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

Background

Sexual and gender minority (SGM) people are more likely than their cisgender, heterosexual counterparts to report negative alcohol-related outcomes. Although the association between individual- and interpersonal-level minority stressors and negative alcohol-related outcomes among SGM people is well-established, structural-level minority stressors are understudied. This systematic review examined structural-level stigma and alcohol-related outcomes among SGM people to inform future research, interventions, and policy.

Methods

We used five electronic databases to search for studies published between January 2010 and May 2022 that examined associations between structural stigma and alcohol use among SGM adults in the United States. Peer-reviewed, quantitative studies available in English were included. We conducted quality appraisal using the Joanna Briggs Institute checklist.

Results

The final sample included 11 studies. Overall, there was moderate to strong support for a positive association between structural stigma and negative alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Structural stigma was most commonly measured as a state-level index. Alcohol measures were heterogeneous. Multilevel stigma and resiliency factors were understudied.

Conclusions

Addressing structural stigma is critical in reducing negative alcohol-related outcomes and inequities among SGM people. Research is needed that includes probability samples, longitudinal designs, and samples that reflect the diversity of SGM people. Future studies should examine the influence of multilevel stigma and resiliency factors on alcohol-related outcomes.

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

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

Understanding the Link Between Adolescent Same-Gender Contact and Unintended Pregnancy: The Role of Early Adversity and Sexual Risk Behavior

Past research suggests an apparent paradox: Women who engage in same-gender sexual behavior show higher rates of unintended pregnancy than women with exclusive other-gender sexual behavior. Such women also have disproportionate rates of early adversity (both harshness, such as abuse or neglect, and unpredictability, such as father absence). We used the Add Health data (N = 5,617 cisgender women) to examine the relative contributions of early adversity, adolescent same-gender sexual behavior, and general sexual risk behavior to women's risks for adult unintended pregnancy. Women who engaged in adolescent same-gender sexual behavior were more likely to report childhood adversity, and both childhood adversity and adolescent same-gender behavior made independent contributions to subsequent rates of unintended pregnancy. The association between adolescent same-gender sexual behavior and adult unintended pregnancy was partially attributable to the fact that women with adolescent same-gender sexual behavior engaged in greater sexual risk behavior more broadly. These findings suggest that same-gender sexual behavior in adolescence may relate to a broader set of sexual risk behaviors that augment future risk for unintended pregnancy, independent of sexual identity. We draw on life history theory to explain this pattern of results and suggest directions for future research.

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

OBJECTIVE

To document associations between socioeconomics and indicators of sexual wellbeing.

METHODS

We obtained our data from the HER Salt Lake Initiative, a large, longitudinal cohort study of family planning clients in the United States who accessed free contraceptive services between March 2016 and March 2017. Baseline socioeconomic measures included Federal Poverty Level, receipt of public assistance, and difficulty paying for housing, food, and other necessities. Sexual wellbeing measures assessed sexual functioning and satisfaction, frequency of orgasm, and current sex-life rating. Among participants who had been sexually active in the last month (N = 2581), we used chi-square tests to examine bivariate associations between sexual and socioeconomic measures.

RESULTS

We found strong and consistent relationships between sexual wellbeing and economic resources: those reporting more socioeconomic constraints also reported fewer signs of sexual flourishing.

CONCLUSIONS

Financial scarcity appears to constrain sexual wellbeing. To support positive sexual health, the public health field must continue to focus on economic reform, poverty reduction, and dismantling of structural classism as critical aspects of helping people achieve their full health and wellbeing potential. ClinialTrials.gov Identifier: NCT02734199.

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

BACKGROUND

Contraceptives are used to prevent unwanted pregnancies and treat certain gynecologic conditions, but many women report non-use or inconsistent use because of method dissatisfaction. The sexual acceptability of contraception-how birth control methods affect users' sexual well-being-is likely an important component of contraceptive satisfaction but has yet to be systematically examined.

OBJECTIVE

This study aimed to assess contraceptive satisfaction among new-start contraceptive users and examine whether sexual acceptability measures predict contraceptive satisfaction at 3 months while controlling for more commonly measured contraceptive side effects.

