Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

Localized and Widespread Chronic Pain in Sexual and Gender Minority People - An Analysis of The PRIDE Study

Sex related differences, without taking gender into account, in chronic pain have been widely researched over the past few decades in predominantly cisgender and heterosexual populations. Historically, chronic pain conditions have a higher incidence and prevalence in cisgender women, including but not limited to fibromyalgia, irritable bowel syndrome, and migraine. The goal of the present study was to identify and characterize the presence and characteristics of chronic pain in SM and GM persons using data from The PRIDE Study, which is the first large-scale, long-term national cohort health study of people who identify as lesbian, gay, bisexual, transgender, queer, or as another sexual or gender minority person. A total of 6189 adult participants completed The PRIDE Study 2022 Annual Questionnaire at the time of data analysis. A total of 2462 participants reported no chronic pain, leaving 2935 participants who reported experiencing chronic pain. The findings from this study highlight that chronic pain is present to a significant degree in sexual and gender minority adults who participated in The PRIDE Study with chronic spine pain being the most common location/region of pain. Notably, more than one-third of non-binary persons, transgender men, and people who selected another gender experienced chronic widespread pain, defined by having 3 or more total regions of chronic pain. The lowest prevalence of chronic widespread pain was among transgender women and cisgender men. When considering sexual orientation, the highest prevalence of widespread pain was in participants who selected another sexual orientation, followed by queer and asexual, demisexual, gray ace, with the lowest prevalence of chronic widespread pain being in those who identify as straight or heterosexual, bisexual, pansexual, gay, and lesbian. Future studies are planned to elucidate how a variety of biopsychosocial mechanisms may influence chronic pain in sexual and gender minority persons.

Interest in over-the-counter progestin-only pills among transgender, nonbinary, and gender-expansive individuals in the United States

BACKGROUND

In July 2023, the US Food and Drug Administration approved the first nonprescription oral contraceptive, a progestin-only pill, in the United States. Transgender, nonbinary, and gender-expansive people assigned female or intersex at birth face substantial contraceptive access barriers and may benefit from over-the-counter oral contraceptive access. However, no previous research has explored their perspectives on this topic.

OBJECTIVE

This study aimed to measure interest in over-the-counter progestin-only pill use among transgender, nonbinary, and gender-expansive individuals assigned female or intersex at birth.

STUDY DESIGN

We conducted an online, cross-sectional survey from May to September 2019 (before the US Food and Drug Administration approval of a progestin-only pill) among a convenience sample of transgender, nonbinary, and gender-expansive people assigned female or intersex at birth who were aged 18 to 49 years from across the United States. Using descriptive statistics and logistic regression analyses, we estimated interest in over-the-counter progestin-only pill use (our outcome) overall and by sociodemographic and reproductive health characteristics (our exposures). We evaluated separate logistic regression models for each exposure. In each model, we included the minimally sufficient adjustment set to control for confounding pathways between the exposure and outcome. For the model for age, we ran a univariable logistic regression model; for all other exposures, we ran multivariable logistic regression models.

RESULTS

Among 1415 participants in our sample (median age, 26 years), 45.0% (636/1415; 95% confidence interval, 42.3-47.6) were interested in over-the-counter progestin-only pill use. In separate logistic regression models for each exposure, there were higher odds of interest among participants who were aged 18 to 24 years (odds ratio, 1.67; 95% confidence interval, 1.33-2.10; vs those aged 25-34 years), those who were uninsured (adjusted odds ratio, 1.91; 95% confidence interval, 1.24-2.93; vs insured), those who currently used oral contraceptives (adjusted odds ratio, 1.69; 95% confidence interval, 1.17-2.44; vs non-users), had ≤high school degree (adjusted odds ratio, 3.02; 95% confidence interval, 1.94-4.71; vs college degree), had ever used progestin-only pills (adjusted odds ratio, 2.32; 95% confidence interval, 1.70-3.17; vs never users), and who wanted to avoid estrogen generally (adjusted odds ratio, 1.32; 95% confidence interval, 1.04-1.67; vs those who did not want to avoid estrogen generally) or specifically because they viewed it as a feminizing hormone (adjusted odds ratio, 1.72; 95% confidence interval, 1.36-2.19; vs those who did not want to avoid estrogen because they viewed it as a feminizing hormone). There were lower odds of interest among participants with a graduate or professional degree (adjusted odds ratio, 0.70; 95% confidence interval, 0.51-0.96; vs college degree), those who were sterilized (adjusted odds ratio, 0.31; 95% confidence interval, 0.12-0.79; vs not sterilized), and those who had ever used testosterone for gender affirmation (adjusted odds ratio, 0.72; 95% confidence interval, 0.57-0.90; vs never users).

CONCLUSION

Transgender, nonbinary, and gender-expansive individuals were interested in over-the-counter progestin-only pill use, and its availability has the potential to improve contraceptive access for this population.

Family building and pregnancy experiences of cisgender sexual minority women

BACKGROUND

Although 10% to 20% of cisgender women aged 18 to 40 years have a sexual minority identity (eg, bisexual, lesbian, and queer), there is limited research on the family building and pregnancy experiences of sexual minority cisgender women. Improving our understanding of the family building and pregnancy experiences of cisgender sexual minority women is critical for improving the perinatal health of this population.

OBJECTIVE

This study aimed to compare the mode of family building, past pregnancy experiences, and future pregnancy intentions among cisgender sexual minority women by sexual orientation.

