Rates of Urinary Tract Infection in Transgender Women Postvaginoplasty vs Cisgender Women: A Retrospective Cohort Study in a Large US Health Network.

OBJECTIVE: To describe urinary tract infection (UTI) risk 3-month postvaginoplasty (VP) in transgender women (TW) compared to cis women (CW). METHODS: Using TriNetX (TriNetX, Inc, Cambridge, MA), we built cohorts of 2041 TW and 48,374,745 CW. Outcomes were ≥1 instance of UTI or Cystitis, and assessed from 3-6, 3-12, 3-36months, and 3months-10years post-VP. TW and CW were age-cohorted (18-39, 40-59, 60-74) and compared at each time interval. Kaplan-Meier was used to account for loss to follow-up, along with hazard ratios and log-rank tests to determine significance (P <.05). RESULTS: For all time intervals and age ranges, TW had a significantly (P <.0001-P = .0088) higher probability of developing a UTI compared to CW. The largest difference was ages 40-59 ten-year post-VP. In this analysis, CW and TW had a 12.96% and 29.34% cumulative outcome incidence, respectively. Cox proportional hazard analysis demonstrated increased hazard for TW compared to CW. Hazard ratios between CW and TW ranged from 1.363 (ages 18-39 at 10years, 95%CI: 1.119,1.660) to 3.522 (ages 60-74 at 12months, 95%CI: 1.951,6.360). CONCLUSION: We found a significantly higher probability of TW developing UTIs compared to age-cohorted CW. Contributing factors may include difficulties with neovaginal perineal hygiene, lack of commensal bacteria and vaginal mucosa, larger urethral meatus, high rates of meatal stenosis, and nonnative bacteria introduced through dilators and douching. These findings may help improve quality of postoperative care in TW.

Community Support for Harm Reduction and Treatment of Opioid Use Disorder.

As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.

Mediating role of food insecurity in the relationship between perceived MSM related stigma and depressive symptoms among men who have sex with men in Nepal.

BACKGROUND: Previous studies have indicated the association between stigma and depressive symptoms among frequently stigmatized groups, such as men who have sex with men (MSM). While this association has been suggested in the literature, there is a dearth of evidence that examines whether food insecurity statistically mediates the relationship between stigma and depressive symptoms. METHODS: This cross-sectional study conducted between October and December 2022 among a sample of 250 MSM in Kathmandu, Nepal, recruited through respondent-driven sampling. An unadjusted model including the exposure (stigma), mediator (food insecurity), and outcome variables (depressive symptoms) and an adjusted model that controlled for sociodemographic, behavioral, and health-related confounders were used. Bootstrapping was utilized to estimate the coefficients of these effects and the corresponding 95% confidence intervals. Via bootstrap approach, we find out the mediating role of food insecurity in the association between stigma and depressive symptoms. RESULTS: Depressive symptoms, stigma, and food insecurity were 19.6%, 24.4%, and 29.2%, respectively, among MSM. Food insecurity was associated with higher age (b = 0.094; 95% CI = 0.039, 0.150) and monthly income (b = -1.806; 95% CI = -2.622, -0.985). Depressive symptoms were associated with condom-less sex in past six months (b = -1.638; 95% CI = -3.041, -0.092). Stigma was associated with higher age (b = 0.196; 95% CI = 0.084, 0.323) and PrEP uptake (b = 2.905; 95% CI = 0.659. 5.248). Food insecurity statistically mediated 20.6% of the indirect effect of stigma in depressive symptoms. CONCLUSION: Our findings show that food insecurity affects the relationship between stigma and depressive symptoms in this population. Reducing food insecurity and addressing the stigma surrounding sexual orientation should be a priority when addressing mental health concerns among MSM in Nepal and other resource-limited countries with similar socio-cultural settings.

Compulsive Sexual Behavior and Changes in Solitary Sexual Behaviors During the COVID-19 Pandemic.

The aim of with this brief report is to examine how the COVID-19 pandemic differentially impacted solitary sexual behaviors in those with and without clinically significant compulsive sexual behavior (CSB). A total of 944 individuals in the United States completed an online cross-sectional survey in October 2020. Participants were asked to retrospectively report their frequency of masturbation and pornography use during the pandemic and prior to the pandemic. Participants also completed assessments of CSB, depression symptoms, and experiences of financial stress caused by the pandemic. Individuals who screened positive for clinically significant CSB reported statistically significant increases in masturbation and pornography use during the pandemic. Those who screened negative for CSB reported no significant increase in masturbation and a very small, statistically significant increase in pornography use. Those screening positive for CSB also reported significantly higher levels of depression symptoms but did not report increased likelihood of experiencing financial distress due to the pandemic. This suggests that increases in masturbation and pornography use reported by some, but not all, recent studies on sexual behaviors during the COVID-19 pandemic may be driven by individuals with CSB. Future research on sexual behaviors during the pandemic should assess CSB to further clarify its relationship with sexual behavior changes.