STUDY DESIGN

This analysis used data derived from the baseline, 1-month, and 3-month surveys of the HER Salt Lake Contraceptive Initiative, a prospective cohort study of new contraceptive clients. From March 2016 to March 2017, enrolled participants received their desired contraceptive method at no cost and could switch or discontinue at any time (up to 3 years). This analysis included individuals who continued their new contraceptive method for at least 1 month and completed all relevant survey measures. We used ordered logistic regression modeling to predict contraceptive satisfaction at 3 months. Primary predictor variables included changes in sexual functioning (6-item Female Sexual Function Index), sexual satisfaction (New Sexual Satisfaction Scale), and perceived impact of the contraceptive method on sex life at 1 month. Covariates included vaginal bleeding changes, physical side effects, and mood-related side effects.

RESULTS

Our analytical sample included 1879 individuals. At 3 months, 52.1% of participants were "completely satisfied" with their contraceptive method, 30.7% were "somewhat satisfied," 4.2% were "neither satisfied nor dissatisfied," 6.9% were "somewhat dissatisfied," and 6.2% were "completely dissatisfied." Compared with patients who said their contraceptive method made their sex life "a lot" worse at 1 month, patients whose method improved their sex life "a lot" had a 7.7 times increased odds of greater satisfaction at 3 months (95% confidence interval, 4.02-14.60; P<.0001) and patients whose method improved their sex life a "little" had a 5.88 times increased odds of greater satisfaction (confidence interval, 3.12-11.11; P<.001). To a much lesser degree, experiencing less or no bleeding was significantly associated with increased satisfaction, whereas worsening of physical side effects was linked to decreased satisfaction. The only other factors significantly associated with satisfaction were changes in bleeding and physical side effects.

CONCLUSION

Our findings suggest that patients' sexual experiences of their contraceptive methods are important correlates of satisfaction. Clinicians may wish to underscore that sexual experiences of birth control methods matter and encourage patients to find a contraceptive method that works for them sexually.

Differences in Perinatal Outcomes of Birthing People in Same-Sex and Different-Sex Marriages

It is unknown whether people in same-sex relationships who give birth have different perinatal outcomes than people in different-sex relationships, despite differences in risk factors such as use of assisted reproductive technologies, obesity, smoking, and poor mental health. Marriage equality has established birth certificates as a promising new source of population-based data on births to same-sex married parents. We used birth certificate data from Massachusetts for 201,873 singletons born to married parents from 2012 to 2016. We estimated the associations of several birth outcomes with having a birth parent in a same-sex marriage using propensity score-matched and -unmatched samples. We also tested whether these associations were modified by the use of assisted reproductive technologies. People in same-sex marriages who gave birth had perinatal outcomes related to decreased fetal growth and preterm birth that were similar to those of their peers in different-sex marriages. Use of assisted reproductive technology was associated with decreased fetal growth and increased risk of preterm birth for infants with different-sex parents but not for infants with same-sex parents. More research is needed across other states and to understand why use of assisted reproductive technology is not a risk factor for poor birth outcomes for those in same-sex marriages.

A randomized controlled trial of motivational interviewing as a tool to enhance secondary prevention strategies in cardiovascular disease (MICIS study)

Physical activity/exercise has consistently been shown to improve objective measures of functional capacity, enhance quality of life, improve coronary risk profile, and reduce mortality for individuals with coronary heart disease. Despite the gains achieved by those who attend cardiac rehabilitation (CR) many individuals fail to maintain lifestyle changes.

The aims of this study were to evaluate the effectiveness of motivational interviewing as a strategy for promoting maintenance of cardiac risk factor modification in patients who had participated in standard, 6-week outpatient CR programs.

In a randomized controlled trail, participants in usual care and intervention group (Motivational interviewing supplemental to a standard 6-week CR program) were followed up at 6-weeks and 12-months. The primary outcome was distance walked on the six-minute walk test (6MWT), used as both an indicator of functional capacity and habitual physical activity. Secondary outcomes included modifiable coronary risk factors (smoking, self-reported physical activity, waist circumference, body mass index and medication adherence), psychological status (depression, anxiety, stress, perceived cardiac control, perceived social support, exercise self-efficacy) and quality of life.

Total 110 patients, usual care (n = 58) and intervention (n = 52), consented to participate in the study. Overall, demographic and clinical characteristics did not differ between groups at baseline. Motivational interviewing was no more likely to promote maintenance of cardiac risk factor modification (both primary and secondary outcomes) than a standard CR program alone. Both intervention and control groups maintained the gains achieved during CR at the 12-month follow-up except for weight loss.