STUDY DESIGN

This is an observational study which was conducted using cross-sectional data collected in 2019 from a national sample of 1369 cisgender sexual minority women aged 18 to 45 years.

RESULTS

Most participants (n=794, 58%) endorsed multiple sexual orientations, most commonly queer (n=641, 47%), lesbian (n=640, 47%), and/or bisexual (n=583, 43%). There were 243 (18%) cisgender sexual minority women who were parents. Pregnancy was used by 74% (181/243) of women to build their families. Among participants who used pregnancy, 60% (108/181) became pregnant through sexual activity with another parent of the child, whereas 27% (64/243) of women used donor sperm. An additional 10% (n=24) became parents through second-parent adoption, 10% (n=25) through adoption, and 14% (n=35) through step-parenting. Bisexual women more often used sexual activity to become parents (61/100, 61%) compared with queer (40/89, 45%) and lesbian women (40/130, 31%). In contrast, lesbian (50/130, 39%) and queer (25/89, 27%) women more often used donor sperm to become parents compared with bisexual women (11/100, 11%). Among the 266 (19%) cisgender sexual minority women who had ever been pregnant, there were 545 pregnancies (mean, 2.05 pregnancies per woman). Among those pregnancies, 59% (n=327) resulted in live birth, 23% (n=126) resulted in miscarriage, 15% (n=83) resulted in abortion, and 2% (n=9) resulted in ectopic pregnancy. A quarter of women had future pregnancy intentions, with no differences by sexual orientation. Overall, few participants (16%) reported that all of their healthcare providers were aware of their sexual orientation.

CONCLUSION

Cisgender sexual minority women primarily built their families through pregnancy and a quarter have future pregnancy desires. In addition, there were important differences in family building methods used by sexual orientation. Providers should be aware of the pregnancy and family-building patterns, plans, and needs of cisgender sexual minority women.

Substance Use Over Time Among Sexual and Gender Minority People: Differences at the Intersection of Sex and Gender

Purpose: Sexual and gender minority (SGM) people are at greater risk for substance use than heterosexual and cisgender people, but most prior work is limited by cross-sectional analyses or the examination of single substance use. This study examined substance use over time among SGM people to identify patterns of polysubstance use at the intersection of sex and gender. Methods: Data were collected annually over 4 years from SGM respondents (n = 11,822) in The Population Research in Identity and Disparities for Equality (PRIDE) Study. Differences in substance use patterns (any prior 30-day use of 15 substances) by gender subgroup were examined with latent class analysis, and multinomial regression models tested relationships between gender subgroup and substance use. Results: Eight classes of substance use were observed. The three most common patterns were low substance use (49%), heavy episodic alcohol use (≥5 alcoholic drinks on one occasion) with some cannabis and tobacco use (14%), and cannabis use with some tobacco and declining heavy episodic alcohol use (13%). Differences observed included lower odds of patterns defined by heavy episodic alcohol use with some cannabis and tobacco use in all gender subgroups relative to cisgender men and persons with low substance use (odds ratios [ORs] 0.26-0.60). Gender expansive people assigned female at birth, gender expansive people assigned male at birth, and transgender men had greater odds of reporting cannabis use with small percentages of heavy episodic alcohol and tobacco use (ORs: 1.41-1.60). Conclusion: This study suggests that there are unique patterns of polysubstance use over time among gender subgroups of SGM people.

Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth

BACKGROUND

Testosterone use among transgender people likely impacts their experience of sexual function and vulvovaginal pain via several complex pathways. Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function. However, data on pelvic and vulvovaginal pain among transgender men and nonbinary people assigned female at birth are scarce.

OBJECTIVE

This study aimed to assess the association between testosterone and sexual function with a focus on symptoms that are commonly associated with vaginal atrophy.

STUDY DESIGN

We conducted a cross-sectional analysis of 1219 participants aged 18 to 72 years using data collected from 2019 to 2021 from an online, prospective, longitudinal cohort study of sexual and/or gender minority people in the United States (The Population Research in Identity and Disparities for Equality Study). Our analysis included adult transgender men and gender diverse participants assigned female at birth who were categorized as never, current, and former testosterone users. Sexual function was measured across 8 Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction domains.

RESULTS

Overall, 516 (42.3%) participants had never used testosterone, and 602 (49.4%) currently used testosterone. The median duration of use was 37.7 months (range, 7 days to >27 years). Most participants (64.6%) reported genital pain or discomfort during sexual activity in the past 30 days, most commonly in the vagina or frontal genital opening (52.2%), followed by around the clitoris (29.1%) and labia (24.5%). Current testosterone use was associated with a greater interest in sexual activity (β=6.32; 95% confidence interval, 4.91-7.74), higher ability to orgasm (β=1.50; 95% confidence interval, 0.19-2.81), and more vaginal pain or discomfort during sexual activity (β=1.80; 95% confidence interval, 0.61-3.00). No associations were observed between current testosterone use and satisfaction with sex life, lubrication, labial pain or discomfort, or orgasm pleasure.

CONCLUSION

Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.

Investigating the factor structure and measurement invariance of the eating disorder examination questionnaire (EDE-Q) among cisgender gay men and lesbian women from the United States

BACKGROUND

Although the Eating Disorder Examination-Questionnaire (EDE-Q) is one of the most widely used self-report assessments of eating disorder symptoms, evidence indicates potential limitations with its original factor structure and associated psychometric properties in a variety of populations, including sexual minority populations. The aims of the current investigation were to explore several previously published EDE-Q factor structures and to examine internal consistency and measurement invariance of the best-fitting EDE-Q model in a large community sample of cisgender gay men and cisgender lesbian women.

