of the adapted intervention, and to assess HIV knowledge, depressive symptoms, coping, condom use self-efficacy, and condom use via pre- and post-intervention surveys. We found the adapted program to be feasible to implement and acceptable to participants. We also found significant decreases in depressive symptoms and increases in positive coping from pre- to post-intervention, although replication with a larger sample and a control group comparison is needed to determine efficacy with this population.

'They think that gays have money': gender identity and transactional sex among Black men who have sex with men in four South African townships.

Transactional sex has not been studied much among men who have sex with men in Africa. Consequently, little is understood about attitudes towards the practice, the circumstances that give rise to it or how transactional sex relationships are managed. We conducted in-depth interviews with 81 Black men aged 20-44 from four low-resourced townships in Tshwane, South Africa. We found that transactional sex was a widely used strategy for initiating and sustaining relationships with regular and casual partners, and was motivated by both the need for subsistence and for consumption. Alcohol-based exchanges in particular provided men in the townships with a covert and safe platform to communicate erotic, sexual and romantic attraction to other men, and bars and other drinking places were a popular venue for meeting potential sexual partners. The majority of 'feminine-identifying' men had engaged in transactional sex as the providers of money and material goods compared to men who identified as either 'masculine' or as 'both masculine and feminine'. Surprisingly, however, this did not necessarily give them greater control in these relationships. Our study provides an initial foray into a complex sociosexual phenomenon and suggests that gender identity is an important construct for understanding transactional sex relationships among men in Africa.

"This will not enter me": painful anal intercourse among Black men who have sex with men in South African townships.

Little is known about painful receptive anal intercourse (RAI) and its relationship to HIV risk and protective behaviors among men who have sex with men (MSM). The purpose of this study was to identify attributions for and responses to painful RAI among Black MSM in South African townships. In-depth interviews were conducted with 81 Black MSM (ages 20-39 years) who were purposively recruited from four townships. The semi-structured interviews addressed sexual behavior and identity, alcohol use, and safer sex. Pain during RAI was brought up by many participants without specific prompting from the interviewer. Analysis of the interview transcripts revealed that pain was a common feature of first RAI experiences but was not limited to first-time experiences. The participants attributed pain during RAI to partner characteristics, interpersonal dynamics, lack of lubricant, and alcohol use or non-use. The main strategies participants used to address pain during RAI were setting sexual boundaries and lubricant use; a small number of participants reported purposefully consuming alcohol to prevent the pain associated with RAI. Black South African MSM can be supported to reduce pain during RAI in ways that reduce their HIV/STI risk. Culturally specific sexual health education, supportive sexual health services, and improved access to condom-compatible lubricants are important components of HIV/STI interventions for this population.

HIV testing practices of South African township MSM in the era of expanded access to ART.

While men who have sex with men (MSM) in Africa are at high risk for HIV infection, few of those already infected know their status. Effectively promoting frequent HIV testing-of increasing importance with the expanding accessibility of antiretroviral treatment-requires an understanding of the testing practices in this population. To understand men's HIV testing practices, including their behavior, experiences, and perceptions, we conducted in-depth interviews with 81 black South African MSM (ages 20-39), purposively recruited from four townships. Many men in the sample had tested for HIV. While ever having tested seemed to facilitate repeat testing, men still expressed a high level of discomfort with testing. It was common to test after having engaged in risky behavior, thus increasing anxiety about testing that was already present. Fear that they might test HIV positive caused some men to avoid testing until they were clearly sick, and others to avoid testing completely. HIV testing may increase in this population if it becomes a routine practice, instead of being driven by anxiety-inducing incidents. Mobilization through social support might facilitate frequent testing while education about current treatment options is needed.

Attitudes toward lesbians and gays among American and Dutch adolescents.

