The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health

Voices and visions: Navigating the landscape of sexual, reproductive, and maternal health and rights in Latin America and the Caribbean: A stakeholder mapping and analysis

This article presents the results of a mapping and analysis of key stakeholders operating in the field of Sexual, Reproductive, and Maternal Health and Rights (SRMHR) who are involved in the entitlement of health rights and access to health services for women, adolescents, LGBTQI+ individuals, migrants, indigenous people, Afro-descendants, and people with disabilities in Latin America and the Caribbean. Our study focuses on Argentina, Colombia, Guatemala, Guyana, Jamaica, Mexico, and Peru. The primary objective was to identify and comprehensively categorise the activities undertaken by them, since their actions shape, and promote or hinder the SRMHR political agenda in the region. The findings of this mapping can be useful in contributing to the development of public policy strategies.

Unveiling lives: A glimpse into the daily routines of individuals affected by leprosy in Malaysia using the walk-and-talk technique

Leprosy, though curable, continues to present physical and psychosocial challenges for those affected. This study explored how individuals affected by leprosy in Malaysia navigated daily life, societal expectations, and personal challenges through the walk-and-talk technique, a participant-led qualitative approach that fostered spontaneous storytelling and reflexivity. By guiding researchers through their environments, participants shaped the narrative, shifting power dynamics and enabling authentic dialogue. Six participants from Kelantan and Selangor shared their everyday activities, aspirations, and coping strategies. Video documentation was used as a supplementary tool to capture non-verbal cues and contextual interactions. Visual, auditory, and field data were transcribed and thematically analysed using NVivo 12, revealing key themes, including resilience and perseverance, employment and economic sustenance, stigma, family support, and community engagement. Work emerged as central to their well-being, fostering dignity and providing financial stability. However, self-imposed stigma limited social inclusion, while strong familial and community bonds provided crucial support. These findings highlighted the effectiveness of the walk-and-talk technique in capturing rich qualitative data and emphasised the need for tailored interventions to address stigma, enhance social inclusion, and support the well-being and economic stability of individuals affected by leprosy.

Suicidal ideation among youth: Examining the intersections of multiple social positions and bias-based bullying

OBJECTIVE

Suicidal ideation is prevalent among minoritized youth. This study identified disparities in suicidal ideation across youth with intersecting social positions-including race and ethnicity, sex assigned at birth, gender, and sexual orientation-and examined the role of bias-based bullying (based on race and ethnicity, gender identity, or sexual orientation) related to these disparities.

METHOD

Data for this study were drawn from the 2017-2019 California Healthy Kids Survey, with a sample of 458,963 students in grades 9 through 12. Around half of the participants identified as Latina/x/o (50.4 %), 49 % were assigned female at birth, 93.7 % identified as cisgender, and 81.9 % identified as straight. Exhaustive Chi-squared Automatic Interaction Detection was used to analyze how rates of suicidal ideation vary among youth with intersecting social positions and multiple forms of bias-based bullying experiences.

RESULTS

Youth with intersecting minoritized social positions, particularly those with both minoritized sexual and gender identities, reported the highest rates of suicidal ideation in the past year (43.9 % to 63.3 %), three to four times higher than the overall sample rate (16.5 %). Furthermore, all youth in the highest prevalence groups of suicidal ideation experienced at least one form of bias-based bullying. Suicidal ideation rates were 26.3 % to 59.0 % higher among youth who experienced bias-based bullying compared to those with the same social positions who did not experience bullying.

CONCLUSION

Suicidal ideation is especially prevalent among youth with intersecting minoritized social positions who have also experienced multiple forms of bias-based bullying.

Utilizing an Intersectional Approach to Examine Experiences of Hunger Among Adolescents During COVID-19: Considering Race/Ethnicity, Sexual Identity, and Employment Disparities in a Nationally Representative Sample

PURPOSE

This study examines correlates of experiences of hunger among adolescents in the United States (U.S) by the intersectionality of race/ethnicity with sociodemographic characteristics (gender, sexual identity, and adolescent/parent job loss) with the aim of identifying subgroups most at risk for hunger during the COVID-19 pandemic.

METHODS

This cross-sectional study uses nationally representative data from the Adolescent Behaviors and Experiences Survey (ABES) collected from January to June 2021. The analytic sample was high school students aged 14-17 with complete data (n = 6023). Descriptive statistics, bivariate, and multivariate logistic regression models were used to examine associations between sociodemographic factors and hunger (1-item measure) among adolescents during the pandemic for the analytic sample and stratified by race/ethnicity.

RESULTS

The prevalence of hunger was 24.1% for the analytic sample and was highest among American Indian/Alaskan Native/Other Pacific Islander youth (37.2%), followed by non-Hispanic Black (31.8%) and Hispanic (28.4%) youth, and lowest among Non-Hispanic White youth (18.6%). In the analytic sample, there were significant differences in experiences of hunger by race/ethnicity, sexual identity, and adolescent/parent job loss during the pandemic (p < 0.05). When stratified by race/ethnicity, there were differential associations of hunger with sexual identity, and adolescent/parent job loss.

CONCLUSIONS

These findings provide evidence of differential experiences of hunger during the pandemic among adolescents by sociodemographic factors. Results highlight the need for taking an intersectional approach when examining issues such as hunger. Future policies and programs should be mindful of factors associated with hunger and should prioritize using an equity-informed approach when engaging with multiply-marginalized adolescents.

Silent suffering: the impact of sexual health challenges on patient-clinician communication and adherence to adjuvant endocrine therapy among Black women with early-stage breast cancer

PURPOSE

Adjuvant endocrine therapy (AET) increases sexual health challenges for women with early-stage breast cancer. Black women are more likely than women of other racial/ethnic groups to report adverse symptoms and least likely to initiate and maintain AET. Little is known about how sexual health challenges influence patient-clinician communication and treatment adherence. This study explores facilitators of and barriers to patient-clinician communication about sexual health and how those factors might affect AET adherence among Black women with early-stage breast cancer.

METHODS

We conducted 32 semi-structured, in-depth interviews among Black women with early-stage breast cancer in the U.S. Mid-South region. Participants completed an online questionnaire prior to interviews. Data were analyzed using thematic analysis.

RESULTS

Participants' median age was 59 (range 40-78 years, SD = 9.0). Adverse sexual symptoms hindered participants' AET adherence. Facilitators of patient-clinician communication about sexual health included female clinicians and peer support. Barriers included perceptions of male oncologists' disinterest in Black women's sexual health, perceptions of male oncologists' biased beliefs about sexual activity among older Black women, cultural norms of sexual silence among Southern Black women, and medical mistrust.

CONCLUSIONS

Adverse sexual symptoms and poor patient-clinician communication about sexual health contribute to lower AET adherence among Black women with early-stage breast cancer. New interventions using peer support models and female clinicians trained to discuss sexual health could ameliorate communication barriers and improve treatment adherence.

IMPLICATIONS FOR CANCER SURVIVORS

Black women with early-stage breast cancer in the U.S. Mid-South may require additional resources to address sociocultural and psychosocial implications of cancer survivorship to enable candid discussions with oncologists.

How intersectional identity and discrimination contribute to depressive symptoms and hair cortisol concentrations among low-income, racially and sexual diverse adults

Significant gaps remain in our understanding of how minority stress patterns health outcomes for adults at the intersection of ethnicity/ race and sexual orientation. In particular, little is known about how cumulative cortisol (measured via hair cortisol concentration as an indicator of chronic stress; HCC) and depressive symptoms are related to holding an intersectional minoritized identity (e.g., sexual minority people of color; SM-POC) and experiencing intersectional discrimination (e.g., heterosexism and racism). The current study examined the relationship between intersectional identity or discrimination and HCC or depressive symptoms. Participants were (N = 69) low-income, predominantly sexual minority and people of color in the Greater Los Angeles area. Participants completed self-report measures and provided a hair sample for cortisol assay. Intersectional identity was not associated with greater HCC or depressive symptoms. However, differences in HCC emerged based on discrimination type (F (2, 66) = 3.74, p = .03, η2= .10). Participants who reported intersectional heterosexism and racism had greater HCC concentrations (M = 30.71, SD = 29.71) than did participants who reported only a single type of discrimination (i.e., racism only or heterosexism only; M = 15.35, SD = 2.60, p = .03, 95 % CI = [2.01, 28.71]), or than participants who reported neither types (M = 12.40, SD = 16.11, p = .01, 95 % CI [4.85, 31.76]). There were no differences in depressive symptoms by discrimination type. These results provide initial empirical support to largely theoretical arguments about how to investigate mechanisms underlying disparities to understand why and how minority stress is patterned. Findings showing associations between intersectional discrimination and HCC, but not depressive symptoms, provide potential support for theories about examining allostatic load markers to identify stress-related etiological mechanisms linked to health disparities among minoritized populations.

Experiences of discrimination across the life course among pregnancy planners in the United States and Canada

Little is known about discrimination among pregnancy planners. We used questionnaire data from Pregnancy Study Online (PRESTO), a preconception cohort study, to characterize experiences, attributions, and responses to discrimination (n = 10,460). Eligible participants were assigned female at birth, aged 21-45 years, U.S. or Canadian residents, and not using contraception or fertility treatment. Participants completed a supplemental questionnaire (2013-2024) that included the Philadelphia Urban ACE Survey, Williams' Everyday Discrimination and Major Experiences of Discrimination scales, and Krieger's instrument on responses to discrimination. Mean age at enrollment was 30.9 years. Overall, 83.8 % of participants identified as non-Hispanic White, and 50.4 % had ≥17 years education. Discrimination across the life course varied: 11 % of participants reported childhood racial discrimination, 80.3 % reported ever experiencing everyday discrimination, and 47.2 % reported ever experiencing lifetime discrimination. The most prevalent types of everyday discrimination included being perceived as not smart (63.4 %) and being treated with disrespect (62.6 %), while job-related discrimination was the most frequently-reported lifetime experience (33.9 %). Most Black participants (non-Hispanic and Hispanic) reported their race or ethnicity as one of the main reasons they were discriminated against (87.7 % and 80 %, respectively), while sex or gender was most commonly-reported by other racial and ethnic groups (range: 75.9-82.4 %). Most participants responded passively to discrimination: keeping it to themselves and accepting it as a fact of life (37.4 %). All participants other than non-Hispanic White reported greater exposure to discrimination across the life course, and attributions for discrimination (e.g., race, gender, education, income level) varied across racial and ethnic groups.