METHODS

Data were drawn from 1624 adults (1060 cisgender gay men, 564 cisgender lesbian women) who participated in The PRIDE Study, a large-scale longitudinal cohort study of sexual and gender minorities from the United States. A series of confirmatory factor analyses (CFAs) were conducted to explore the fit of eight proposed EDE-Q models; internal consistency (Cronbach's alphas, Omega coefficients) and measurement invariance (multi-group CFA) were subsequently evaluated.

RESULTS

A brief seven-item, three-factor (dietary restraint, shape/weight overvaluation, body dissatisfaction) model of the EDE-Q from Grilo et al. (Obes Surg. 23:657-662, 2013), consistently evidenced the best fit across cisgender gay men and lesbian women. The internal consistencies of the three subscales were adequate in both groups, and measurement invariance across the groups was supported.

CONCLUSIONS

Taken together, these findings support the use of the seven-item, three-factor version of the EDE-Q for assessing eating disorder symptomatology in cisgender gay men and lesbian women. Future studies can confirm the current findings in focused examinations of the seven-item, three-factor EDE-Q in diverse sexual minority samples across race, ethnicity, socioeconomic status, and age ranges.

Self-Reported Barriers to Care Among Sexual and Gender Minority People With Disabilities: Findings From The PRIDE Study, 2019-2020

Objectives. To examine the associations of self-reported disability status with health care access barriers for sexual and gender minority (SGM) people. Methods. The Population Research in Identity and Disparities for Equality (PRIDE) Study participants lived in the United States or its territories, completed the 2019 annual questionnaire (n = 4961), and self-reported their disability and health care access experiences, including whether they had a primary care provider, were uninsured, delayed care, and were unable to obtain care. We classified disabilities as physical, mental, intellectual, and other; compared participants to those without disabilities; and performed logistic regression to determine the associations of disability status and health care access barriers. Results. SGM people with disabilities were less likely to have a usual place to seek health care (69.0% vs 75.3%; P ≤ .001) and more often reported being mistreated or disrespected as reasons to delay care (29.0% vs 10.2%; P ≤ .001). SGM people with disabilities were more likely to delay care (adjusted odds ratio [AOR] = 3.28; 95% confidence interval [CI] = 2.83, 3.81) and be unable to obtain care (AOR = 3.10; 95% CI = 2.59, 3.71). Conclusions. Future work should address culturally competent health care to ameliorate disparities for the SGM disability community. (Am J Public Health. 2023;113(9):1009-1018. https://doi.org/10.2105/AJPH.2023.307333).

Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study

BACKGROUND

Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently.

METHODS

We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently.

RESULTS

Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings.

CONCLUSIONS

Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings.

Investigating the factor structure and measurement invariance of the Eating Disorder Examination-Questionnaire (EDE-Q) in a community sample of gender minority adults from the United States

OBJECTIVE

The Eating Disorder Examination-Questionnaire (EDE-Q) is one of the most widely used self-report assessments of eating disorder symptoms. However, evidence indicates potential problems with its original factor structure and associated psychometric properties in a variety of populations, including gender minority populations. The aim of the current investigation was to explore several previously published EDE-Q factor structures and to examine internal consistency and measurement invariance of the best-fitting EDE-Q model in a large community sample of gender minority adults.

METHODS

Data were drawn from 1567 adults (337 transgender men, 180 transgender women, and 1050 gender-expansive individuals) who participated in The PRIDE Study, a large-scale longitudinal cohort study of sexual and gender minorities from the United States. A series of confirmatory factor analyses (CFAs) were conducted to explore the fit of eight proposed EDE-Q models; internal consistency (Cronbach's alphas, Omega coefficients) and measurement invariance (multi-group CFA) were subsequently evaluated.

RESULTS

A brief seven-item, three-factor (dietary restraint, shape/weight overvaluation, body dissatisfaction) model of the EDE-Q consistently evidenced the best fit across gender minority groups (transgender men, transgender women, gender-expansive individuals). The internal consistencies of the three subscales were adequate in all groups, and measurement invariance across the groups was supported.

DISCUSSION

Taken together, these findings support the use of the seven-item, three-factor version of the EDE-Q for assessing eating disorder symptomatology in gender minority populations. Future studies can confirm the current findings in focused examinations of the seven-item, three-factor EDE-Q in diverse gender minority samples across race, ethnicity, socioeconomic status, and age ranges.

PUBLIC SIGNIFICANCE STATEMENT

Although transgender individuals have greater risk of developing an eating disorder, the factor structure of the Eating Disorder Examination-Questionnaire, one of the most widely used eating disorder assessment measures, has not been explored in transgender adults. We found that a seven-item model including three factors of dietary restraint, shape and weight overvaluation, and body dissatisfaction had the best fit among transgender and nonbinary adults.

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program

Importance

Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation.

Objective

To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people.

Design, Setting, and Participants

This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility.

Exposures

Self-identified gender identity and sexual orientation group.

Main Outcomes and Measures

Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group.

Results

The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups.