A comprehensive analysis of YouTube videos on gender affirmation surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to comprehensively analyze YouTube™ videos focusing on genital gender-affirmation surgery (GAS) from the perspective of urologists and gynecologists and to utilize results to create educational videos for transgender individuals with accurate and engaging content. METHODS: A YouTube search was performed using the keywords "Metoidioplasty," "Phalloplasty," "Gender affirmation surgery," "Transgender surgery," "Vaginoplasty," and "Male-to-female surgery." Video results that were duplicated, non-English, of low relevance, non-audio, and/or short duration (under 2 min) were excluded. The upload source was classified as university/nonprofit physician or organization, health information websites, medical advertisement/for-profit organizations, or individual patient experience. Viewer engagement metrics were obtained for each video. Each video was evaluated using the DISCERN, Global Quality Score (GQS), and Patient Education Materials Assessment Tool for audio-visual content (PEMAT A-V) tools. RESULTS: A total of 273 videos were evaluated. Viewer engagement metrics of videos from the patient experience group were higher than those of both universities/nonprofit physicians and medical advertisement/for-profit groups. DISCERN and GQS scores were significantly lower in videos uploaded by the patient experience group than in each of the other upload sources. More videos covered female-to-male (FtM) transition (168, 61.5%) than covered male-to-female (MtF; 71, 26.0%), and both (34, 12.5%). MtF transition videos had significantly higher total view counts than videos from the other groups (p<0.001). The like counts of videos were significantly higher in both MtF transition and FtM transition groups than for videos explaining both types of transition within the same video. The total DISCERN score was significantly lower in FtM transition videos than in the other content groups. Two educational videos were prepared, informed by the tools and results of this study, and hosted on YouTube. CONCLUSIONS: The findings suggest that genital GAS videos with less technical content have higher audience engagement. This information should be used to aid medical organizations when creating YouTube content to provide accurate information to larger audiences in the transgender community.

Stigma as a barrier and sex work as a protective factor for HIV testing among trans women in Nepal.

Stigma towards trans women in Nepal creates individual and system-level risks for HIV. A critical protective factor is access to HIV prevention. Research is needed to determine the impact of stigma on HIV testing among trans women in Nepal. We conducted a secondary analysis of data collected using respondent driven sampling in 2019 on HIV risk among trans women in Nepal. Data analysis was restricted to trans women who were HIV negative at testing through the parent study. Descriptive statistics, tests for bivariable associations between HIV testing and stigma variables, and binomial Poisson regression were conducted to examine HIV testing outcomes. There were 173 participants who tested negative for HIV in our sample. The majority were under age 35 (59%) and most had a grade school education or less (64.7%). No trans women were homeless and most rented a room (70.5%) or owned their home (19.7%). The majority were currently sex workers (57.8%). Almost all HIV-negative trans women had ever been tested for HIV (90.8%), but only 53.5% in the last 3 months. The most frequently cited reason for not having been tested was thinking they were at low risk for HIV (40.9%) and being afraid of receiving a positive test result (22.7%). HIV and anti-trans stigma were high across most measures, including that almost all (94.2%) believed that most people in Nepal would discriminate against people with HIV. And most participants thought trans women were not accepted in Nepali Society (65.9%). Most participants also reported high social support (70.5%). Social cohesion among participants varied, with most experiencing medium (41.6%) or high (33.5%) social cohesion. Just over half had high social participation (55.5%). Participants who reported current sex work had lower prevalence of not testing for HIV in the last 3 months (prevalence ratio, PR = 0.54, 95% confidence interval, 95%CI = 0.32-0.92, p = 0.02). Every one-unit increase in social cohesion was associated with 1.05 times the prevalence of not testing for HIV in the last 3 months (95%CI = 1.01-1.09, p-value = 0.02). Trans women who did sex work were more likely to be HIV tested while those who were more socially connected to peers were less likely to have recently been tested for HIV. HIV stigma may result in fear of social rejection from peers if one tests positive. Interventions that focus on addressing stigma within trans women's social networks and strategies to mitigate HIV stigma in society may result in increased frequency of HIV testing among trans women in Nepal.

"Sex Seems Less Important When You Are Worried About a Deadly Virus." A Content Analysis of Reported Reasons for Changes in Sexual Behavior and Satisfaction During the COVID-19 Pandemic.