Although both groups maintained the gains achieved during CR for physical activity, there was no effect of the intervention on maintenance of cardiac risk factor modification on both primary and secondary outcomes.

Family Planning for Sexual Minority Women

The family planning needs of sexual minority women (SMW) are an understudied but growing area of research. SMW have family planning needs, both similar to and distinct from their exclusively heterosexual peers. Specifically, SMW experience unintended pregnancies at higher rates than their exclusively heterosexual peers, but factors that increase this risk are not well understood. Contraception use is not uncommon among SMW, but lesbian women are less likely to use contraception than bisexual or exclusively heterosexual women. High rates of unintended pregnancy suggest contraception is underused among SMW. Contraception counseling guidelines specific to SMW do not yet exist, but greater adoption of current best practices is likely to meet the needs of SMW. SMW may have unique needs for their planned pregnancies as well, for which obstetrics and gynecology (Ob/Gyn) providers should provide care and referrals. In general, understandings of the distinct family planning needs for SMW are limited and further research is needed, with particular attention to issues of overlapping health disparities related to status as a SMW and other factors such as race/ethnicity that may add additional layers of stigma and discrimination. Clinical resources are needed to help Ob/Gyns make their practice more welcoming to the needs of SMW.

The Influence of Health Literacy and Depression on Diabetes Self-Management: A Cross-Sectional Study

Despite an increasing focus on health literacy in the clinical setting and in the literature, there is still ongoing debate about its influence on diabetes self-management. The aim of the study was to examine the relationships of sociodemographic, clinical, and psychological factors on health literacy and diabetes self-management. A cross-sectional survey was undertaken on 224 patients with type 2 diabetes at two diabetes centres in Sydney, Australia. Findings showed that people with low health literacy were more likely to (a) have lower educational attainment; (b) be migrants; and (c) have depressed mood. Unexpectedly, those who met HbA1c threshold of good glucose control were more likely to have low health literacy. Predictors of low diabetes self-management included (a) younger age group (AOR: 2.58, 95% CI: 1.24-4.64); (b) having postsecondary education (AOR: 2.30, 95% CI: 1.05-5.01); (c) low knowledge of diabetes management (AOR: 2.29, 95% CI: 1.25-4.20); and (d) having depressed mood (AOR: 2.30, 95% CI: 1.30-4.06). The finding that depressed mood predicted both low health literacy and low diabetes self-management stresses the importance of screening for depression. Increasing people's understanding of diabetes self-management and supporting those with depression are crucial to enhance participation in diabetes self-management.

Understanding the Educational Attainment of Sexual Minority Women and Men

National studies have not analyzed sexual identity disparities in high school completion, college enrollment, or college completion in the United States. Using Add Health data, we document the relationship between adult sexual orientation and each of these outcomes. Many sexual minority respondents experienced disadvantages in adolescent academic achievement, school experiences, and social environments. This translates into educational attainment in complex, gendered ways. We find that the socially privileged completely heterosexual identity predicts higher educational attainment for women, while for men it is often a liability. Mostly heterosexual and gay identities are educationally beneficial for men but not women. There are college completion disparities between gay and mostly heterosexual women and their completely heterosexual counterparts. Bisexual respondents, especially women, have particularly problematic outcomes. Adolescent experiences, attitudes, and social contexts explain some of these differences. From adolescence through college, sexual minority groups, but especially females, need intervention to reduce substantial educational disparities.

Longitudinal Associations among Discordant Sexual Orientation Dimensions and Hazardous Drinking in a Cohort of Sexual Minority Women

We examined differences between sexual minority women's (SMW's) sexual identity and sexual behavior or sexual attraction as potential contributors to hazardous drinking across a 10-year period. Data are from a longitudinal study examining drinking and drinking-related problems in a diverse, community-based sample of self-identified SMW (Wave 1: n = 447; Wave 2: n = 384; Wave 3: n = 354). Longitudinal cross-lagged models showed that SMW who report higher levels of identity-behavior or identity-attraction discordance may be at greater risk of concurrent and subsequent hazardous drinking. Results of multigroup models suggest that sexual orientation discordance is a more potent risk factor for risky drinking outcomes among SMW in older adulthood than in younger adulthood. Findings support that discordance between sexual orientation dimensions may contribute to hazardous drinking among SMW and provide evidence that cognitive-behavioral consistency is important for individuals expressing diverse and fluid sexual identities, attraction, and behavior.