Conclusions and Relevance

In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

Reports of Negative Interactions with Healthcare Providers among Transgender, Nonbinary, and Gender-Expansive People assigned Female at Birth in the United States: Results from an Online, Cross-Sectional Survey

Over one million people in the United States are transgender, nonbinary, or gender expansive (TGE). TGE individuals, particularly those who have pursued gender-affirming care, often need to disclose their identities in the process of seeking healthcare. Unfortunately, TGE individuals often report negative experiences with healthcare providers (HCPs). We conducted a cross-sectional online survey of 1684 TGE people assigned female or intersex at birth in the United States to evaluate the quality of their healthcare experiences. Most respondents (70.1%, n = 1180) reported at least one negative interaction with an HCP in the past year, ranging from an unsolicited harmful opinion about gender identity to physical attacks and abuse. In an adjusted logistic regression model, those who had pursued gender-affirming medical care (51.9% of the sample, n = 874) had 8.1 times the odds (95% CI: 4.1-17.1) of reporting any negative interaction with an HCP in the past year, compared to those who had not pursued gender-affirming care, and tended to report a higher number of such negative interactions. These findings suggest that HCPs are failing to create safe, high-quality care interactions for TGE populations. Improving care quality and reducing bias is crucial for improving the health and well-being of TGE people.

Understanding the social and community support experiences of sexual and gender minority individuals in 12-Step programs

Sexual and gender minority individuals (e.g., gay, bisexual, non-binary, transgender; SGMI) are 2-6 times as likely as cisgender heterosexual individuals to experience alcohol or other substance use disorders. SGMI participate in 12-Step groups, such as Alcoholics Anonymous (AA), at high rates. Though social support is an established mechanism through which 12-Step programs support reductions in substance use, little is known about SGMI's experiences of the social support in 12-Step programs. This qualitative study aims to understand the experiences of social and community support among SGMI involved in 12-Step programs. This study employed thematic analysis to interpret open-ended responses from 302 SGMI who had participated in 12-Step programs. Data was from The PRIDE Study, a large, national, online. longitudinal, cohort study of SGMI. Two themes emerged about how SGMI experienced social and community support in 12-Step programs: beneficial connections and harmful environments. Beneficial connections included a sense of community, shared experiences, and skills provision. Harmful environments included marginalization, oppression, violence, and bullying. This study highlights the variability of experiences of SGMI participating in 12-Step programs. These findings suggest that many SGMI may benefit from 12-Step programs but may need support in coping with potential harms that can emerge through participation.

Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals

BACKGROUND AND OBJECTIVES

This study sought to describe migrainous headache frequency and severity and to examine the relationship between trauma, discrimination, and migraine-associated disability in a sample of sexual and/or gender minority (SGM) adults.

METHODS

We performed a cross-sectional study of SGM people in The Population Research in Identity and Disparities for Equality Study from August to October 2018. The primary exposure was any trauma or discrimination, regardless of attribution. The primary outcome was moderate-severe migraine disability, as defined by a Migraine Disability Assessment (MIDAS) Questionnaire score of ≥11. We performed descriptive analysis comparing respondents with any migrainous headache with those without. Multivariable logistic regression examined the association between trauma/discrimination and migraine disability, controlling first for sociodemographic and clinical factors and then for psychiatric comorbidities.

RESULTS

Of the 3,325 total respondents, 1,126 (33.9%) screened positive for migrainous headache by ID-Migraine criteria. Most people with migraine self-reported moderate (n = 768, 68.2%) or severe (n = 253, 22.5%) intensity. The median MIDAS score was 11 (interquartile range 5-25). Most respondents with migraine (n = 1,055, 93.7%) reported a history of trauma or discrimination. In unadjusted analysis, exposure to both trauma and discrimination was associated with higher odds of moderate-severe disability (OR 1.76, 95% CI 1.34-2.32). After adjustment for self-reported psychiatric comorbidities of anxiety, depression, and posttraumatic stress disorder, this association lost statistical significance.

DISCUSSION

Migrainous headache is common among our sample of SGM adults, and prior experiences with trauma and discrimination are associated with increased migraine disability. Our findings suggest that psychiatric comorbidities play a significant role in this relationship, identifying a potentially modifiable risk factor for disability in SGM people with migraine.

Psychometric validation of the Muscle Dysmorphic Disorder Inventory (MDDI) among U.S. transgender men

Muscle dysmorphia (MD) is characterized by a pervasive belief or fear of insufficient muscularity and an elevated drive for muscularity, representing the pathological and extreme pursuit of muscularity. Psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have yet to be evaluated in transgender men despite emerging evidence suggesting differential risk for MD symptoms in this population. In this study, we assessed the psychometric properties of the MDDI in a sample of 330 transgender men ages 18-67 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults in the U.S. Using a two-step, split-sample approach, an initial exploratory factor analysis supported a three-factor structure and a subsequent confirmatory factor analysis of a re-specified three-factor model demonstrated good overall fit (χ2/df = 1.84, CFI =0.94, TLI =0.92, RMSEA =0.07 [90% CI =0.05,.09], SRMR =0.08). Moreover, results supported the internal consistency and convergent validity of the MDDI subscales in transgender men. Findings inform the use of the MDDI among transgender men and provide a foundation to support further work on the MDDI and MD symptoms among gender minority populations.