Medical gendered racism and Black women's experiences of genito-pelvic pain/penetration disorder in the USA - A conceptual exploration

Medical gendered racism in the USA has been and continues to be a significant issue for Black women across various healthcare domains, including sexual and pelvic healthcare. The experiences of Black women with Genito-Pelvic Pain/Penetration Disorder, characterised by pain with sexual intercourse, are particularly understudied in relation to medical gendered racism. This paper advances existing research on Genito-Pelvic Pain/Penetration Disorder by employing Black feminist thought and intersectionality as theoretical frameworks. We seek to conceptualise how medical gendered racism impacts Black women's experiences with genito-pelvic pain and the quality of their healthcare. We offer a nuanced, culturally sensitive approach to doing so and to clinical practice, and provide actionable recommendations for healthcare professionals. This work aims to equip researchers and healthcare practitioners with the knowledge and tools to acknowledge, understand, and support effective treatment of genito-pelvic pain experienced by Black women in the USA.

Can nutrition-sensitive agriculture interventions address intersectional inequalities in women's diets? A mediation analysis using cross-sectional trial data from Odisha, India

BACKGROUND

Improving nutrition for all requires understanding how interventions influence nutrition inequalities within society. Intersectionality, which considers how multiple disadvantages intersect, may offer more precise insight into the equity of these interventions.

OBJECTIVE

Using an intersectionality-informed approach and mediation with exposure-mediator interaction, we investigated how participation in nutrition-sensitive agriculture interventions tested in the 'UPAVAN' trial affected inequalities in women's diets in Odisha, India.

METHODS

We analysed cross-sectional endline data from 3,294 mothers of children aged 0-23 months in 111 UPAVAN intervention villages. We estimated dietary inequalities as excess relative risk of minimum dietary diversity (MDD-W) according to Scheduled Tribe identity (ST, non-ST), education (≥5, <5 years), or wealth (higher, lower), and comparing intersectional groups that combine ST/non-ST with education or wealth group. We used a 4-way decomposition to estimate whether these MDD-W inequalities were affected by social group differences in: intervention participation rates (mediation only), participation benefits (interaction only), or both combined (mediated interaction).

RESULTS

Intervention participation and MDD-W were greater among the more advantaged groups of non-ST, higher education, or higher wealth. Often, the more disadvantaged groups had greater participation benefits (interaction only), which narrowed MDD-W inequalities. However, intersectional groups with two disadvantaged characteristics (e.g., poorer ST) had smaller participation benefits than those with one (e.g., wealthier ST), which widened MDD-W inequalities. Differences in participation rates had negligible effects on MDD-W inequalities. Often, any marginal widening of MDD-W inequalities due to disadvantaged groups participating less (mediation only) was suppressed by their greater participation benefits (mediated interaction).

CONCLUSION

To our knowledge, this is the first intersectionality-informed analysis of nutrition interventions. UPAVAN interventions mostly had equitable impacts, reducing several inequalities in maternal diet quality. We demonstrate how intersectionality-informed analyses can help identify inequities in nutrition interventions and inform the design of inclusive interventions that reach and benefit the most marginalised groups.

What can we learn from an intersectionality-informed description of study participants? Results from the German National Cohort

BACKGROUND

Intersectionality has contributed to novel insights in epidemiology. However, participants of epidemiological studies have rarely been characterised from an intersectional perspective. We aimed to show the gained insights of an intersectionality-informed approach to describing a study population by comparing it to a conventional approach.

METHODS

We used data of the German National Cohort (NAKO), which recruited 205,415 participants between 2014 and 2019. In the conventional approach, marginal proportions of educational level, cohabitation status, and country of birth were compared between the study populations of the NAKO and the German census survey (MZ) of 2014. In the intersectionality-informed approach, so-called intersectional population strata were constructed by cross-classifying educational level, cohabitation status, and country of birth. Proportions of these strata were also compared between NAKO and MZ. All analyses were stratified by sex and age group.

RESULTS

The conventional approach showed that the proportion of people with low education was lower in the NAKO compared to the MZ in all sex and age strata. Similarly, proportions of all intersectional population strata with low education were lower in the NAKO. Concerning cohabitation, the conventional approach showed that the proportion of those living without a partner was lower in the NAKO than in the MZ for women under 60 and men. The intersectionality-informed approach revealed that the proportions of some subgroups of those living without a partner were higher in the NAKO than in the MZ. These were intersectional population strata who lived without a partner, had a high level of education and were born in Germany. The intersectionality-informed approach revealed similar within-group heterogeneity for country of birth, showing that not all proportions of foreign-born people were lower in the NAKO compared to the MZ. Proportions of foreign-born with high education who lived with a partner were higher.

CONCLUSIONS

Our results showed that heterogeneity within social categories can be revealed by applying the concept of intersectionality when comparing study participants with an external population. This way, an intersectionality-informed approach contributes to describing social complexity among study participants more precisely. Furthermore, results can be used to reduce participation barriers in a more targeted way.

Study protocol for the Rainbow Austrian Longitudinal Family (RALF) study: a longitudinal, multi-method, multi-rater investigation of risk and resilience factors in Austrian LGBTQ+ parent families

BACKGROUND

Research on LGBTQ+ parent families is evolving to include a growing range of family systems, identities, methodologies, and topics. However, studies that examine minority-specific risk and resilience factors and their associations with within-family processes remain scarce, particularly outside a US-American context. Addressing these research gaps quantitatively poses challenges for researchers, because traditional modelling techniques based on (generalized) linear models are not ideally suited to capture the complexity and intersectionality of family experiences. Within this study protocol, we introduce the Rainbow Austrian Longitudinal Family (RALF) study. Its main goal is to comprehensively investigate general and minority-specific factors that affect the well-being of LGBTQ+ parent family members in Austria.

METHODS

RALF is a three-wave, longitudinal study over two years that examines risk and resilience factors at the individual, couple, and family level using a multi-method, multi-rater approach. We will assess child adjustment outcomes across three child cohorts, parental mental health, and family processes across three annual data waves through online questionnaires. We aim to recruit N = 150 LGBTQ+ parent families from a variety of family forms and with various identities residing in Austria. A focal sample (target n = 60) will additionally participate in observational, video-based assessments. Our participatory research approach aims to actively engage community members and stakeholders throughout the study. A community advisory board ensures that the study reflects the lived experiences of LGBTQ+ parent families adequately, while community events and accessible dissemination strategies for study results, such as the open access data explorer ExploRALF, support community engagement and facilitate the dissemination and discussion of results. Data will be analyzed using machine learning-based approaches designed to capture complex, non-linear interactions, which are ideally suited to model intersectional experiences of LGBTQ+ parent families.

DISCUSSION

The RALF study is the first prospective study to comprehensively investigate minority-specific risk and resilience factors in Austrian LGBTQ+ parent families. Findings have the potential to fill key research gaps, inform policy, and guide clinical practices that support LGBTQ+ parent families.

Development and Pilot Testing of an Addiction Clinic-Based Pre-Exposure Prophylaxis Uptake and Adherence Intervention for Women with Substance Use Disorders: Protocol for a Pilot Randomized Trial

BACKGROUND

Black and Hispanic women in the United States continue to bear disproportionate incidence of HIV related to sexual transmission and injection drug use. Specifically, women with substance use disorders (SUDs) are more likely to engage in vaginal or anal condomless sex associated with HIV transmission. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool but is not widely used by racial or ethnic minority women. Effective interventions for engaging women with SUDs in HIV prevention interventions that are culturally appropriate and, therefore, more appealing to racial or ethnic minority women with SUDs are critically needed.

OBJECTIVE

This 3-phased study, including a pilot randomized controlled trial (RCT), will assess the initial efficacy, feasibility, and acceptability of an addiction clinic-based behavioral and PrEP services intervention to increase the uptake and adherence to PrEP among racial or ethnic minority women.

METHODS

A 3-phased mixed methods research design will involve formative qualitative methods using thematic analysis to design the intervention (phase 1), theatre testing to adapt and refine the intervention (phase 2), and RCT methods to pilot test the intervention for efficacy, feasibility, and acceptability (phase 3). The pilot RCT will enroll and randomize 60 women to either the standard SUD treatment program or SUD treatment integrated with PrEP services. The addiction clinic-based behavioral intervention will include 4 motivational counseling sessions guided by the Information-Motivation-Behavioral Skills Model to increase the uptake of PrEP. A mobile health app will be used to engage participants with the intention of motivating PrEP initiation and supporting adherence to PrEP. Following phase 3, generalized linear modeling will be used to model effects of the proportion of participants who fill their prescription and take at least 1 dose as a function of the intervention group.

RESULTS

Findings from individual qualitative interviews informed the development of the addiction clinic-based behavioral intervention. Study recruitment for the randomized pilot (phase 3) launched in May 2024. Additional statistical analyses will be performed upon completion of the study.

CONCLUSIONS

This addiction clinic-based behavioral intervention aims to increase PrEP uptake and adherence among racial or ethnic minority women who engage in sexual and substance use behaviors associated with increased susceptibility to HIV transmission. The addiction clinic-based behavioral intervention has the potential to reduce HIV-related disparities among Black and Hispanic women with SUDs. Findings from this study will provide a foundation for future HIV prevention interventions for racial or ethnic minority women with SUDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06158607; https://clinicaltrials.gov/study/NCT06158607?term=NCT06158607&rank=1.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64961.