Health Behavior, Status, and Outcomes Among a Community-Based Sample of Lesbian and Bisexual Women

PURPOSE

To compare health behaviors, and physical and mental health outcomes in a community-based sample of bisexual and lesbian women.

METHODS

The Chicago Health and Life Experiences of Women (CHLEW) study is a longitudinal study of sexual minority women's health. Wave 3 of the CHLEW used a modified version of respondent-driven sampling to recruit a supplemental sample of bisexual-identified women into the study, with an additional focus on younger women, and Black and Latina women. Face-to-face interviews were conducted and data were captured using computer-assisted interviews. Data from the supplemental Wave 3 sample are reported here.

RESULTS

Bisexual (n=139) and lesbian women (n=227) did not differ on most health outcomes, either in terms of prevalence or adjusted odds. Bisexual women were at higher risk of ever being diagnosed with a sexually transmitted infection (STI) (AOR=3.01) and scoring 10 or more on the Center for Epidemiologic Studies Depression Scale (CES-D) (AOR=1.73) compared to lesbian women.

CONCLUSION

In contrast to the prevailing view of bisexual women as being at higher risk for many/most negative health outcomes, we found relatively few differences between bisexual and lesbian women in the current study. Additional research is needed to better understand risk and resilience factors among bisexual women specifically, and sexual minority women more broadly.

Sexual orientation identity change and depressive symptoms: a longitudinal analysis

Several new studies have documented high rates of sexual identity mobility among young adults, but little work has investigated the links between identity change and mental health. This study uses the National Longitudinal Study of Adolescent to Adult Health (N = 11,727) and employs multivariate regression and propensity score matching to investigate the impact of identity change on depressive symptoms. The results reveal that only changes in sexual identity toward more same-sex-oriented identities are associated with increases in depressive symptoms. Moreover, the negative impacts of identity change are concentrated among individuals who at baseline identified as heterosexual or had not reported same-sex romantic attraction or relationships. No differences in depressive symptoms by sexual orientation identity were found among respondents who reported stable identities. Future research should continue to investigate the factors that contribute to the relationship between identity change and depression, such as stigma surrounding sexual fluidity.

Factors Associated with Sexual Orientation and Gender Disparities in Chronic Pain Among U.S. Adolescents and Young Adults

OBJECTIVE

This research investigated factors associated with sexual orientation disparities in chronic pain frequency among youth.

METHOD

Data were analyzed from 4534 female and 3785 male youth from Waves I-IV (1995-2009) of the U.S. National Longitudinal Study of Adolescent to Adult Health. Gender-stratified weighted logistic regression models controlled for sociodemographic characteristics and included sexual orientation (primary predictor) and frequency of three types of chronic pain (outcomes). Models with sexual orientation only were compared to models with factors hypothesized to increase or decrease risk of pain. Significant odds ratios (OR) for chronic pain frequency (daily/weekly vs. rarely) with confidence intervals (CI) and associated factors are reported.

RESULTS

Compared to same-gender heterosexual females, mostly heterosexuals were more likely to report headaches (OR=1.40, CI=1.09, 1.79) and mostly heterosexuals and bisexuals were more likely to report muscle/joint pain (mostly heterosexual OR=1.69, CI=1.29, 2.20; bisexual OR=1.87, CI=1.03, 3.38). Compared to same-gender heterosexual males, gay males were more likely to report headaches (OR=2.00, CI=1.06, 3.82), but less likely to report muscle/joint pain (OR=0.28, CI=0.11, 0.74). Significant disparities were attenuated by up to 16% when associated factors were added to the model.

CONCLUSION

Sexual orientation disparities in chronic pain were partially explained by associated factors, but more research is needed to develop intervention and prevention strategies.

Gender differences in hypertension and hypertension awareness among young adults

Previous research has shown that men have higher levels of hypertension and lower levels of hypertension awareness than women, but it remains unclear if these differences emerge among young adults. Using the National Longitudinal Study of Adolescent to Adult Health (Add Health), this study examines gender differences in hypertension and hypertension awareness among U.S. young adults, with special focus on factors that may contribute to observed disparities (N = 14,497). Our results show that the gender disparities in hypertension status were already evident among men and women in their twenties: women were far less likely to be hypertensive compared to men (12% vs. 27%). The results also reveal very low levels of hypertension awareness among young women (32% of hypertensive women were aware of their status) and even lower levels among men (25%). Finally, this study identifies key factors that contribute to these observed gender disparities. In particular, health care use, while not related to the actual hypertension status, fully explains the gender differences in hypertension awareness. The findings thus suggest that regular medical visits are critical for improving hypertension awareness among young adults and reducing gender disparities in cardiovascular health.