The purpose of this study is to assess how the COVID-19 pandemic impacted various sexual behaviors and levels of sexual and relationship satisfaction by performing a content analysis of participants' (N = 1051 American adults) responses to open-ended survey questions. Results revealed a variety of impacts that increased, decreased, or otherwise qualitatively changed sexual behavior and satisfaction. Major themes included emotions and mental health, changes in routines, social distancing and fears related to COVID-19, and changes in romantic relationships. These findings are contextualized within the emerging quantitative research on COVID-19 and sexuality, and areas for future research based on these findings are discussed.

The Impact of the COVID-19 Pandemic on Sexual Behaviors: Findings From a National Survey in the United States.

BACKGROUND: Studies from the first months of the coronavirus disease 2019 (COVID-19) pandemic and the resulting lockdown and social distancing measures have shown that there have been decreases in sexual frequency and relationship satisfaction. AIM: To evaluate the ongoing impact of the COVID-19 pandemic on sexual behavior, relationship satisfaction, and intimate partner violence in the United States using a large national convenience sample. METHODS: About 1,051 participants across the United States were recruited in October 2020 to complete a cross-sectional online survey. OUTCOMES: Participants were asked to retrospectively report their sexual behavior frequency, relationship satisfaction, and intimate partner violence during the pandemic and prior to the pandemic RESULTS: There was a small but significant decrease in some retrospectively-reported partnered sexual activities, and men reported a small increase in masturbation and pornography use. There was no evidence for a change in relationship satisfaction or intimate partner violence, but both men and women reported a small decrease in sexual pleasure, and women reported a small decrease in sexual desire. The sexual behaviors with greatest reduction were casual sex, hookups, and number of partners, and the most diminished as aspect of sexual functioning was sexual enjoyment. Depression symptoms, relationship status, and perceived importance of social distancing emerged as predictors of these reductions. Less than half of individuals who engaged with casual sex partners before the start of the pandemic ceased this behavior completely after the start of the pandemic. Individuals waited on average 6-7 weeks before reengaging in casual sex. CLINICAL IMPLICATIONS: These results inform public health response to the effects of the pandemic and add to our understanding of how the pandemic has continued to impact sexual behavior. STRENGTHS AND LIMITATIONS: This is the first known study to evaluate sexual behavior several months into the COVID-19 pandemic using a large national sample. However, the results of this study are limited by its convenience sampling method and cross-sectional design. CONCLUSION: These results indicate that the changes in sexual behavior observed in the early months of the pandemic have continued, with small but significant decreases in many partnered sexual behaviors and a small increase in men's solitary sexual behaviors. Gleason N, Banik S, Braverman J, et al. The Impact of the COVID-19 Pandemic on Sexual Behaviors: Findings From a National Survey in the United States. J Sex Med 2021;18:1851-1862.

Population-based HIV prevalence, stigma and HIV risk among trans women in Nepal.

BACKGROUND: Transgender women (trans women) in Nepal are underserved in the HIV response. Data are needed to determine the HIV prevalence disaggregated from other key populations and to identify the particular risks faced by this community. Trans women are marginalized around the world and research is also needed to determine the impact of stigma on HIV risk to inform trans-specific interventions. METHODS: In 2019, we conducted the first population-based HIV behavioral surveillance study of trans women disaggregated from other key populations using respondent driven sampling (RDS). We estimated the HIV prevalence for trans women, and bivariate and multivariate Poisson binomial regression models were constructed to examine the relationship between HIV risk and stigma. RESULTS: Trans women participants (N = 200) had a mean age of 33 years old (SD = 10.96). We found a weighted HIV prevalence of 11.3% (95% CI 6·82% - 18·13). We found that depression and anxiety (aPR 0.81; 95% CI 0.67-0.97; p = 0·02) and current engagement in sex work (aPR 1.31; 95% CI 1.01-1.71; p = 0·046) were significantly associated with greater prevalence of condomless receptive anal intercourse. We found that experienced stigma of ever being verbally abused due to gender identity was significantly associated with lower prevalence of depression and anxiety (aPR 0.42; 95% CI 0.20-0.87; p = 0·002). Feeling unaccepted in Nepali society and believing people thought they were a criminal because of their trans identity was significantly associated greater prevalence of current sex work (aPR 1.36; 95% CI 1.03-1.78; p = 0·03; aPR 1.45; 95% CI 1.03-2.07; p = 0.04). Every measure of experienced stigma assessed was significantly associated with greater prevalence of current engagement in sex work. CONCLUSIONS: Trans women are highly stigmatized in Nepal, leading to individual and systems factors that impact their risk for HIV. Interventions are needed that support the economic and mental wellbeing of trans women to prevent their heighted risk of HIV from stigma.