State-Level Policy Environments, Discrimination, and Victimization among Sexual and Gender Minority People

Legislation has been passed in some states to reduce discrimination and victimization toward sexual and gender minority people (SGM; people who are not solely heterosexual and/or whose gender identity is not equal to what is socially associated with sex assigned at birth). The purpose of these analyses is to test whether state-level policy environments are associated with past-year discrimination and victimization among SGM people. Cross-sectional data from The Population Research in Identity and Disparities for Equality (PRIDE) Study annual questionnaire (collected 2018−2019), a national study of the health of SGM adults in the USA, were used for these analyses. Measures included related to discrimination, victimization, and demographic characteristics. State-level policy environments were measured using data from the Movement Advancement Project. Logistic regression analyses evaluated state-level policy environment scores and past-year discrimination and victimization among gender identity categories. In this sample, 7044 people (gender minority n = 2530) were included. Cisgender sexual minority (odds ratio [OR] = 1.007, p = 0.041) and the gender expansive subgroup of gender minority people (OR = 1.010, p = 0.047) in states with more protective policy environments had greater odds of discrimination. The gender expansive subgroup was found to have greater odds of victimization in states with more protective policy environments (OR = 1.003, p < 0.05). There was no relationship between state-level policy environments and victimization among any other study groups. SGM people may experience increased risk for discrimination and victimization despite legislative protections, posing continued risks for poor health outcomes and marginalization. Evaluation of factors (e.g., implementation strategies, systems of accountability) that influence the effectiveness of state-level polices on the reported experiences of discrimination and victimization among SGM people is needed.

Subjective Cognitive Decline Associated with Discrimination in Medical Settings among Transgender and Nonbinary Older Adults

Background: Transgender and nonbinary (TNB) individuals report greater subjective cognitive decline (SCD) compared to non-TNB people. SCD involves self-reported problems with memory and thinking and is a potential risk for Alzheimer’s disease and related dementias (ADRD). We explored psychosocial factors, such as discrimination in medical settings, associated with SCD in a sample of TNB older adults. Methods: We utilized cross-sectional data on aging health, SCD (memory complaints and worsening memory in the past year), and discrimination in medical settings from The PRIDE Study for LGBTQ+ adults aged 50+ including TNB adults (n = 115). Associations were tested using multivariate logistic regression. Results: Nearly 16% of TNB participants rated their memory as poor/fair, and 17% reported that their memory was worse than a year ago. TNB older adults with SCD were more likely to report experiencing discrimination in medical settings. After adjustment, those reporting discrimination in medical settings had 4.5 times higher odds of reporting worsening memory than those who did not (OR: 4.5; 95%-CI: 1.5–13.2; p = 0.006), and 7.5 times more likely to report poor/fair memory (OR: 7.49; 95%-CI: 1.7–32.8; p = 0.008); Conclusions: TNB older adults reported high frequencies of SCD and discrimination in medical settings. Further research exploring affirmative cognitive screening and healthcare services is needed.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

PURPOSE

Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.

METHODS

We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.

RESULTS

Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.

CONCLUSIONS

These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.

Associations among romantic and sexual partner history and muscle dysmorphia symptoms, disordered eating, and appearance- and performance-enhancing drugs and supplement use among cisgender gay men

This study examined relationship status (e.g., single versus not single) and number of sexual partners in relation to muscularity- and disordered eating-related attitudes and behaviors among 1090 cisgender gay men enrolled in The PRIDE Study in 2018. Participants completed measures assessing muscle dysmorphia (MD) symptoms, disordered eating attitudes and behaviors, and appearance- and performance-enhancing drug or supplement (APEDS) use. In linear regression models adjusting for theoretically relevant covariates, neither relationship status nor number of past-month sexual partners was associated with disordered eating attitudes. In terms of MD symptoms, single (versus not single) relationship status was associated with greater appearance intolerance, and a greater number of sexual partners was associated with greater drive for size and functional impairment. In adjusted logistic regression models, a greater number of past-month sexual partners was associated with use of anabolic-androgenic steroids, synthetic performance-enhancing substances, protein supplements, and creatine supplements, as well as greater likelihood of engaging in compelled/driven exercise. Across all associations, effect sizes were generally small. Overall, results support that inquiring about sexual partners may have utility in evaluating risk for muscularity-oriented attitudes and behaviors among cisgender gay men. Future work will need to replicate these findings, particularly in more diverse samples.

Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

OBJECTIVE

Appearance and performance-enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.

METHOD

Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.

RESULTS

Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.

PUBLIC SIGNIFICANCE

This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.

COVID-19 News and Its Association with the Mental Health of Sexual and Gender Minority Adults: A Cross-Sectional Study

Background

Sexual and gender minority (SGM; people whose sexual orientation is not heterosexual or whose gender identity varies from what is traditionally associated with the sex assigned to them at birth) people experience high rates of trauma and substantial disparities in anxiety and posttraumatic stress disorder (PTSD). Exposure to traumatic stressors such as news related to COVID-19 may be associated with symptoms of anxiety and PTSD.

Objective

This study aims to evaluate the relationship of COVID-19 news exposure with anxiety and PTSD symptoms in a sample of SGM adults in the United States.

Methods

Data were collected between March 23 and August 2, 2020, from The PRIDE Study, a national longitudinal cohort study of SGM people. Regression analyses were used to analyze the relationship between self-reported news exposure and symptoms of anxiety using the Generalized Anxiety Disorder-7 and symptoms of COVID-19–related PTSD using the Impact of Events Scale-Revised.

Results

Our sample included a total of 3079 SGM participants. Each unit increase in COVID-19–related news exposure was associated with greater anxiety symptoms (odds ratio 1.77, 95% CI 1.63-1.93; P<.001) and 1.93 greater odds of PTSD (95% CI 1.74-2.14; P<.001).