Lifetime Victimization, Hazardous Drinking, and Depression Among Heterosexual and Sexual Minority Women

PURPOSE

Substantial research documents sexual-orientation-related mental health disparities, but relatively few studies have explored underlying causes of these disparities. The goals of this article were to (1) understand how differences in sexual identity and victimization experiences influence risk of hazardous drinking and depression, and (2) describe variations across sexual minority subgroups.

METHODS

We pooled data from the 2001 National Study of Health and Life Experiences of Women and the 2001 Chicago Health and Life Experiences of Women study to compare rates of victimization, hazardous drinking, and depression between heterosexual women and sexual minority women (SMW), and to test the relationship between the number of victimization experiences and the study outcomes in each of five sexual identity subgroups.

RESULTS

Rates of each of the major study variables varied substantially by sexual identity, with bisexual and mostly heterosexual women showing significantly higher risk than heterosexual women on one or both of the study outcomes. The number of victimization experiences explained some, but not all, of the risk of hazardous drinking and depression among SMW.

CONCLUSION

Although victimization plays an important role, sexual-minority-specific stressors, such as stigma and discrimination, likely also help explain substance use and mental health disparities among SMW.

A longitudinal study of the correlates of persistent smoking among sexual minority women

INTRODUCTION

We conducted a longitudinal evaluation of factors associated with persistent smoking behaviors among sexual minority women (SMW; lesbians and bisexual women).

METHODS

Structured interview data were collected as part of a larger longitudinal study of SMW's health: the Chicago Health and Life Experiences of Women study. We conducted multivariate analyses to evaluate the influence of 4 groups of predictor variables on smoking: (a) demographic, (b) childhood victimization, (c) other substance use, and (d) health variables.

RESULTS

At Wave 1, 30.9% (n = 138) of participants reported current smoking, with substance-use and demographic factors having the strongest relationships to smoking status. The majority (84.9%) of Wave 1 smokers were also smoking at Wave 2. Among demographic variables, level of education was inversely associated with continued smoking. With respect to substance use, hazardous drinking and cocaine/heroin use were significantly associated with continued smoking. None of the victimization or health variables predicted smoking status.

CONCLUSIONS

Consistent with previous studies, smoking rates in this sample of SMW were elevated. Despite intensive efforts to reduce smoking in the general population, 84% of SMW smokers continued smoking from Wave 1 to Wave 2. Findings suggest that the majority of SMW will continue to smoke over time. Additional research is needed to increase motivation and access to smoking cessation resources.

Differences in hypertension by sexual orientation among U.S. young adults

Using a nationally representative data set, this study provides the first estimates of differences in hypertension by sexual orientation using objective measures of systolic and diastolic blood pressure. Logistic regressions showed that there were no differences in hypertensive risk between mostly heterosexual/bisexual identified-respondents and heterosexual-identified respondents among both men and women. Gay men, however, are almost twice as likely (odds ratio = 1.92, p < .01) to be hypertensive compared to heterosexual men. The elevated risk is not explained by measures of minority stress, nor by cardiovascular disease risk factors such as smoking, alcohol use, drug use, BMI, or physical activity. No differences in hypertension risk by sexual orientation were detected among female respondents. The results suggest that gay men face an excess risk for hypertension compared to heterosexual men that is not explained by differences in measured health behaviors.

Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students

OBJECTIVES

We examined purging for weight control, diet pill use, and obesity across sexual orientation identity and ethnicity groups.

METHODS

Anonymous survey data were analyzed from 24 591 high school students of diverse ethnicities in the federal Youth Risk Behavioral Surveillance System Survey in 2005 and 2007. Self-reported data were gathered on gender, ethnicity, sexual orientation identity, height, weight, and purging and diet pill use in the past 30 days. We used multivariable logistic regression to estimate odds of purging, diet pill use, and obesity associated with sexual orientation identity in gender-stratified models and examined for the presence of interactions between ethnicity and sexual orientation.