Mental health and the role of social support in the lives of vulnerabilized sexual minority women

INTRODUCTION

Sexual minority women (SMW; women who self-identify as lesbian, queer, etc., as well as heterosexually-identified women who experience attraction to romantic or sexual partnerships with women) and vulnerabilized women (those marginalized due to structural forces such as housing insecurity, violence, sex exchange, drug use, or HIV positive status) experience a range of mental health challenges compared to their heterosexual and general population counterparts. General populations studies show a positive relationship between social support and mental health; less is known about SMW experiencing intersecting multi-layered vulnerabilities. This study characterizes mental health stressors, identifies social support sources and forms, and explores the relationship between social support and mental health among vulnerabilized SMW in Baltimore, MD.

METHODS

We conducted virtual, in-depth semi-structured interviews with vulnerabilized cisgender SMW (n = 25) between June and October 2021. We utilized an inductive analytical approach to identify central themes and develop a categorization structure. Results are presented using narrative synthesis and illustrative quotes. To understand different forms of mental health-related social support provided across sources, data was sorted into a matrix and analyzed.

RESULTS

Vulnerabilized SMW commonly self-reported depression and anxiety. Participants identified three primary mental health stressors: 1) managing identity-related stigma; 2) relationships, loss, and isolation; and 3) financial struggles. The most important type of social support for mental health was non-judgement related to sexual orientation and/or mental health struggles. Family, friends, and partners were providing similar amounts of support, primarily emotional support.

DISCUSSION

Vulnerabilized SMW have unique mental health and social support-related experiences and needs, potentially attributed to experiences with multiple marginalization, compounded by struggles with intersecting structural vulnerabilities. More research is warranted to explore different sources and forms of social support as predictors of mental health. Findings indicate need for public health interventions that address sexual orientation and mental health stigma.

Correlates of longitudinal patterns of racial discrimination in midlife and older Black adults: Evidence from the health and retirement study

OBJECTIVE

Single cross-sectional discrimination measures may mask dynamic patterns of cumulative experiences and exposure to racial discrimination. However, there is a dearth of studies assessing trajectories of racial discrimination, particularly among midlife and older Black adults in the United States. The study aims to identify trajectories of racial discrimination over 12 years. We also examine the association between sociodemographic characteristics and resilience resources with racial discrimination trajectories.

METHODS

Using data from the Health and Retirement Study (2006-2020), repeated measures latent profile analysis was employed to identify racial discrimination trajectories among Blacks aged 50+ (N = 1710). Multinomial logistic regression examined the association between sociodemographic and resilience resources with racial discrimination trajectories.

RESULTS

Three racial discrimination trajectories were identified: low-stable (70 %), moderate (23 %), and persistently high and increasing (7 %). Individuals reporting higher levels of major lifetime experiences of discrimination and greater neighborhood social cohesion were associated with membership in the "moderate" and the "persistently high and increasing" racial discrimination trajectory groups. Those reporting positive social support and psychological resilience were less likely to be in the "moderate" or the "persistently high and increasing trajectory" groups.

CONCLUSIONS

These findings suggest heterogeneity in the cumulative patterning of racial discrimination among midlife and older Black adults. Racial discrimination trajectories may enable greater precision in estimating the health consequences of cumulative exposure to discrimination. Future studies are warranted to determine whether membership in specific discrimination trajectory groups confers differential risk to age-related conditions.

Intersectional Impact of Allosexism Experiences on Non-Suicidal Self-Injury Among Asexual Youth

PURPOSE

Asexual youth encounter significant challenges concerning mental and behavioral health, including non-suicidal self-injury (NSSI). However, limited research has examined how experiences of allosexism impact sexual and gender minority youth, their engagement in NSSI, and the mechanisms underlying these relationships. This study aims to investigate the intersectional effects of allosexism experiences on NSSI among asexual youth.

METHODS

A moderated mediation analysis was conducted using data from the 2021 Ace Community Survey (N = 5559), an international online survey exploring allosexism experiences among asexual individuals. Sociodemographic characteristics and key variables were compared between cisgender and transgender and gender non-conforming (TGNC) subsamples. We also assessed indirect effects through emotional impairment and social isolation and examined whether TGNC identity moderated these associations.

RESULTS

Asexual TGNC youth reported significantly higher levels of allosexism experiences, emotional impairment, social isolation, and NSSI compared to cisgender respondents. Allosexism experiences positively influenced NSSI via emotional impairment and social isolation, with the indirect effect through social isolation moderated by gender identity. However, moderation effects regarding emotional impairment and NSSI were not significant.

DISCUSSION

Enhanced efforts are necessary to promote the mental health and overall well-being of asexual youth. Future research, practices, and policies should consistently incorporate intersectional perspectives to effectively address health disparities and advocate strongly for sexual and gender diversity.

Intersecting gender, ethnicity, and sexual orientation identities and HIV stigma: results from the People Living with HIV Stigma Index study in three provinces in Canada

Stigma remains a significant burden for people living with HIV and while studies have examined the impacts of gender, ethnicity, and sexual orientation on stigma separately, little is known about how these factors may intersect and potentially exacerbate levels of stigma. This study examines how these intersecting social positions may relate to levels of internalised, enacted and anticipated HIV stigma. Participants were recruited in Ontario, Alberta, and Québec (n = 1040) as part of the People Living with HIV Stigma Index study in Canada. Three-way interaction models were constructed by creating interaction terms from the product of gender, ethnicity, and sexual orientation variables that predicted each type of stigma. Levels of internalised, enacted and anticipated stigma were consistent across most intersecting groups; however, people occupying certain intersections experienced significantly higher levels of stigma. Three-way interaction analyses showed that for internalised stigma, people at the intersection of African/Caribbean/Black, lesbian, cis-women identities had significantly higher scores (b = 0.90, p = 0.06), while people at the intersection of Indigenous, lesbian, and cis-women identities had higher scores for enacted stigma (b = 1.21, p = 0.01) compared to the White, heterosexual, cis-men reference group. Interventions designed for populations that take intersectionality into account may be effective in reducing HIV stigma, although more quantitative intersectionality work must be done to understand these implications fully.

Sexual Orientation and Internalized Homophobia of Middle Aged and Older Gay and Lesbian Adults: The Role of Social Relationships

OBJECTIVES

Research is needed about the role of families in relation to issues faced by middle-aged and older gay and lesbian adults, such as internalized homophobia and families of choice. This study examines how families of choice and families of origin shape experiences of internalized homophobia in midlife and older gay and lesbian adults, a population uniquely affected by the cumulative effects of societal stigma over the life course.

METHODS

We sampled 409 adults aged 50+ (range: 50-85) who self-identify as lesbian women or gay men. They answered a questionnaire about families of choice, families of origin, and internalized homophobia. Mediation models examined the role of families in the association of gender and internalized homophobia.

RESULTS

Lesbian women reported lower internalized homophobia compared to gay men, and this was partially explained by their greater likelihood of citing spouses/partners and children as close others. Friends in one's family of choice were not associated with gender or internalized homophobia. Men were more likely to cite close siblings, and this was related to lower internalized homophobia, although siblings did not mediate the association of gender and internalized homophobia.

DISCUSSION

Higher internalized homophobia of gay men in later life might be partially explained by being less likely to have a spouse/partner and children, reflecting cumulative effects of lifelong discrimination and stigma. These findings could foster better interventions aimed at specific needs of aging men and women from sexual minorities, considering their life course experiences and social resources.

Understanding the intersections between ethnicity, area-level deprivation, and inpatient-related features amongst patients with psychotic disorders: a mental health electronic records analysis

PURPOSE

Ethnic and area-level deprivation disparities in psychiatric inpatient outcomes amongst patients with psychotic disorders are known. However, how these two variables intersect to influence features of inpatient care is unclear. We investigated this intersection.

METHODS

Using de-identified electronic health data from inpatient services at a large south London mental healthcare provider, we identified a sample of 6767 working-age patients with non-affective psychotic disorders who were admitted between 2016 and 2019. Logistic and negative binomial regressions were used to examine the relationships between ethnicity (and then deprivation) with inpatient-related features (compulsory admission, psychiatric intensive unit admission, length of stay and number of admissions), adjusting for confounders. The sample was stratified by area-level deprivation to understand the intersection of ethnicity, deprivation and these inpatient-related features.

RESULTS

Patients from all areas except the least deprived were at greater risk of compulsory admission, admission to psychiatric intensive care units and more frequent admissions compared with patients from the least deprived areas. All minoritised ethnic patients were more likely to be compulsorily admitted compared with White British patients. Living in the least deprived areas appeared to offer protection against compulsory admission for some ethnic minority groups, but not Black British or Asian patients.

CONCLUSIONS

This study showed how psychiatric inpatient-related features for patients with non-affective psychotic disorders were explained not only by the separate effects of area-level deprivation and ethnicity but also by the unique intersections of these two factors. Our findings have implications for policy and interventions aimed at reducing the drivers of inpatient admissions by addressing social stressors in deprived areas and among ethnic minority patients.

Racial, Ethnic, and Sex Differences in Need and Receipt of Support for Social Needs Among Veterans

Importance

Health-related social needs, downstream manifestations of social determinants or drivers of health, impact patients' health and well-being. To develop equity-driven social care interventions, health care systems must apply an intersectional equity lens when assessing patients' social needs.

Objective

To evaluate racial, ethnic, and sex differences in social needs and receipt of support among veterans receiving health care in the Veterans Health Administration (VHA).

Design, Setting, and Participants

A cross-sectional survey study of VHA primary care patients seen in January or February 2023 was carried out in a national sample of veterans, stratified by race and ethnicity (Black, Hispanic, White), and sex (male, female). Participants were invited by mail to complete a survey online or by mail. Of those invited (N = 38 759), 7095 (18.3%) responded. Data collection occurred from March 2, 2023, through May 9, 2023. Analyses were conducted from February 15, 2024, through July 16, 2024.

Exposures

Intersection of self-identified race, ethnicity, and sex.

Main Outcomes and Measures

Age-adjusted prevalence ratio (aPR) of reported need for and receipt of support across 13 social need domains.