Conclusions

Our study found that COVID-19 news exposure was positively associated with greater symptoms of anxiety and PTSD among SGM people. This supports previous literature in other populations where greater news exposure was associated with poorer mental health. Further research is needed to determine the direction of this relationship and to evaluate for differences among SGM subgroups with multiple marginalized identities.

Do Ask, Tell, and Show: Contextual Factors Affecting Sexual Orientation and Gender Identity Disclosure for Sexual and Gender Minority People

Purpose:

Sexual and gender minority (SGM) people—including members of lesbian, gay, bisexual, transgender, and queer communities—remain underrepresented in health research due to poor collection of sexual orientation and gender identity (SOGI) data. We sought to understand the contextual factors affecting how SGM research participants interact with SOGI questions to enhance participant experience and increase the accuracy and sensitivity of research findings.

Methods:

We recruited SGM adults for in-person semi-structured focus groups or online cognitive interviews from 2016 to 2018. During focus groups and cognitive interviews, we asked participants to respond to SOGI question sets. We employed template analysis to describe the contextual factors that affected SGM participants' responses to SOGI questions.

Results:

We had a total of 74 participants, including 55 participants organized into nine focus groups and 19 participants in cognitive interviews. Most self-identified as a sexual minority person (88%), and 51% identified as a gender minority person. Two main themes were: (1) the need to know the relevance (of why SOGI questions are asked) and (2) the importance of environmental and contextual cues (communicating physical safety and freedom from discrimination that influenced SOGI disclosure).

Conclusions:

Contextualizing the relevance of SOGI data sought could help improve the accuracy and sensitivity of data collection efforts. Environmental cues that communicate acceptance and safety for SGM individuals in research settings may support disclosure. Researchers should consider these contextual factors when designing future studies to improve research experiences for SGM individuals and increase the likelihood of future participation.

Appearance and performance-enhancing drugs and supplements (APEDS): Lifetime use and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people

PURPOSE

Appearance and performance-enhancing drugs and supplements (APEDS) are used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people.

METHODS

Participants were cisgender sexual minority people (1090 gay men, 100 bisexual plus men, 564 lesbian women, and 507 bisexual plus women) recruited from The PRIDE Study in 2018 who reported lifetime APEDS use and completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Muscle Dysmorphic Disorder Inventory (MDDI). Regression analyses stratified by gender and sexual orientation examined associations of any APEDS use with EDE-Q and MDDI scores.

RESULTS

Lifetime APEDS use was common across the four groups of cisgender sexual minority people (44% of gay men, 42% of bisexual plus men, 29% of lesbian women, and 30% of bisexual plus women). Protein supplements and creatine supplements were the most commonly used APEDS. Any APEDS use was associated with higher EDE-Q scores on one or more subscales in all sexual minority groups. Further, any APEDS use was associated with higher MDDI Total Scores in all groups; any APEDS use was associated with all MDDI subscale scores in cisgender gay men only.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in sexual minority men and women, thus highlighting the importance of assessing for these behaviors and symptoms among these populations in clinical settings.

Healthcare Mistreatment, State-Level Policy Protections, and Healthcare Avoidance Among Gender Minority People

INTRODUCTION

This study examined whether past experiences of mistreatment in healthcare were associated with greater healthcare avoidance due to anticipated mistreatment among gender minority (GM) people. We evaluated whether state-level healthcare policy protections moderated this relationship.

METHODS

Data from the 2018 Annual Questionnaire of The PRIDE Study, a national longitudinal study on sexual and gender minority people's health, were used in these analyses. Logistic regression modeling tested relationships between lifetime healthcare mistreatment due to gender identity or expression and past-year healthcare avoidance due to anticipated mistreatment among GM participants. Interactions between lifetime healthcare mistreatment and state-level healthcare policy protections and their relationship with past-year healthcare avoidance were tested.

RESULTS

Participants reporting any lifetime healthcare mistreatment had greater odds of past-year healthcare avoidance due to anticipated mistreatment among gender expansive people (n = 1290, OR = 4.71 [CI]: 3.57-6.20), transfeminine people (n = 263, OR = 10.32 [CI]: 4.72-22.59), and transmasculine people (n = 471, OR = 3.90 [CI]: 2.50-6.13). Presence of state-level healthcare policy protections did not moderate this relationship in any study groups.

CONCLUSIONS

For GM people, reporting lifetime healthcare mistreatment was associated with healthcare avoidance due to anticipated mistreatment. State-level healthcare policy protections were not a moderating factor in this relationship. Efforts to evaluate the implementation and enforcement of state-level policies are needed. Continued efforts to understand instances of and to diminish healthcare mistreatment of GM people are recommended.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13178-022-00748-1.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BACKGROUND

Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.

METHODS

In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings.

RESULTS

Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost.

CONCLUSIONS

These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.