Predicting the hotspots of age-adjusted mortality rates of lower respiratory infection across the continental United States: Integration of GIS, spatial statistics and machine learning algorithms.

OBJECTIVE: Although lower respiratory infections (LRI) are among the leading causes of mortality in the US, their association with underlying factors and geographic variation have not been adequately examined. METHODS: In this study, explanatory variables (n = 46) including climatic, topographic, socio-economic, and demographic factors were compiled at the county level across the continentalUS.Machine learning algorithms - logistic regression (LR), random forest (RF), gradient boosting decision trees (GBDT), k-nearest neighbors (KNN), and support vector machine (SVM) - were employed to predict the presence/absence of hotspots (P < 0.05) for elevated age-adjusted LRI mortality rates in a geographic information system framework. RESULTS: Overall, there was a historical shift in hotspots away from the western US into the southeastern parts of the country and they were highly localized in a few counties. The two decision tree methods (RF and GBDT) outperformed the other algorithms (accuracies: 0.92; F1-scores: 0.85 and 0.84; area under the precision-recall curve: 0.84 and 0.83, respectively). Moreover, the results of the RF and GBDT indicated that higher spring minimum temperature, increased winter precipitation, and higher annual median household income were among the most substantial factors in predicting the hotspots. CONCLUSIONS: This study helps raise awareness of public health decision-makers to develop and target LRI prevention programs.

Hepatitis C Virus Screening Among Adolescents Attending a Drug Rehabilitation Center.

BACKGROUND: Hepatitis C virus (HCV) infection has a strong association with intravenous drug use (IVDU). IVDU is a growing public health concern, even in the adolescent population. To our knowledge, there are no published HCV screening studies targeting high-risk adolescents who attend drug rehabilitation centers.This study was designed to determine the seroprevalence of HCV infection utilizing point-of-care (POC) testing at an adolescent drug rehabilitation center and gain a preliminary understanding of the acceptance rate for HCV screening in this high-risk population. METHODS: This single-center, observational study was conducted at a major drug rehabilitation center in northeast Ohio from July 2016 to June 2017. The consented adolescents who presented at the center were recruited to participate in HCV screening. The participants were administered a survey to assess their demographics and risk behavior profile followed by HCV testing utilizing a POC test. RESULTS: During the study period, 150 adolescents were admitted to the drug rehabilitation center, of whom 100 were approached and 85 agreed to participate. Forty percent of the participants (34/85) were females, and 78% (66/85) were white. HCV prevalence among participants was 5% (4/85), all of whom were females. History of heroin use was reported by 15% (13/85) and it was associated with HCV seropositivity; 100% (4/4) of all HCV-positive individuals reported the use of heroin vs only 11% (9/81) of HCV-negative individuals (P = .0004). CONCLUSIONS: Our study showed a high prevalence of HCV among adolescents attending a drug rehabilitation center with high acceptance of POC HCV testing.

Challenges and opportunities in examining and addressing intersectional stigma and health.

BACKGROUND: 'Intersectional stigma' is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research. DISCUSSION: Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. CONCLUSIONS: Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.

Humanizing an Invisible Population in India: Voices from Bisexual Men Concerning Identity, Life Experiences, and Sexual Health.

Research examining the sexual identities, behaviors, and experiences of bisexual men outside of Western contexts (including in India) is limited. Individuals who self-identify as bisexual due to their orientation toward partners of more than one gender face distinct psychosocial challenges relative to exclusively heterosexual, gay/lesbian, or other individuals. We conducted four focus group discussions (n = 22) and in-depth interviews (n = 50) with self-identified bisexual men (age 18 years and older) who were recruited from the metropolitan area of Mumbai, India, between June and August 2013. We triangulated and analyzed focus group and interview data using standard qualitative research techniques. Findings from our study suggest that multiple factors influence the sexual experiences of self-identified bisexual men in Mumbai, including contexts of sexual interactions, sexual positioning, and the gender of sexual partners. Participants described cultural meaning systems and psychosocial dynamics that regulate bisexual identity development, disclosure, and sexual decision making with male, female, and other partners. Secrecy, discretion, and sexual pleasure also influenced sexual behaviors and relationships. Although Western sexual identity categories are not necessarily equivalent in the Indian context, it is interesting and important to note that a number of individuals in India continue to use the identity label of "bisexual." Before developing interventions to meet unique sexual health needs of bisexual men, it is crucial to understand how these men perceive themselves, reconcile the ordinary aspects of their lives with their sexuality, and structure their relationships with partners.