Results

Analyses included 6611 respondents representing 939 467 veterans (unweighted No. of participants [weighted %]; 1089 [4.1%] Black women; 1144 [19.4%] Black men; 941 [1.6%] Hispanic women; 1281 [11.3%] Hispanic men; 805 [5.3%] White women; 1351 [58.4%] White men). After age adjustment, compared with White men, Black men had significantly higher aPRs of need for support in all domains except childcare and employment (aPRs ranged from 1.35 [95% CI, 1.09-1.69] for social isolation to 2.73 [95% CI, 1.89-3.95] for managing discrimination). Hispanic women had higher aPRs in 8 domains: childcare (aPR, 2.78; 95% CI, 1.19-6.48), discrimination (aPR, 2.69; 95% CI, 1.68-4.29), internet (aPR, 1.81; 95% CI, 1.17-2.79), housing (aPR, 1.81; 95% CI, 1.10-2.99), legal issues (aPR, 1.70; 95% CI, 1.02-2.84), loneliness (aPR, 1.67; 95% CI, 1.28-2.18), food (aPR, 1.55; 95% CI, 1.03-2.35), and social isolation (aPR, 1.40; 95% CI, 1.05-1.87). Black women had higher aPRs for discrimination (aPR, 2.68; 95% CI, 1.82-3.95), legal issues (aPR, 2.04; 95% CI, 1.40-2.97), food (aPR, 1.74; 95% CI, 1.28-2.37), loneliness (aPR, 1.60; 95% CI, 1.28-2.01), paying for basics (aPR, 1.57; 95% CI, 1.15-2.14), and social isolation (aPR, 1.48; 95% CI, 1.18-1.87). Hispanic men had higher aPRs for housing (aPR, 1.88; 95% CI, 1.18-3.02), legal issues (aPR, 1.81; 95% CI, 1.14-2.86), internet (aPR, 1.56; 95% CI, 1.13-2.16), and loneliness (aPR, 1.44; 95% CI, 1.10-1.88). White women had higher aPRs for childcare (aPR, 3.37; 95% CI, 1.36-8.35) and discrimination (aPR, 1.60; 95% CI, 1.03-2.50). There was 1 significant difference in receiving support: Black women had a lower prevalence of receiving support for work (aPR, 0.58; 95% CI, 0.35-0.94).

Conclusions and Relevance

This study found that there was wide variation in the health-related social need domains in which VHA race, ethnicity, and sex subpopulations reported needing support. Applying an intersectional lens when evaluating social needs lays the groundwork for equity-guided social care interventions in the VHA.

An Empirical Investigation of Disability-Related Interpersonal Violence Through an Intersectional Research Paradigm: Methodological Considerations and Implications

The study uses an econometric approach to disaggregate data on disability-related violence reported in Accident and Emergency departments in London to investigate the extent to which the intersections of gender, ethnicity, and age characteristics of disabled people increase their risk of experiencing interpersonal violence. Our empirical findings suggest that females and older individuals are generally more likely to be interpersonal violence victims. The disability dummy is positive and significant, irrespective of gender or ethnicity. This implies that persons with disabilities are more likely to be victims of interpersonal violence than individuals without disabilities, regardless of gender and ethnicity. The most important discovery concerns the magnitude of the dummy coefficient regarding the disability of individuals. The coefficient is the largest for females of Black origin with disabilities, followed by Asians, with white origin exhibiting the smallest coefficient. This suggests that people with disabilities of Black origin are more likely to experience interpersonal violence than the Asian or white community. The study outcomes provide novel and rigorous empirically validated knowledge of the intersectional vectors of power that impact the risk of experiencing disability-related interpersonal violence while informing the development of intersectionality-based policy approaches to tackling disability-related interpersonal violence.

The Role of Friendship in Mediating and Moderating the Relationship Between Exposure to Gendered Racism and Mental Health among Young Women of Color

Young women of color frequently face discrimination, reflecting the intersecting societal influences of sexism and racism. Although friendships play a significant role in women's lives, there is a lack of research on the role of friendships in navigating exposure to gendered racial discrimination (in-person and social media) and associated mental health. This study investigated the extent to which the content of friendship conversations (i.e., co-rumination against gendered racism, socializing messages related to gendered racial pride and empowerment and oppression awareness) and perceived friendship intimacy and support mediated or moderated the positive association between exposure to gendered racism and mental health. Co-rumination was tested as a mediator, while the other variables were examined as moderators. Online survey data were collected from 339 cisgender women aged 18-24 (M age = 20.90, SD = 1.96; 32.74% Asian, 33.92% Black, and 33.33% Hispanic or Latina; 68.14% identified as straight or heterosexual). Participants described friendship communications and perceived intimacy and support with a same gender and race close friend. Exposure to gendered racial discrimination was significantly associated with depressive and anxiety symptoms and substance use as a coping mechanism. Co-rumination about gendered racism was positively correlated with depressive and anxiety symptoms. Conversely, pride and empowerment socialization was negatively associated with substance use for coping, while oppression awareness socialization was positively correlated with depressive and anxiety symptoms. Structural Equation Modeling Analyses indicated that co-rumination partially mediated the relationship between gendered racism exposure and anxiety symptoms, with other friendship indices not moderating these associations. These findings highlight co-rumination about gendered racism as a risk factor for young women of color and underscore the importance of exploring how the multifaceted nature of friendships is associated with exposure to gendered racism and mental health.

Direct and indirect pathways linking gentrification to adolescent reading and math achievement via educational aspirations and psychological distress

This study examined how living in a gentrifying neighborhood may impact adolescents' reading and math achievement via educational aspirations and psychological distress and asked whether these pathways differ according to socioeconomic status and race. A framework combining theories of adolescent development and neighborhood effects was empirically tested using a racially diverse sample of adolescents living in urban neighborhoods in North Carolina matched to administrative school records and census data (N = 1,045, Mage = 12, 8% American Indian, 4% Asian, 32% Black, 62% White, 15% multiracial, 16% Latinx, categories not mutually exclusive). At the population level, structural equation models found no relation between the extent of gentrification occurring in youths' neighborhood of residence and reading and math achievement, educational aspirations, or psychological distress. However, moderated mediation models revealed a positive association between gentrification and psychological distress among youth with low (but not high) subjective family economic status, leading to a small negative indirect effect of gentrification on math achievement. The link between gentrification and increased psychological distress was largest among Black youth with low subjective family economic status, who may face both heightened racism and classism-related social stressors as their neighborhood gentrifies. Findings have theoretical and policy implications, as they challenge the assumption that living in proximity to higher income, higher educated peers will benefit youth from disadvantaged neighborhoods. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

An Almost Empty Scoping Review: State of the Research on Tobacco Prevention and Cessation Messaging Strategies for Black and/or Latine LGBTQ+ Youth and Young Adults

Research has yet to offer strong recommendations for effective tobacco prevention and cessation messaging that can reduce tobacco-related health disparities among Black and/or Latine LGBTQ+ youth and young adults. As a result of predatory marketing strategies and community stressors, among other factors, LGBTQ+ youth and young adults use tobacco products at higher rates than their non-LGBTQ+ peers. These disparities are uniquely complex among Black and/or Latine youth and young adults within the LGBTQ+ community, but there has been little research addressing the communication strategies that can promote tobacco prevention and cessation for these groups. Given the promise and history of successful health communication campaigns for tobacco control, this research is crucial. We thus conducted a scoping review to identify trends and gaps in the empirical research published from 2002-2022 that analyzed tobacco prevention and cessation communication strategies for Black and/or Latine LGBTQ+ youth and young adults (ages 12-30) living in the United States. Despite an initial search query of 3,182 articles after deleting duplicates, only five articles were eligible for inclusion, three of which evaluated the This Free Life campaign. Accordingly, we view our scoping review as an almost empty review. Although our results offer preliminary insight into messaging strategies used in these campaigns, our larger contribution is to expose the scarcity of tobacco-related communication research being conducted among Black and/or Latine LGBTQ+ communities. Given the marginalization these communities face, we issue a call to action for researchers and campaign designers and offer a series of suggestions for future research.

Health insurance, race, and receipt of a postpartum visit among patients giving birth in a referral hospital in the US South

BACKGROUND

The United States faces a maternal mortality crisis with stark and unacceptable disparities. Postpartum care (PPC) is crucial for identifying and managing complications after childbirth. However, access to PPC is inconsistent, especially for marginalized individuals such as Black birthing people and Medicaid beneficiaries. We examined the effect of the intersection of race and insurance type on the patients' receipt of postpartum care (PPC) in a large referral hospital in the Southeast US.

METHODS

In this cross-sectional retrospective cohort study, we analyzed data from electronic health records for 14,531 people who gave birth from January 2014 to March 2020 in a labor and delivery unit caring for more than 4000 births per year in the Southern US. Variables included race/ethnicity, insurance status, maternal age, number of living children, mode of delivery, and presence of chronic conditions. We produced descriptive statistics and used multivariable log-binomial models to estimate adjusted risk ratios (RR) for receiving PPC, including interaction terms between race and insurance.

RESULTS

In a retrospective analysis of electronic health records of 14,531 patients who gave birth in a large health system in the US South, 53.0% of patients received a clinic-based PPC visit. Having private insurance, compared to Medicaid insurance, was associated with a higher likelihood of receiving clinic-based PPC but a lower likelihood of visiting the Maternity Evaluation Unit, a special unit for urgent or emergency care.

CONCLUSION

Type of insurance is associated with receipt of postpartum care. Disparities in PPC are modestly influenced by the interaction between race and insurance type. Private insurance, as compared to Medicaid insurance, increases the likelihood of postpartum care across all racial groups with some differences in this relationship by race/ethnicity. Next steps should include qualitative research that helps us better understand the differences in receipt of PPC by insurance coverage and the interactions between insurance status and race. Implementation research should also test practical strategies to increase access to postpartum care, particularly for Medicaid-insured and other marginalized individuals.