From 'Shark-Week' to 'Mangina': An Analysis of Words Used by People of Marginalized Sexual Orientations and/or Gender Identities to Replace Common Sexual and Reproductive Health Terms

Purpose: To explore sexual and reproductive health (SRH)-related word-use among sexual and gender minority (SGM) individuals in the United States. Methods: In 2019, we fielded an online quantitative survey on the SRH experiences of SGM adults. Eligible participants included transgender, nonbinary, and gender-expansive (TGE) people assigned female or intersex at birth, and cisgender sexual minority women (CSMW) in the United States. The survey asked participants to indicate if they used each of nine SRH terms, and if not, to provide the word(s) they used. We analyzed patterns in replacement words provided by respondents and tested for differences by gender category with tests of proportions. Results: Among 1704 TGE and 1370 CSMW respondents, 613 (36%) TGE respondents and 92 (7%) CSMW respondents replaced at least 1 SRH term (p-for-difference <0.001). Many (23%) replacement words/phrases were entirely unique. For six out of the nine terms, TGE respondents indicated that use of the provided term would depend on the context, the term did not apply to them, or they did not have a replacement word/phrase that worked for them. Conclusions: SRH terms commonly used in clinical and research settings cause discomfort and dysphoria among some SGM individuals. To address inequities in access to and quality of SRH care among SGM individuals, and to overcome long standing fear of mistreatment in clinical settings, more intentional word-use and elicitation from providers and researchers could increase the quality and affirming nature of clinical and research experiences for SGM people.

Psychometric evaluation of the Muscle Dysmorphic Disorder Inventory (MDDI) among cisgender gay men and cisgender lesbian women

Despite increasing empirical interest in muscle dysmorphia (MD), a dearth of research has assessed this construct in sexual minority populations. In particular, the psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have not been evaluated in sexual minority populations despite emerging evidence suggesting differential risk for MD symptoms across sexual orientation groups. In this study, we assessed the psychometric properties of the MDDI in a sample of 715 cisgender gay men and 404 cisgender lesbian women ages 18-50 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults. The factor structure of the MDDI was examined in each sample using a two-step, split-sample exploratory and confirmatory factor analytic approach. Exploratory factor analysis supported a three-factor structure in both samples, which were confirmed by confirmatory factor analysis. Moreover, results supported the internal consistency reliability and convergent validity of the MDDI subscales in both samples. Cumulatively, these findings suggest that the MDDI is an appropriate measure of MD symptoms among cisgender gay men and cisgender lesbian women.

Online health information seeking, health literacy, and human papillomavirus vaccination among transgender and gender-diverse people

Objective

The purpose of this study is to describe online health information seeking among a sample of transgender and gender diverse (TGD) people compared with cisgender sexual minority people to explore associations with human papillomavirus (HPV) vaccination, and whether general health literacy and eHealth literacy moderate this relationship.

Materials and Methods

We performed a cross-sectional online survey of TGD and cisgender sexual minority participants from The PRIDE Study, a longitudinal, U.S.-based, national health study of sexual and gender minority people. We employed multivariable logistic regression to model the association of online health information seeking and HPV vaccination.

Results

The online survey yielded 3258 responses. Compared with cisgender sexual minority participants, TGD had increased odds of reporting HPV vaccination (aOR, 1.5; 95% CI, 1.1-2.2) but decreased odds when they had looked for information about vaccines online (aOR, 0.7; 95% CI, 0.5-0.9). TGD participants had over twice the odds of reporting HPV vaccination if they visited a social networking site like Facebook (aOR, 2.4; 95% CI, 1.1-5.6). No moderating effects from general or eHealth literacy were observed.

Discussion

Decreased reporting of HPV vaccination among TGD people after searching for vaccine information online suggests vaccine hesitancy, which may potentially be related to the quality of online content. Increased reporting of vaccination after using social media may be related to peer validation.

Conclusions

Future studies should investigate potential deterrents to HPV vaccination in online health information to enhance its effectiveness and further explore which aspects of social media might increase vaccine uptake among TGD people.

Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender minority populations

PURPOSE

Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of heightened body image-related concerns among gender minority populations, little is known about the degree of MD symptoms among gender minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to assess community norms of the MDDI in gender-expansive people, transgender men, and transgender women.

METHOD

Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people, were examined. We calculated means, standard deviations, and percentiles for the MDDI total and subscale scores among gender-expansive people (i.e., those who identify outside of the binary system of man or woman; n = 1023), transgender men (n = 326), and transgender women (n = 177). The Kruskal-Wallis test was used to assess group differences and post hoc Dunn's tests were used to examine pairwise differences.

RESULTS

Transgender men reported the highest mean MDDI total score (30.5 ± 7.5), followed by gender-expansive people (27.2 ± 6.7), then transgender women (24.6 ± 5.7). The differences in total MDDI score were driven largely by the Drive for Size subscale and, to a lesser extent, the Functional Impairment subscale. There were no significant differences in the Appearance Intolerance subscale among the three groups.

CONCLUSIONS

Transgender men reported higher Drive for Size, Functional Impairment, and Total MDDI scores compared to gender-expansive people and transgender women. These norms provide insights into the experience of MD symptoms among gender minorities and can aid researchers and clinicians in the interpretation of MDDI scores among gender minority populations.

Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships

Background

Sexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma.

Purpose

To examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people.

Methods

Participants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes.

Results

Among cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health.

Conclusion

Safe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.

Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among cisgender sexual minority men and women

BACKGROUND

Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of elevated body image-related concerns among sexual minority populations, little is known about the degree of muscle dysmorphia (MD) symptoms among sexual minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to examine the nature and severity of MD symptoms in cisgender sexual minority men and women and provide community norms of the MDDI for these populations.

METHODS

Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people from the United States, were examined. Participants included cisgender gay men (N = 1090), cisgender bisexual plus (bisexual, pansexual, and/or polysexual) men (N = 100), cisgender lesbian women (N = 563), and cisgender bisexual plus women (N = 507). We calculated means, standard deviations (SD), and percentiles for the MDDI total and subscale scores for cisgender sexual minority men and women. We compared MDDI scores by sexual orientation using linear regression models, both unadjusted and adjusted for sociodemographics.