Social support relationships for sexual minority women in Mumbai, India: a photo elicitation interview study.

Little research exists on women who do not identify as heterosexual in India. Social support for sexual minority women may protect against the effects of discrimination. An examination of significant social relationships may point to both strengths and weaknesses in this support. We aimed to understand relationship prioritisation and communication patterns associated with the social support of sexual minority women in Mumbai. In partnership with the Humsafar Trust, India's oldest and largest sexual and gender minority-advocacy organisation, we conducted photo-elicitation interviews with 18 sexual minority women, using participants' photographs to prompt dialogue about their social support. Intimate partners were a source of dependable support and many of those without relationships were seeking them. Participants' extended networks included friends and family as well as less formal relationships of social support. Participants mediated their communication with particular social network members, which involved filtering information sexual identity, romantic interests, and personal aspirations, among others. The diverse relationships that sexual minority women have in their social support networks may be used to guide programmes to improve health outcomes.

A multi-method study of health behaviours and perceived concerns of sexual minority females in Mumbai, India.

BACKGROUND: This multi-method study explores the perceived health status and health behaviours of sexual minority (i.e. self-identifying with a sexual identity label other than heterosexual) females (i.e. those assigned female at birth who may or may not identify as women) in Mumbai, India, a population whose health has been generally absent in scientific literature. METHODS: Using community-based participatory research approaches, this study is a partnership with The Humsafar Trust (HST). HST is India's oldest and largest LGBT-advocacy organisation. An online survey targeted towards sexual minority females was conducted (n=49), with questions about sexual identity, perceived health and wellbeing, physical and mental healthcare access and experiences, and health behaviours (including substance use). Additionally, photo-elicitation interviews in which participants' photos prompt interview discussion were conducted with 18 sexual minority females. RESULTS: Sexual minority females face obstacles in health care, mostly related to acceptability and quality of care. Their use of preventative health screenings is low. Perceived mental health and experiences with care were less positive than that for physical health. Participants in photo-elicitation interviews described bodyweight issues and caretaking of family members in relation to physical health. Substance use functioned as both a protective and a risk factor for their health. CONCLUSION: Our findings point to a need for more resources for sexual minority females. Education on screening guidelines and screening access for sexual minority females would also assist these individuals in increasing their rates of preventative health.

Sexual Relationships, Behaviors, and Experiences among Bisexual Men in Mumbai, India.

This exploratory study aimed to assess a range of sexual behaviors, relationships and related factors among a sample of bisexual men in Mumbai, India. Data collection occurred in two separate phases: 1. focus group discussions were facilitated with local community members in order to finalize an interviewer-administered questionnaire, and 2. structured interviews were conducted with a sample of 50 bisexual men using this questionnaire. Participants self-reported a wide range of sexual behaviors and relationships. Findings have implications for future research and practice focusing on bisexual men in India, as well as their partners of all genders.

Perceived health concerns among sexual minority women in Mumbai, India: an exploratory qualitative study.

The experiences of sexual minority women (i.e., women who do not identify as 'heterosexual') in India have largely been absent in scientific literature. In partnership with India's oldest and largest sexual and gender minority-advocacy organisation, the Humsafar Trust, our study used community-based participatory research principles to explore the lived experiences and health concerns of sexual minority women in Mumbai. Study methodologies included interviews with key informants, a focus group comprised of six women, and an additional 12 in-person interviews with sexual minority women to identify important physical, mental, social and other health priorities from these women's perspectives. Thematic data are organised within the framework offered by the social ecological model, including individual, interpersonal, micro and macro levels. Findings from this study are important in providing the groundwork for future research and intervention involving sexual minority women in India, a dramatically underserved population.

The Utility of the Two-Step Gender Measure Within Trans and Cis Populations.

It has been acknowledged that more research into the health and well-being of trans people is needed in order to identify important health issues. While recent studies have suggested using a two-question gender status measure to assess assigned sex at birth and gender identity, it is not well understood how participants understand and subsequently answer the questions. The study recruited a convenience sample of 50 people (25 trans and 25 cis) from the general population of Cleveland and Akron, OH. The study used cognitive interviewing methods with scripted, semi-structured and spontaneous probes when appropriate. Participants were asked to read questions out-loud, answer the questions, and explain why they answered the way they did. Interviews were audio recorded and transcribed prior to analysis. The gender status questions were found to be easy to use and understood by both trans and cis participants. The two-question gender status measure was able to encompass a diversity of identities within a trans sample and be consistently answered by the study's cis participants. The measures were able to differentiate between trans and cis groups. The two-step gender measure can be a useful tool in examining gender diversity within general population studies.