Overexposed and Understudied: Environmental Risks Among Older Adults Experiencing Homelessness in Phoenix, Arizona

Individuals experiencing homelessness are highly vulnerable to urban environmental hazards, such as heat and air pollution, due to a lack of stable housing and limited access to indoor or cooled spaces. These risks are heightened for older adults and individuals with preexisting health conditions. With intensifying summer heat in the American Southwest and the persistence of urban homelessness, this study explores how older adults experiencing homelessness in Phoenix, Arizona perceive and interact with heat and air pollution as well as the adequacy of available coping resources and information. A survey was co-produced with community members with lived experience. A sub-group of community members assisted in proctoring the surveys among adults 55 and older at a downtown service agency. Survey results informed the location of data collection using MaRTy-a mobile biometeorological cart-and remotely sensed fine particulate matter (PM2.5). Findings reveal that heat and air pollution significantly influence travel decisions and contribute to health issues for many respondents. Midday and evening thermal radiation levels regularly exceeded safe thresholds, while PM2.5 concentrations often surpassed annual air quality guidelines, though they posed less acute health risks. Most participants reported awareness of health risks and employed strategies to reduce exposure. However, many expressed that city-level, public resources are insufficient to prevent heat- and air pollution-related health issues. Findings underscore the need for targeted interventions-such as better access to transportation and essential healthcare and extended hours of operation for service providers-to enhance resource accessibility and mitigate environmental health risks for vulnerable populations.

Adolescent Dating Violence and Suicide Planning Among Girls in US High Schools: An Intracategorical Intersectional Analysis by Race and Ethnicity

Objectives. To examine associations between adolescent dating violence (ADV) and suicide planning among girls and differences by race/ethnicity. Methods. Data were from the 2021 Youth Risk Behavior Survey (YRBS), a cross-sectional, nationally representative study of 9th- to 12th-grade adolescents from US high schools (n = 3886). We used weighted logistic regression to examine associations between ADV and suicide planning and assess moderation by race/ethnicity. Results. Compared with girls who did not experience any ADV, girls who experienced both physical and sexual ADV had greater odds of making a suicide plan (adjusted odds ratio [AOR] =  5.35; 95% confidence interval [CI] =  3.27, 8.74), and the effect size was larger than for experiencing either type of ADV alone. The relationship between sexual ADV and suicide planning was exacerbated for Latina girls (AOR =  6.36; 95% CI =  3.96, 10.19) compared with White girls (AOR =  2.51; 95% CI =  1.45, 4.35). Conclusions. Experiencing any form of ADV increases the odds of suicide planning among girls, with stronger impacts for Latina girls experiencing only sexual ADV. Public Health Implications. Prevention of suicide planning for Latina girls who experience sexual ADV may be strengthened by integrating contextually tailored suicide prevention into prevention programs addressing healthy relationships and prevention of sexual violence. (Am J Public Health. Published online ahead of print May 1, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308043).

Intersectional and Marginal Debiasing in Prediction Models for Emergency Admissions

Importance

Fair clinical prediction models are crucial for achieving equitable health outcomes. Intersectionality has been applied to develop algorithms that address discrimination among intersections of protected attributes (eg, Black women rather than Black persons or women separately), yet most fair algorithms default to marginal debiasing, optimizing performance across simplified patient subgroups.

Objective

To assess the extent to which simplifying patient subgroups during training is associated with intersectional subgroup performance in emergency department (ED) admission models.

Design, Setting, and Participants

This prognostic study of admission prediction models used retrospective data from ED visits to Beth Israel Deaconess Medical Center Medical Information Mart for Intensive Care IV (MIMIC-IV; n = 160 016) from January 1, 2011, to December 31, 2019, and Boston Children's Hospital (BCH; n = 22 222) from June 1 through August 13, 2019. Statistical analysis was conducted from January 2022 to August 2024.

Main Outcomes and Measures

The primary outcome was admission to an in-patient service. The accuracy of admission predictions among intersectional subgroups was measured under variations on model training with respect to optimizing for group level performance. Under different fairness definitions (calibration, error rate balance) and modeling methods (linear, nonlinear), overall performance and subgroup performance of marginal debiasing approaches were compared with intersectional debiasing approaches. Subgroups were defined by self-reported race and ethnicity and gender. Measures include area under the receiver operator characteristic curve (AUROC), area under the precision recall curve, subgroup calibration error, and false-negative rates.

Results

The MIMIC-IV cohort included 160 016 visits (mean [SD] age, 53.0 [19.3] years; 57.4% female patients; 0.3% American Indian or Alaska Native patients, 3.7% Asian patients, 26.2% Black patients, 10.0% Hispanic or Latino patients, and 59.7% White patients; 29.5% admitted) and the BCH cohort included 22 222 visits (mean [SD] age, 8.2 [6.8] years; 52.1% male patients; 0.1% American Indian or Alaska Native patients, 4.0% Asian patients, 19.7% Black patients, 30.6% Hispanic or Latino patients, 0.2% Native Hawaiian or Pacific Islander patients, 37.7% White patients; 16.3% admitted). Among MIMIC-IV groups, intersectional debiasing was associated with a reduced subgroup calibration error from 0.083 to 0.065 (22.3%), while marginal fairness debiasing was associated with a reduced subgroup calibration error from 0.083 to 0.074 (11.3%; difference, 11.1%); among BCH groups, intersectional debiasing was associated with a reduced subgroup calibration error from 0.111 to 0.080 (28.3%), while marginal fairness debiasing was associated with a reduced subgroup calibration error from 0.111 to 0.086 (22.6%; difference, 5.7%). Among MIMIC-IV groups, intersectional debiasing was associated with lowered subgroup false-negative rates from 0.142 to 0.125 (11.9%), while marginal debiasing was associated with lowered subgroup false-negative rates from 0.142 to 0.132 (6.8%; difference, 5.1%). Fairness improvements did not decrease overall accuracy compared with baseline models (eg, MIMIC-IV: mean [SD] AUROC, 0.85 [0.00], both models). Intersectional debiasing was associated with lowered error rates in several intersectional subpopulations compared with other strategies.

Conclusions and Relevance

This study suggests that intersectional debiasing better mitigates performance disparities across intersecting groups than marginal debiasing for admission prediction. Intersectionally debiased models were associated with reduced group-specific errors without compromising overall accuracy. Clinical risk prediction models should consider incorporating intersectional debiasing into their development.

From dialogue to action: Assessing best practices and actionable steps for oral health professions education clinical and learning environments

The American Dental Education Association (ADEA) embarked upon a path to broadly assess the clinical and learning environments across dental school and allied oral health programs. Assessing clinical learning environments has provided an important opportunity for gaining feedback from learners and team members about their experiences, responding to their needs on an intentional basis and forming context-specific understanding of and evidence for the impact of curriculum, pedagogical, and even patient care practices. This article presents key highlights of the overall usefulness of climate studies across higher education, corporate environments and health professions education. Moving from dialogue to action, it presents clear recommendations for moving forward and maximizing change efforts toward optimally inclusive, equitable, and ethically-centered oral health professions education clinical and learning environments.

"There's no real urgency when it comes to us": Critical discourse analysis of Black communities' lived experience with opioid overdose response in Indianapolis area

This study aims to examine how Black communities construct their discourses about opioid overdose response from lived experiences in the Indianapolis area. We randomly selected and analyzed 20 out of 50 interviews as data saturation was reached. Our analysis was informed by critical discourse analysis (CDA) and intersectionality as an overarching framework for the interpretation process. Each interview lasted about 60 min and consisted of ten open-ended questions. Participants were Black residents over 18 years old, who lived in four zip code areas in Indianapolis that had the highest rates of opioid overdose deaths in the city. The interviews revealed complex ways in which Black communities in Indianapolis navigated the opioid overdose crisis. The discourses on opioid overdose response are shaped by the intersectionality of various factors, including institutionalized racism, social discrimination, and fear of mistreatment. Moreover, the normalization of inadequate opioid overdose response is exacerbated by the stereotypes on Black communities, lack of access to resources and information, and historical mistrust in healthcare and law enforcement bodies. Our findings indicate that future intervention to reduce overdose deaths in the Black communities should move away from isolated approaches to holistic ones. These should encompass various intersecting factors, including structural racism, stigma of drug use, fear of mistreatment, lack of resources, and mistrust of law enforcement.

Race, Ethnicity, Sex, Sexual Orientation, and Discrimination in the Adolescent Brain Cognitive Development Study

Importance

Children are disproportionately exposed to sexual orientation-based discrimination and ethnic or racial discrimination due to intersections of sexual orientation, ethnicity, race, and assigned sex at birth. Yet, there is sparse evidence in clinical settings.

Objective

To investigate how social strata of sexual orientation, ethnicity, race, and assigned sex at birth intersect and are associated with experiences of sexual orientation-based discrimination and ethnic or racial discrimination.

Design, Setting, and Participants

This survey study included data retrieved from children enrolled in the Adolescent Brain Cognitive Development Study between 2016 and 2020. Children were recruited from 21 study sites across 17 states. Eligible participants were between ages 9 and 11 years at recruitment. Baseline data (2016-2018), first-year follow-up data (2017-2019), and second-year follow-up data (2018-2020) were included. Analyses were conducted between June and October 2024.

Main Outcomes and Measures

Logistic regressions were conducted to test the association between children's social strata indicated by intersections of sexual orientation, ethnicity, race, and assigned sex at birth and discrimination based on sexual orientation and ethnic or racial discrimination.