Attitudes toward lesbians and gays vary across national populations, and previous research has found relatively more accepting attitudes in the Netherlands as compared to the United States. In this study, we compared beliefs about and attitudes toward lesbians and gays in samples of Dutch and American heterosexual adolescents, utilizing survey data from 1,080 American adolescents (mean age = 15.86 years) attending two schools and from 1,391 Dutch adolescents (mean age = 16.27 years) attending eight schools. Findings indicated the Dutch participants were more tolerant of lesbians and gays, after adjusting for the gender, age, and racial/ethnic minority status of the participants. However, between-country differences were attenuated by accounting for the beliefs about lesbians and gays that participants used to justify their attitudes. American participants were more likely to justify their attitudes using beliefs related to social norms and religious opposition, while the Dutch participants were more likely to justify their attitudes using beliefs related to individual rights and the biological/genetic basis of homosexuality. The results suggest that the relative importance of particular beliefs about lesbians and gays to attitudes at the group level may be context dependent but also that certain beliefs are salient to attitudes across national contexts.

Understanding Teachers' Responses to Enactments of Sexual and Gender Stigma at School.

Although teachers may be in a position to address enactments of sexual and gender stigma among their students, little is known about their motivations to intervene in such situations. We surveyed secondary school teachers in the Netherlands, assessing how beliefs, norms, and self-efficacy were related to their intentions to intervene in two hypothetical situations that involved bullying of lesbian/gay or gender non-conforming students. We found significantly stronger intentions to intervene among teachers who were more confident in their abilities to intervene successfully and who had stronger beliefs that intervening in the situation would produce a positive outcome.

Experiences of female partners of masculine-identifying trans persons.

This paper explores the intimate relationship experiences of the cisgender (i.e., not transgender) female partners of masculine-identifying transgender persons, with a particular focus on these partners' self-understanding of their sexual orientation. Limited research about this topic has been conducted to date. Semi-structured interviews were conducted with eight South African women who are or have been cisgender female partners of masculine-identifying trans persons. Although the interviews showed that the relationship experiences of female partners of masculine-identifying trans persons are diverse, several common themes emerged in the narratives. The way that participants labelled their sexual orientation did not change from before to after their relationship with a transgender partner. The participants reported varied family and community responses to their relationships. Specific emotional and informational support needs for women with transgender partners were identified.

Gender, Ethnicity, Religiosity, and Same-sex Sexual Attraction and the Acceptance of Same-sex Sexuality and Gender Non-conformity.

This study explored the role of gender, ethnicity, religiosity, and sexual attraction in adolescents' acceptance of same-sex sexuality and gender non-conformity. Using an intersectionality perspective, we also tested whether the effects of gender, ethnicity, and religiosity on adolescents' attitudes would function differently in adolescents with and without same-sex attractions. Data for this study were collected by means of a paper questionnaire completed by 1,518 secondary school students (mean age = 14.56 years, SD = 1.05) in Amsterdam, the Netherlands. The sample was 48.1% female and 51.9% male. Approximately one third of adolescents in the sample were of a non-Western ethnic background (32.3%, n = 491) and 7.5% of the participants (n = 114) reported experiencing same-sex attractions. Results of our analyses showed that adolescents in our sample who were male, of non-Western ethnicity, and who were more religious (as indicated by frequency of religious service attendance), were less accepting of same-sex sexuality and gender non-conformity in comparison to female, Western and less religious peers. We also found a significant interaction effect between religiosity and sexual attractions, but only in relation to evaluation of same-sex attracted, gender nonconforming females. The negative effect of religiosity on acceptance of same-sex attracted, gender non-conforming females was stronger among those adolescents who reported same-sex attractions.

Sexual orientation and gender identity/expression related peer victimization in adolescence: a systematic review of associated psychosocial and health outcomes.

This article reviews research on psychosocial and health outcomes associated with peer victimization related to adolescent sexual orientation and gender identity or expression. Using four electronic databases and supplementary methods, we identified 39 relevant studies. These studies were published between 1995 and 2012 and conducted in 12 different countries. The studies were diverse in terms of their approaches to sampling participants, assessing participants' sexual orientation, operationalizing peer victimization, and with regard to the psychosocial and health outcomes studied in relation to peer victimization. Despite the methodological diversity across studies, there is fairly strong evidence that peer victimization related to sexual orientation and gender identity or expression is associated with a diminished sense of school belonging and higher levels of depressive symptoms; findings regarding the relationship between peer victimization and suicidality have been more mixed. Peer victimization related to sexual orientation and gender identity or expression is also associated with disruptions in educational trajectories, traumatic stress, and alcohol and substance use. Recommendations for future research and interventions are discussed.

Homophobic name-calling among secondary school students and its implications for mental health.