RESULTS

Lesbian, gay, and bisexual (LGB) identity was associated with substantially elevated odds of purging and diet pill use in both girls and boys (odds ratios [OR] range = 1.9-6.8). Bisexual girls and boys were also at elevated odds of obesity compared to same-gender heterosexuals (OR = 2.3 and 2.1, respectively).

CONCLUSIONS

Interventions to reduce eating disorders and obesity that are appropriate for LGB youths of diverse ethnicities are urgently needed.

STD and HIV risk factors among U.S. young adults: variations by gender, race, ethnicity and sexual orientation

CONTEXT

STDs, including HIV, disproportionately affect individuals who have multiple minority identities. Understanding differences in STD risk factors across racial, ethnic and sexual minority groups, as well as genders, is important for tailoring public health interventions.

METHODS

Data from Waves 3 (2001-2002) and 4 (2007-2008) of the National Longitudinal Study of Adolescent Health were used to develop population-based estimates of STD and HIV risk factors among 11,045 young adults (mean age, 29 at Wave 4), by gender, race and ethnicity, and sexual orientation (heterosexual, mixed-oriented, gay). Regression analyses were conducted to examine associations between risk factors and young adults' characteristics.

RESULTS

Overall, sexual-minority women in each racial or ethnic group had a higher prevalence of sexual risk behaviors-including a history of multiple partners, forced sex and incarceration-than their heterosexual counterparts. Mixed-oriented women in each racial or ethnic group were more likely than heterosexual white women to have received an STD diagnosis (odds ratios, 1.8-6.4). Black men and sexual-minority men also appeared to be at heightened risk. Gay men in all racial and ethnic groups were significantly more likely than heterosexual white men to report having received an STD diagnosis (2.3-8.3); compared with heterosexual white men, mixed-oriented black men had the highest odds of having received such a diagnosis (15.2).

CONCLUSIONS

Taking account of multiple minority identities should be an important part of future research and intervention efforts for STD and HIV prevention.

The effects of children's migration on elderly kin's health: a counterfactual approach

Recent studies of migration and the left-behind have found that elders with migrant children actually experience better health outcomes than those with no migrant children, yet these studies raise many concerns about self-selection. Using three rounds of panel survey data from the Indonesian Family Life Survey, we employ the counterfactual framework developed by Rosenbaum and Rubin to examine the relationship between having a migrant child and the health of elders aged 50 and older, as measured by activities of daily living (ADL), self-rated health (SRH), and mortality. As in earlier studies, we find a positive association between old-age health and children's migration, an effect that is partly explained by an individual's propensity to have migrant children. Positive impacts of migration are much greater among elders with a high propensity to have migrant children than among those with low propensity. We note that migration is one of the single greatest sources of health disparity among the elders in our study population, and point to the need for research and policy aimed at broadening the benefits of migration to better improve health systems rather than individual health.

Correlates and consequences of parent-teen incongruence in reports of teens' sexual experience

Using the National Longitudinal Study of Adolescent Health, factors associated with incongruence between parents' and adolescents' reports of teens' sexual experience were investigated, and the consequences of inaccurate parental knowledge for adolescents' subsequent sexual behaviors were explored. Most parents of virgins accurately reported teens' lack of experience, but most parents of teens who had had sex provided inaccurate reports. Binary logistic regression analyses showed that many adolescent-, parent-, and family-level factors predicted the accuracy of parents' reports. Parents' accurate knowledge of their teens' sexual experience was not found to be consistently beneficial for teens' subsequent sexual outcomes. Rather, parents' expectations about teens' sexual experience created a self-fulfilling prophecy, with teens' subsequent sexual outcomes conforming to parents' expectations. These findings suggest that research on parent-teen communication about sex needs to consider the expectations being expressed, as well as the information being exchanged.

Polymorphisms in Toll-like receptors-2 and -4 are not associated with disease manifestations in acute Q fever

Coxiella burnetii is a macrophage-tropic, Gram-negative organism, which causes acute Q fever infection in humans. This zoonotic infection causes illness ranging from asymptomatic seroconversion to severe and protracted disease featuring hepatitis and pneumonia. Interactions between C. burnetii lipopolysaccharide (LPS) and host Toll-like receptors (TLR)-2 and -4 have been implicated in pathogen recognition, phagocytosis and signaling responses. Nonconservative single nucleotide polymorphisms in the coding regions of TLR-2 (Arg677Trp and Arg753Gln) and TLR-4 (Asp299Gly) have been found to correlate with mycobacterial infections and Gram-negative sepsis respectively. Associations between the TLR-2 and -4 polymorphisms, illness characteristics and immune response parameters were examined in subjects with acute Q fever (n=85) and comparison subjects with viral infections (n=162). No correlation was demonstrated between these polymorphisms and susceptibility to Q fever, illness severity or illness course.