Results

Among 9854 children (mean [SD] age at baseline, 9.5 [0.5] years; 4582 girls [46.5%]; 202 Asian [2.0%], 1488 Black [15.1%], 2030 Latinx [20.6%], 906 multiple races [9.2%], 4921 White [49.9%]), White sexual minority girls reported the highest percentage of sexual orientation-based discrimination (113 of 312 [36.2%]). Ethnically or racially minoritized boys reported the highest percentage of ethnic or racial discrimination (41 of 174 [23.7%]). After accounting for covariates, ethnically or racially minoritized sexual minority girls were less likely to report sexual orientation-based discrimination compared with ethnically or racially minoritized heterosexual boys (odds ratio [OR], 0.60; 95% CI, 0.43-0.85). Ethnically or racially minoritized sexual minority boys (OR, 3.17; 95% CI, 1.71-5.88) and girls (OR, 2.09; 95% CI, 1.47-2.97) were more likely to report ethnic or racial discrimination compared with ethnically or racially minoritized heterosexual boys. Moreover, ethnically or racially minoritized sexual minority boys (OR, 3.39; 95% CI, 1.81-6.34) and girls (OR, 2.24; 95% CI, 1.56-3.21) were more likely to report ethnic or racial discrimination compared with ethnically or racially minoritized heterosexual girls.

Conclusions

In this survey study investigating experience of sexual orientation-based discrimination alongside ethnic or racial discrimination during late childhood, findings highlighted that intersections of sexual orientation, ethnicity, race, and assigned sex at birth contributed to disproportionate exposures to sexual orientation-based discrimination and ethnic or racial discrimination among children. These findings provide valuable insight into intersectional experiences of discrimination among children.

Discrimination and health: A cross-sectional study comparing Muslims with other-religious

AIMS

The aim of this study is to report perceived discrimination among Muslims living in Norway and to address and compare associations between perceived discrimination and health among Muslims with an immigrant background and other-religious with an immigrant background.

METHOD

A representative sample of individuals with an immigrant background in Norway was used in a cross-sectional study design that included 5484 respondents aged 16 to 74 years. The respondents were sub-grouped after religious affiliation, and as immigrants and Norwegian-born. This sample is from 'The Survey on living conditions among persons with an immigrant background 2016', conducted by Statistics Norway. Multivariate logistic regression analyses were conducted to investigate the relationship between perceived discrimination and self-rated health and between perceived discrimination and mental health problems.

RESULTS

Our findings show that Muslims with an immigrant background are more likely to report perceived discrimination than non-Muslims with an immigrant background. Perceived discrimination was associated with poor self-rated health and mental health problems among immigrant Muslims and Norwegian-born Muslims. Among other-religious with an immigrant background, perceived discrimination had an inverse relationship with mental health problems among immigrants, while an association between perceived discrimination and poor self-rated health was found among Norwegian-born.

CONCLUSIONS

Our findings suggest that perceived discrimination does play a role in health among minorities with an immigrant background in Norway, regardless of religion. However, the association between perceived discrimination and poor health seems to be stronger among Muslims, especially Norwegian-born Muslims.

Everyday discrimination and subclinical indicators of stroke in midlife women

Disparities between Black and White women in stroke risk in the United States are present during midlife, a period during which subclinical indicators of stroke risk accelerate in women. Racism and forms of discrimination have long been associated with cardiovascular pathophysiology. However, few studies have examined midlife discrimination among women and subclinical carotid atherosclerosis, a strong predictor of stroke and myocardial infarction. The Everyday Discrimination Scale, which measures discriminatory experiences, was administered to 304 (including 120 White and 76 Black) midlife women (mean age = 54, SD = 3.9) free of clinical cardiovascular disease. At the same visit, using ultrasonography, we measured four markers of subclinical carotid atherosclerosis, including plaque count, grey scale median, and maximum plaque height. The majority (85%) of women experienced at least one form of discrimination in their daily life. Black women reported experiencing greater discrimination than White women with a mean (SD) Everyday Discrimination Score of 7.3 (5.2) versus 5.7 (4.3). These experiences were most attributed to race, age, income, and "other." Black participants had a higher prevalence of carotid plaque compared to White participants (52% versus 46%). Using Poisson regression, higher discrimination was associated with higher plaque count among Black women only, adjusted for age, systolic blood pressure, low-density lipoprotein cholesterol, and education, such that one standard deviation increase in the Everyday Discrimination Scale was associated with a 25% higher plaque count. Further adjusting for financial strain did not reduce the effect size. We did not observe an association between discrimination and other carotid plaque measures in Black or White women. In Black women, higher levels of discrimination was associated with greater carotid atherosclerosis. Clarifying the relationship between discrimination and subclinical indicators of stroke risk could inform social and healthcare interventions to reduce discrimination and potential associated stroke risk.

Transgender Women in India: A Syndemic and Intersectional Framework Addressing HIV Care Gaps

The prevalence of HIV among transgender women (TGW) in India is disproportionately high, estimated at 4% to 8% in comparison with the national average of 0.2%. Despite free antiretroviral therapy (ART) provided by the government, TGW encounter multilevel barriers-including stigma, poverty, and lack of gender-affirming care-that hinder HIV care access and retention. Existing behavioral frameworks fail to address the compounded effects of systemic oppression on the health of TGW with HIV in India. We present a conceptual framework integrating syndemic theory and intersectionality to examine structural and syndemic factors shaping HIV care barriers. Informed by key informants-including TGW with HIV, community leaders, health providers, and Indian researchers-the framework highlights how systemic marginalization, particularly through discriminatory policies, shapes social position and exacerbates inequities in HIV care outcomes. It also underscores the role of community mobilization and collective action in overcoming these barriers. The framework provides a foundation for interventions tailored to the needs of TGW. By centering community-driven strategies and addressing structural inequities, it offers a pathway to improve HIV care engagement and health outcomes among TGW in India. (Am J Public Health. Published online ahead of print May 1, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308046).

Racial equity in and through medical interaction scholarship: A scoping review

OBJECTIVE

We conducted a systematic scoping review to characterize the landscape of communication scholarship within racial health equity in and through the patient-provider interaction.

METHODS

We employed three waves of data collection to identify relevant articles (N = 454) about racial equity within provider-patient interactions. We iteratively developed a codebook concerning article characteristics, coding for journal names, data source, descriptive characteristics for the study samples, and presence of theory and equity in sections of the manuscripts.

RESULTS

This search identified studies (N = 206) that were published in 76 peer-reviewed scientific journals. The majority of studies reported primary data analyses and used survey and interview methodology. Many studies examined participants as patients generally rather than in reference to particular health conditions. Among those with a specific health condition, the largest proportion focused on cancer control. Very few studies included samples with Native American and Pacific Island heritage. Most studies included cisgender men and/or women, but none included transgender men or women. The vast majority of research focused on the patient experience; few centered on providers' and caregivers' experiences. The body of scholarship was largely atheoretical; the most frequently noted constructs were patient-provider communication (including patient-centered communication and patient-centered care), implicit/explicit racial bias, shared decision-making. There was wide variation in the extent to which equity was woven through the manuscripts. Equity is typically mentioned in the literature review, and racial identity in the sample may serve as a marker of racialized experiences.

CONCLUSION

This study demonstrates the need for the development of theory that elevates the centrality of health equity to attend to the bi- or multi-directional flow of communication that shapes the quality of these interactions.

PRACTICE IMPLICATIONS

These insights can serve as a strong foundation for the development of interventions to address equity in clinical interactions.

Policing Black autistic children: A qualitative approach to understanding Black caregivers' concerns

In the United States, Black autistic youth face elevated risk of negative outcomes during police interactions. Although the outcomes of these interactions are well-documented, less is known about Black autistic youths' experiences during police encounters, as the current literature has largely examined the experiences of autistic adults, mostly White American samples, and/or autistic youth abroad. This study utilizes qualitative methods to examine the perceptions and concerns of 43 Black caregivers (N = 43; 98% parents; 2% legal guardians; 93% mothers) of Black autistic children (mean age: 16.5; 79% male) regarding police interactions with their autistic children. Four themes emerged: concerns regarding the Quality of police officers' training, children's Autistic behaviors being inappropriately policed, the explicit Threat of harm and murder, and the hope for Mindful Policing. These findings demonstrate that caregivers' concerns about police behaviors are inextricably linked to their concerns about the quality of police officers' training. The results of this study highlight (1) the importance of including racially and ethnically diverse individuals in research exploring autistic individuals' police interactions, (2) the need for culturally responsive adaptations to existing policing interventions designed for autistic people, and (3) the urgency of integrating Black caregivers' concerns into law enforcement training efforts.Lay abstractIn the United States, Black autistic youth face elevated risk of negative outcomes during police interactions. Although the outcomes of these interactions are well-documented, less is known about Black autistic youths' experiences during police encounters, as the current literature has largely examined the experiences of autistic adults, mostly White American samples, and/or autistic youth abroad. This study utilizes qualitative methods to examine the perceptions and concerns of 43 Black caregivers (N = 43; 98% parents; 2% legal guardians; 93% mothers) of Black autistic children (mean age: 16.5; 79% male) regarding police interactions with their autistic children. Through phenomenological analysis, four dominant themes emerged: concerns regarding the Quality of police officers' training, children's Autistic behaviors being inappropriately policed, the explicit Threat of harm and murder, and the hope for Mindful Policing. These findings demonstrate that caregivers' perceptions of police behavior are inextricably linked to their concerns about the quality of police officers' training. This study highlights (1) the importance of including racially and ethnically diverse individuals in research exploring autistic individuals' police interactions, (2) the need for culturally responsive and neuro-affirming adaptations to existing policing interventions designed for autistic people, and (3) the urgency of integrating Black caregivers' concerns into law enforcement training efforts.

The behavioral health needs of legally involved sexual minority female adolescents

BACKGROUND

Sexual minority (SM) female adolescents involved in the legal system experience marginalization and health inequities. This study examined the differences in psychosocial functioning and risk behaviors among legally involved SM and heterosexual female adolescents to better understand their behavioral health needs. We hypothesized that SM females, as individuals at the intersection of two marginalized groups, would demonstrate greater psychiatric symptom severity and engagement in risk behaviors than their heterosexual counterparts.

METHODS

Adolescents involved in the legal system (N = 423) enrolled in a prospective cohort study and completed baseline surveys assessing their demographics, SM status, psychiatric symptoms, substance use, and engagement in self-injurious, delinquent, and sexual risk behaviors. The responses of SM and heterosexual female adolescents (n = 193) were compared using bivariate and regression analyses.