Although homophobic verbal victimization has been associated with negative mental health outcomes, little actually is known about its general prevalence and relationship to mental health among adolescents. In addition, the relationship of homophobic name-calling to mental health in gender non-conforming adolescents is not well understood. This study examined the relationship between homophobic verbal victimization and mental health in adolescents, accounting for their sexual orientation and level of gender non-conformity. Survey data was collected from 513 adolescents (ages 11-17) who attended eight schools in and around Amsterdam, the Netherlands; 56.7 % of the participating adolescents were female and 11.1 % reported same-sex attractions. As hypothesized, male adolescents and those with same-sex attractions were more likely to report victimization from homophobic name-calling than were their female and non-same-sex attracted peers. Contrary to expectations, homophobic name-calling was not independently associated with psychological distress after controlling for gender, sexual attractions, gender non-conformity, and other negative treatment by peers. The hypothesis that homophobic name-calling would be more strongly associated with psychological distress in male, same-sex attracted, and gender non-conforming adolescents was also not supported. The results suggest that same-sex attracted and gender non-conforming youth are particularly vulnerable to homophobic name-calling, in the Netherlands as in other contexts, but also that other forms of peer victimization may be more strongly related to mental health.

Addressing sexual problems in HIV primary care: experiences from patients.

Evidence suggests that sexual problems are common among people living with HIV and may be related to sexual risk taking and treatment adherence. This study explored the extent to which sexual problems experienced by people with HIV are addressed in primary care as well as how primary care responses to sexual problems are experienced by patients. Structured interviews were conducted with 60 patients at an urban HIV clinic. The average age of the participants (37 male, 23 female) was 45.8 years (SD = 7.9). Sexual problems were common. The most common sexual problem experienced in the past year was a lack of interest in sex (53.3 % reported) and the least common problem was painful intercourse (reported by 20 %). There were no gender differences in reports of sexual problems, except that painful intercourse was more frequently reported by women than men. Relatively few individuals who experienced sexual problems had discussed them with their provider, but these individuals were generally pleased with the counseling they had received and could identify several factors that facilitated a positive patient-provider interaction. Those who offer primary care services to people with HIV should be aware of sexual problems their patients may be experiencing and should feel confident in their ability to successfully address these problems. Providers may need additional training in order to adequately address sexual problems among people with HIV in primary care settings.

Intergroup contact, attitudes toward homosexuality, and the role of acceptance of gender non-conformity in young adolescents.

This study explored how contact with gay and lesbian persons affects adolescents' attitudes toward them, and whether this association is mediated or moderated by one's acceptance of gender non-conformity. We analyzed survey responses from 456 Dutch adolescents aged 12-15 who reported having no same-sex attractions. Data were collected in 2008 at 8 schools in Amsterdam, the Netherlands. Preliminary analyses showed that contact with lesbian/gay persons outside of school was positively associated with attitudes toward lesbians and gay men. Multilevel analyses showed that acceptance of gender non-conformity mediated rather than moderated the relationship between intergroup contact and sexual prejudice in males. The effect of intergroup contact on females' attitudes toward lesbian women was no longer significant in multilevel analyses. The findings suggest that attention to both intergroup contact and acceptance of gender non-conformity would enhance our understanding of attitudes toward homosexuality in adolescents.

School environment and the mental health of sexual minority youths: a study among Dutch young adolescents.

OBJECTIVES: We examined whether structural elements of the school environment, in particular cultural pluralism and consistency and clarity of school rules and expectations of students, could mitigate the risk for mental health problems among young sexual minority adolescents. METHODS: Data were collected in 2008 by means of a computer-based questionnaire completed at school by 513 young Dutch adolescents (12-15 years old) during regular class times. Eleven percent of these students, who were enrolled in 8 different schools, reported having at least some feelings of same-sex attraction. RESULTS: Adolescents with same-sex attractions in schools where rules and expectations were experienced as less consistent and clear reported significantly more mental health problems than their peers with no same-sex attractions in the same schools. Such differences were absent in schools where rules and expectations were experienced as more consistent and clear. There were no such effects of cultural pluralism. CONCLUSIONS: Our results suggest that schools with consistent and clear rules and expectations mitigate the risk for mental health problems among students with same-sex attractions and underscore the importance of structural measures for the health of sexual minority youth.