Identification of Isolates that Cause a Leaf Spot Disease of Brassicas as Xanthomonas campestris pv. raphani and Pathogenic and Genetic Comparison with Related Pathovars

ABSTRACT Twenty-five Xanthomonas isolates, including some isolates received as either X. campestris pv. armoraciae or pv. raphani, caused discrete leaf spot symptoms when spray-inoculated onto at least one Brassica oleracea cultivar. Twelve of these isolates and four other Xanthomonas isolates were spray- and pin-inoculated onto 21 different plant species/cultivars including horseradish (Armoracia rusticana), radish (Raphanus sativus), and tomato (Lycopersicon esculentum). The remaining 13 leaf spot isolates were spray-inoculated onto a subset of 10 plant species/cultivars. The leaf spot isolates were very aggressive on several Brassica spp., radish, and tomato causing leaf spots and dark sunken lesions on the middle vein, petiole, and stem. Based on the differential reactions of several Brassica spp. and radish cultivars, the leaf spot isolates were divided into three races, with races 1 and 3 predominating. A differential series was established to determine the race-type of isolates and a gene-for-gene model based on the interaction of two avirulence genes in the pathogen races and two matching resistance genes in the differential hosts is proposed. Repetitive-DNA polymerase chain reaction-based fingerprinting was used to assess the genetic diversity of the leaf spot isolates and isolates of closely related Xanthomonas pathovars. Although there was variability within each race, the leaf spot isolates were clustered separately from the X. campestris pv. campestris isolates. We propose that X. campestris isolates that cause a nonvascular leaf spot disease on Brassica spp. should be identified as pv. raphani and not pv. armoraciae. Race-type strains and a neopathotype strain for X. campestris pv. raphani are proposed.

Community treatment orders: ethical practice in an era of magical thinking

With the passage of legislation in June 2000, coercive measures in the form of community treatment orders (CTOs) have become part of the community mental health landscape in Ontario. Given that community practitioners place a high value upon their ability to create voluntary and egalitarian partnerships with clients, the question of whether ethical practice is possible under conditions of legislated coercion is relevant. Based upon a review of the pro and con arguments that preceded CTO legislation, followed by an examination of available research on effectiveness, this paper suggests that forms of magical thinking have been at work on both sides of the CTO debate. A broader definition of coercion is proposed--one that envelopes both overt and covert forms. Finally, the author offers an approach to ethical practice which is based on the use of transformative power rather than coercive power, and which includes a 3-step strategy (using liberation tactics, proactive contracting, and procedural justice).

What makes a house a home? An evaluation of a supported housing project for individuals with long-term psychiatric backgrounds

Supported housing (as distinct from supportive housing) emphasizes the values of consumer choice; independence; participation; permanence; normalcy; and flexible, ongoing supports. As a model, it has only recently become popular in the literature and therefore little is known of its effectiveness in serving people with long-term psychiatric backgrounds. In 1989, Homeward Projects, a community mental health agency located in Metropolitan Toronto, established a supported housing project. Homeward included an evaluative component in its program from the outset. In order to give equal weight to the tenants' opinions, both quantitative and qualitative methodologies were employed. In the quantitative component, residential milieu, social support, and service delivery were examined. The qualitative component involved an ethnographic study which allowed the tenants to voice their experiences of living in such a setting. Results provided a rich understanding of the model. Overall, the tenants eventually came to describe their house as a home.

Working together: a consumer participation research project to develop a new model of high-support housing

This paper outlines a participatory approach to developing a new model of service delivery for high-support housing. A consumer committee was recruited from among the inpatients and outpatients of a large psychiatric hospital in Metropolitan Toronto. Their task was to analyze three existing models of high-support housing, using structured interviews and visits, and to develop a new approach. The discussion focuses on the participation experience itself. A number of strategies were employed to reduce the traditional barriers between professionals and consumers. Using both the research results and the consumers' impressions of their experience, these strategies were evaluated for their efficacy.