RESULTS

Participants were 12 to 18 years old (M = 14.49, SD = 1.55), ethnoracially diverse, and 38.3% identified as a SM. SM females, as compared to heterosexual females, reported more PTSD and emotional symptoms, difficulties with anger control and personal adjustment, and engagement in substance use, self-injurious, and sexual risk behaviors.

CONCLUSION

Legally involved SM female adolescents in this study had greater psychiatric, substance use, and sexual health treatment needs compared to their heterosexual peers. These findings highlight the need for enhanced understanding of how to effectively support SM female adolescents, including utilization of culturally sensitive and clinically informative screening practices that do not contribute to further discrimination within the legal system. Future work should aim to develop identity-responsive interventions tailored to this population.

Lifetime heterosexist victimization and diurnal cortisol predict depression trajectories among sexual and gender minority emerging adults

Heterosexist victimization constitutes a severe source of social stress with enduring effects on mental health and the adrenocortical functioning of lesbian, gay, bisexual, transgender, and queer (LGTBQ) emerging adults. However, it is unknown what roles lower or higher diurnal cortisol at waking (cortisol intercepts) and less variable fluctuations ("flatter" slopes) play in the links between heterosexist victimization and depressive symptoms. In accordance with diathesis-stress, allostatic load, and biological embedding perspectives, we examined whether cortisol intercepts and slopes moderated or mediated the predictive associations of heterosexist victimization with depressive symptoms over 24-months. Heterosexist victimization was expected to predict depressive symptoms most strongly for LGBTQ emerging adults with flatter cortisol slopes (i.e., moderation), and cortisol intercepts and slopes were expected to indirectly link heterosexist victimization with depressive symptoms (i.e., mediation). Latinx and White LGBTQ emerging adults (N = 97; ages 18-29, M = 23.91 years, SD = 2.63) provided saliva samples and questionnaire responses during a four-day testing protocol at baseline; two additional assessments of depressive symptoms were completed 9- and 24-months later. Cortisol intercepts and slopes moderated associations of heterosexist victimization with both contemporaneous and prospective depressive symptoms. Heterosexist victimization was positively associated with contemporaneous depressive symptoms and decreases in depressive symptoms over two years when LGBTQ emerging adults also had steeper cortisol slopes. Heterosexist discrimination was associated with increases in depressive symptoms prospectively among participants with lower cortisol intercepts. There was no evidence for mediation. Thus, patterns of diurnal adrenocortical functioning may distinguish between LGBTQ emerging adults who are more prone to acute versus prolonged depressive symptoms when they experience heterosexist victimization.

'I cannot be what I don't see': an evaluation of Academic Intersectionality Mentoring in medical schools (AIMMS Mentoring)

The Academic Intersectionality Mentoring in Medical Schools (AIMMS Mentoring) scheme aims to support the career progression of women from ethnic minority backgrounds working in academic medicine and health sciences who are under-represented in senior roles of academia in the UK. Two questionnaires (baseline and 6 months) captured information about AIMMS Mentoring participants and practical aspects of the scheme. Participants were asked about their experience of and satisfaction with the scheme, whether it matched their expectations and what they felt were the scheme's rewards and challenges. Questions were also asked about the organisation of the scheme and how it could be improved. The productivity of mentoring relationships was explored, including personal and professional development, and whether participants felt it important that mentoring takes place between people with similar characteristics. Sixteen pairs took part in mentoring, with ten mentees and four mentors completing evaluation questionnaires at 6m follow-up. Responses indicated that the scheme was helpful. All mentor and mentee responses reported personal and professional development. Mentee responses in particular reported gaining insight into career development, and both groups felt they had gained understanding about institutional ways of working. Participants rated the scheme positively and indicated they would recommend it to others. Being in mentoring relationships with women from similar backgrounds was ascribed value, as was mentor partners being empathetic. The evaluation revealed ways in which the scheme could be improved. Women from ethnic minorities working in academic medicine and health sciences can face structural barriers into leadership. This formative and summative evaluation of AIMMS Mentoring showed that mentoring and peer support in this group is valuable and can assist with personal, professional and career development. The scheme is an example of positive action and a model national activity aimed at achieving equity of opportunity in academic medicine and health sciences.

10 Limits to Forgiveness in Health Care

Compliance and regulatory bodies often encourage health care providers' disclosure of and apologies for wrongdoing. Patients may perceive that forgiveness is expected and feel pressure to grant it. However, forgiveness carries consequences, which can bring limits to forgiveness. Understanding these limits is crucial for understanding when forgiveness can either heal or add to trauma. This paper explores 10 context-dependent limits to forgiveness across four categories. The first category outlines conceptual limits: not all harm requires forgiveness, some evil acts may be beyond human forgiveness, and blame can be incompatible with forgiveness. Secondly, moral and ethical limits result from how accountability strains forgiveness, how moral absolutism can hinder it, and how proxy forgiveness may lack moral legitimacy. The third category identifies relational and social limits. Forced reconciliation can undermine forgiveness. System negligence diffuses culpability, hindering individual forgiveness, and requires prioritizing the victim's healing and benefit despite the diluted accountability. Finally, the fourth category highlights temporal and process-related limits. It emphasizes that ongoing or unaddressed harm can obstruct forgiveness, while variations in healing trajectories may delay or complicate it. Updating current understanding, this framework adds insight into when forgiveness may be inappropriate. It offers providers ethical guidance in navigating this terrain through a person-centred approach balancing empathy and accountability. The framework aims to facilitate healing for the patient and provider, regardless of whether forgiveness occurs.

Advancing health equity in Nova Scotia by exploring gaps in healthcare delivery: a mixed methods protocol

Population health issues are addressed by various regional initiatives in the Canadian province of Nova Scotia (NS). A need for research on the root causes of health inequities suggests there may be a lack of evidence to inform current initiatives within the region. To address this gap, a three-phase sequential mixed methods study called Advancing Health Equity in NS by Exploring Gaps in Healthcare Delivery will operationalize Intersectionality Theory and employ an integrated knowledge translation approach to identify and explore gaps in health service delivery. This will promote a better understanding of how to improve the integration of health equity in health service and delivery systems and thus population health and well-being. The following objectives will be addressed in each phase: 1) create an inventory of NS-relevant knowledge that relates to health equity, 2) examine the integration of health equity in NS health service and delivery systems using a context-specific health equity lens, and 3) mobilize knowledge on how gaps in service delivery can be addressed to improve the integration of health equity and better meet the needs of people living in NS. The study results from this protocol will be used to integrate health equity in NS health service and delivery systems, enhancing the quality of care for populations rendered vulnerable by structural inequalities, and working to prevent negative impacts to health and wellbeing.

Examining disparities in cervical cancer diagnosis at the intersection of disability and sexual orientation

BACKGROUND

Cervical cancer risk factors are more prevalent among women with disabilities and sexual minorities, yet little is known about how these factors intersect.

OBJECTIVE

To examine differences in cervical cancer diagnosis at the intersection of disability and sexual orientation.

METHODS

Using a nationally representative sample (N = 80,447) obtained from 2014 to 2023 National Health Interview Survey data, we conducted logistic regressions to estimate the odds of cervical cancer diagnosis at the intersection of disability and sexual orientation among women (25-65 years). We calculated three measures of interaction: 1) relative excess risk due to interaction (RERI); 2) proportion attributable to interaction (AP); and 3) synergy index (SI).

RESULTS

Heterosexual women with disabilities were more likely to receive a diagnosis of cervical cancer (aOR = 2.15, 95 % CI: 1.75-2.64) compared to heterosexual women without disabilities. This disparity was even greater among women with disabilities who identified as sexual minorities (aOR = 2.98, 95 % CI: 1.86-4.77). The interaction measures suggest a synergistic effect between disability and sexual orientation on cervical cancer risk. Specifically, women with disabilities in multiple functional areas had increased odds of a cervical cancer diagnosis, regardless of sexual orientation (Heterosexual: aOR = 2.94, 95 % CI: 2.33-3.70; Sexual minorities: aOR = 3.04, 95 % CI: 1.25-7.42).

CONCLUSION

The findings suggest that disability status plays a significant role in exacerbating the risk of cervical cancer, while the combination of disability and minority sexual orientation may further compound adverse experiences that disproportionately contribute to this risk.

"Together we are stronger": YPAR and Latinx immigrant youth resilience and resistance to oppressive immigration policies

Latinx adolescents, representing 25% of the U.S. child population, face significant mental health challenges due to aggressive immigration enforcement and policies rooted in racism, nativism, and ethnocentrism. These systemic issues contribute to increased rates of sadness, hopelessness, and suicidal behaviors among Latinx adolescents. Addressing this crisis requires interventions that mitigate the harms of these policies and promote youth voice and agency to foster resilience and resistance and, ultimately, liberation from oppression. This study explores how Youth Participatory Action Research (YPAR) can empower Latinx immigrant youth to build resilience and resist oppressive systems threatening their well-being. Using a grounded theory qualitative approach, we examined the PARA Jóvenes YPAR project, which engaged 10 Latinx immigrant youth from a community with a history of aggressive immigration enforcement. Through triangulating in-depth interviews, facilitator reflections, and photovoice transcripts, we identified key YPAR components-near-peer mentorship, community building, cultural affirmation, creative expression, and critical inquiry-that promoted and supported youth in developing critical consciousness, cultural authenticity, self-knowledge, and connectedness. This study highlights the transformative potential of YPAR to promote mental health and liberation for Latinx immigrant youth impacted by immigration policies. It underscores the need for further research on its efficacy as an intervention.

"When Somebody Comes into This Country and You Are Trans on Top of That Is Like You Got… Two Strikes on You": Intersectional Barriers to PrEP Use Among Latina Transgender Women in the Eastern and Southern United States

In the United States (U.S.), Latina transgender women (LTW) are highly burdened by HIV and are prioritized for pre-exposure prophylaxis (PrEP). This study explored intersectional barriers and facilitators to PrEP uptake among LTW. Between February-November 2022, in-depth interviews were conducted with 27 LTW in the LITE Study. Participants were purposively sampled from 196 LTW in the cohort based on PrEP uptake (PrEP-naïve n = 8, PrEP-eligible and not user n = 5, current PrEP user n = 6, previous PrEP user n = 8). We conducted content analysis guided by a Modified Social Ecological Model and Intersectionality Framework. The mean age of participants was 32.3 (SD = 12.9). Themes were: (1) Intrapersonal: Medical distrust, acceptability of PrEP modalities, and concerns about long-term health; (2) Interpersonal: Mistreatment in healthcare, discrimination-related healthcare avoidance, difficulty finding trans-competent providers, language barriers, and shame and stigma; and (3) Structural: PrEP in the context of limited access to gender-affirming care and widespread silicone use, immigration status, economic marginalization, lack of community outreach, transphobia and anti-transgender legislative contexts, and xenophobia. This study found multilevel intersectional barriers influence PrEP uptake and persistence. Culturally tailored HIV prevention efforts are needed to address LTW-specific barriers, provide information on programs subsidizing PrEP, and implement policy change to ensure equitable PrEP access.

Accounts of women from Asian ethnic backgrounds about their medical undergraduate experiences in the UK - an interpretative phenomenological study

BACKGROUND

Asian ethnic women face discrimination within UK medical schools. Their experiences, shaped by intersecting identities, demand focused attention and understanding. This study aims to explore their experiences, especially on understanding how the intersecting identities shape their educational journeys.

METHODS

An interpretative phenomenological analysis (IPA) approach was used to explore lived experiences and perceptions of five fourth-year medical students from one institution. Transcripts from semi-structured interviews were analysed following IPA procedures, with an emphasis on understanding the intersectionality of gender and ethnicity in shaping experiences.

RESULTS

Analysis of the transcripts produced four overarching themes with six subthemes. The four themes were: discriminatory action, impact, reaction to the action and expectations and solutions. 'Discriminatory action' highlights the direct and indirect discrimination that the students faced. Students' personal sense of identity shaped the 'impact' theme whilst perseverance, tolerance and acceptance of discrimination defined the 'reaction' theme. The 'expectations and solutions' theme reflects how students anticipate change and propose solutions to mitigate these issues. Participants strongly urged institutions to take more proactive steps in addressing these concerns.

CONCLUSION

Discrimination significantly impacts the wellbeing and education of Asian women medical students. These challenges have implications for career progression and contribute to broader inequities in medicine. We recommend medical schools consider including a curriculum to address these concerns as a priority in the early years of the medical degree.

Discrimination and Mental Health Among Black and Latino People Living with HIV: Understanding the Role of Religion and Spirituality

Despite significant advances in HIV care and treatment, Black and Latino people living with HIV (PWH) still face substantial health disparities due to discrimination and systemic inequities, which adversely affect their mental health. Given the profound significance of religion and spirituality in Black and Latino communities, the effects of religiosity on the relationship between discrimination and mental health should be examined. This study examined religiosity as a moderator between discrimination and mental health among Black and Latino PWH. Using data from the All of Us Research Program collected from 2016 to 2022, we analyzed electronic health records and survey responses from 902 participants, employing descriptive statistics, Chi-squared test, principal component analysis, and binary logistic regression. Results showed significant associations between education, employment, income, discrimination, religiosity, and mental health. Compared with no or low religiosity, those with high religiosity had significant higher odds of good mental health (aOR:2.35, 95% CI:1.16-4.75). Those who experienced discrimination had 59% lower odds of good mental health compared to those who did not report experiences of discrimination (aOR:0.41, 95% CI:0.20-0.83). There was no significant interaction effect of religiosity on the relationship between discrimination and mental health. While religiosity positively influences mental health, it does not mitigate the detrimental effects of compounded discrimination that Black and Latino PWH face. Continued collaborations between religious and spiritual leaders, researchers, and community members is needed to understand better the relationship between these factors and to identify strategies to maximize the protective effect of religiosity.

Community-Based and Public Health Initiatives Drive Cardiovascular Disease Prevention: A State-of-the-Art Review

BACKGROUND

Because of the massive global healthcare burden that cardiovascular diseases (CVD) present, it is critical that effective, highly scalable prevention strategies be identified and implemented to meet this unique health challenge.

PURPOSE

The purpose of this review is to analyze and synthesize current research initiatives for CVD prevention at both community-based and practice-based levels.

CONCLUSIONS

This state-of-the-art review article highlights successful intervention strategies and their outcomes, explores the implications for population-based practice, and discusses the importance of long-term behavior change in achieving sustained CVD prevention. The article also discusses the need for building community capacity through engagement and collaboration and advocates for culturally appropriate dissemination strategies to ensure equitable access to new technologies and interventions in CVD prevention.

CLINICAL IMPLICATIONS

This review suggests that clinicians and researchers should integrate evidence-based, community-engaged, and culturally tailored strategies into practice and future research to promote long-term behavior change and equitable CVD prevention.

Not a Monolith: Regional HIV Implementation Science Lessons With Latino/a/x Populations

ABSTRACT

HIV incidence is increasing among Latino/a/x individuals in the United States, especially among young Latino/x gay, bisexual, and sexual minority men. Latino/a/x populations face heightened structural and social barriers to effective interventions for HIV prevention, including pre-exposure prophylaxis, and across the HIV care continuum. Implementation science provides a timely methodology for developing, testing, and scaling effective interventions into practice. Implementation science considers a specific population's priorities and environment, which is especially relevant given the diversity of Latino/a/x populations. In this article, we present lessons learned from our group's experiences leading HIV-related implementation research with various Latino/a/x populations in the United States and Puerto Rico. We highlight the importance of structural and social determinants of health, community-engaged research, and culturally tailored interventions to address HIV disparities. Implementation researchers and institutional leaders can leverage these lessons learned to drive the multilevel change needed to end the HIV epidemic among Latino/a/x populations.

US Abortion Bans and Fertility

Importance

Abortion bans may lead to births among those who are unable to overcome barriers to abortion. The population-level effects of these policies, particularly their unequal impacts across subpopulations in the US, remain unclear.

Objective

To assess heterogeneity in the association of abortion bans with changes in fertility in the US, within and across states.

Design, Setting, and Participants

Drawing from birth certificate and US Census Bureau data from 2012 through 2023 for all 50 states and the District of Columbia, this study used a bayesian panel data model to evaluate state-by-subgroup-specific changes in fertility associated with complete or 6-week abortion bans in 14 US states. The average percent and absolute change in the fertility rate among females aged 15 through 44 years was estimated overall and by state, and within and across states by age, race and ethnicity, marital status, education, and insurance payer.

Exposure

Complete or 6-week abortion ban.

Main outcome and Measures

Fertility rate (births per 1000 reproductive-aged females) overall and by subgroups.

Results

There were an estimated 1.01 (95% credible interval [CrI], 0.45-1.64) additional births above expectation per 1000 females aged 15 through 44 years (reproductive age) in states following adoption of abortion bans (60.55 observed vs 59.54 expected; 1.70% increase; 95% CrI, 0.75%-2.78%), equivalent to 22 180 excess births, with evidence of variation by state and subgroup. Estimated differences above expectation were largest for racially minoritized individuals (≈2.0%), unmarried individuals (1.79%), individuals younger than 35 years (≈2.0%), Medicaid beneficiaries (2.41%), and those without college degrees (high school diploma, 2.36%; some college, 1.58%), particularly in southern states. Differences in race and ethnicity and education across states explain most of the variability in the state-level association between abortion bans and fertility rates.

Conclusion and Relevance

These findings provide evidence that fertility rates in states with abortion bans were higher than would have been expected in the absence of these policies, with the largest estimated differences among subpopulations experiencing the greatest structural disadvantages and in states with among the worst maternal and child health and well-being outcomes.

Differential attainment in UK postgraduate medical examinations: examining the relationship between sociodemographic differences and examination performance

BACKGROUND

Differential attainment (DA), or differences in performance of groups (rather than individual differences), has been observed in a number of postgraduate medical specialty examinations used in UK medical training. Until now, much of the published research on DA has been limited in scope and size to one specialty, one examination or one type of assessment. This retrospective cohort study addressed this gap by examining the relationship between numerous sociodemographic differences and performance in almost all UK postgraduate medical examinations using a dataset of more than 180,000 examination attempts by UK and international medical graduates, adjusting for prior academic attainment.

METHODS

This retrospective cohort study used the UK Medical Education Database (UKMED) to analyse the impact of a range of sociodemographic factors on performance in all UK postgraduate medical examinations aggregated into written and clinical exams. Pass/fail data at the first examination attempt were analysed for all candidates (UK medical school graduates (UKG) and those from non-UK schools (IMG)) sitting an examination between 2014 and 2020. Univariate analyses identified variables to carry forward into multivariate logistic regression models. Informed by previous research, all models were adjusted for prior academic attainment.

RESULTS

180,890 examination first-attempts were made by UKG and IMG candidates, and 121,745 (67.3%) passed at the first attempt. Multivariate regression models showed that place of primary qualification (UKG vs IMG), gender, age, ethnicity, religion, sexual orientation, disability status and working less than full-time were all statistically significant, independent predictors of examination outcomes for all examination candidates. Additionally, there were significant associations between socioeconomic backgrounds and performance for UKGs alone. The strongest independent predictors of failing written and clinical examinations were graduating from a non-UK medical school, having a minority ethnic background and having a registered disability.

CONCLUSIONS

This, the largest study of UK postgraduate medical examination outcomes, identified sociodemographic differences that were independently predictive of performance in written and clinical postgraduate medical examinations. Further analysis is now required to ascertain whether these group-level differences exist in each postgraduate medical examination, the majority or a select few.

TRIAL REGISTRATION

Not applicable.