RESULTS

Overall, the sample was 85.2% White, 3.0% Asian or Pacific Islander, 2.0% Black, 0.5% Native American, 3.9% multiracial, and 6.6% Hispanic/Latino/a. The mean age was 38.6 (SD = 14.3) and 69.4% had a college degree or higher. Means (SD) for the MDDI total score were 27.4 (7.7) for cisgender gay men, 26.4 (6.4) for cisgender bisexual plus men, 24.3 (6.1) for cisgender lesbian women, and 24.6 (5.5) for cisgender bisexual plus women. There were no significant differences in MDDI scores between cisgender gay and bisexual plus men, or between cisgender lesbian women and bisexual plus women in unadjusted or adjusted models.

CONCLUSIONS

These normative data provide insights into the experience of MD symptoms among cisgender sexual minority men and women and can aid researchers and clinicians in the evaluation of MD symptoms and interpretation of MDDI scores in sexual minority populations.

Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey

Background: Transgender, nonbinary, and gender-expansive (TGE) people experience pregnancy. Quantitative data about pregnancy intentions and outcomes of TGE people are needed to identify patterns in pregnancy intentions and outcomes and to inform clinicians how best to provide gender-affirming and competent pregnancy care. Aims: We sought to collect data on pregnancy intentions and outcomes among TGE people assigned female or intersex at birth in the United States. Methods: Collaboratively with a study-specific community advisory team, we designed a customizable, online survey to measure sexual and reproductive health experiences among TGE people. Eligible participants included survey respondents who identified as a man or within the umbrella of transgender, nonbinary, or gender-expansive identities; were 18 years or older; able to complete an electronic survey in English; lived in the United States; and were assigned female or intersex at birth. Participants were recruited through The PRIDE Study - a national, online, longitudinal cohort study of sexual and gender minority people - and externally via online social media postings, TGE community e-mail distribution lists, in-person TGE community events, and academic and community conferences. We conducted descriptive analyses of pregnancy-related outcomes and report frequencies overall and by racial and ethnic identity, pregnancy intention, or testosterone use. Results: Out of 1,694 eligible TGE respondents who provided reproductive history data, 210 (12%) had been pregnant. Of these, 115 (55%) had one prior pregnancy, 47 (22%) had two prior pregnancies, and 48 (23%) had three or more prior pregnancies. Of the 433 pregnancies, 169 (39%) resulted in live birth, 142 (33%) miscarried, 92 (21%) ended in abortion, two (0.5%) ended in stillbirth, two (0.5%) had an ectopic pregnancy, and seven (2%) were still pregnant; nineteen pregnancies (4%) had an unknown outcome. Among live births, 39 (23%) were delivered via cesarean section. Across all pregnancies, 233 (54%) were unintended. Fifteen pregnancies occurred after initiation of testosterone, and four pregnancies occurred while taking testosterone. Among all participants, 186 (11%) wanted a future pregnancy, and 275 (16%) were unsure; 182 (11%) felt "at risk" for an unintended pregnancy. Discussion: TGE people in the United States plan for pregnancy, experience pregnancy (intended and unintended) and all pregnancy outcomes, and are engaged in family building. Sexual and reproductive health clinicians and counselors should avoid assumptions about pregnancy capacity or intentions based on a patient's presumed or stated gender or engagement with gender-affirming hormone therapy.

What Sexual and Gender Minority People Want Researchers to Know About Sexual Orientation and Gender Identity Questions: A Qualitative Study

Sexual and gender minority (SGM) people-including members of the lesbian, gay, bisexual, transgender, and queer communities-are understudied and underrepresented in research. Current sexual orientation and gender identity (SOGI) questions do not sufficiently engage SGM people, and there is a critical gap in understanding how SOGI questions reduce inclusion and accurate empirical representation. We conducted a qualitative study to answer the question, "For SGM people, what are the major limitations with current SOGI questions?" Focus groups probed reactions to SOGI questions adapted from prior national surveys and clinical best practice guidelines. Questions were refined and presented in semi-structured cognitive interviews. Template analysis using a priori themes guided analysis. There were 74 participants: 55 in nine focus groups and 19 in cognitive interviews. Participants were diverse: 51.3% identified as gender minorities, 87.8% as sexual minorities, 8.1% as Hispanic/Latinx, 13.5% as Black or African-American, and 43.2% as Non-white. Two major themes emerged: (1) SOGI questions did not allow for identity fluidity and complexity, reducing inclusion and representation, and (2) SOGI question stems and answer choices were often not clear as to which SOGI dimension was being assessed. To our knowledge, this represents the largest body of qualitative data studying SGM perspectives when responding to SOGI questions. We present recommendations for future development and use of SOGI measures. Attention to these topics may improve meaningful participation of SGM people in research and implementation of such research within and for SGM communities.

Eating disorder attitudes and disordered eating behaviors as measured by the Eating Disorder Examination Questionnaire (EDE-Q) among cisgender lesbian women

The Eating Disorder Examination Questionnaire (EDE-Q) is a measure of eating disorder attitudes and disordered eating behaviors. Prior descriptive studies of the EDE-Q for women either did not assess or omitted reporting sexual orientation. This study's objective was to assess eating disorder attitudes and disordered eating behaviors as measured by the EDE-Q among cisgender lesbian women. We present mean scores and standard deviations for the EDE-Q among 563 self-identified cisgender lesbian women ages 18-77 who were recruited from The PRIDE Study in 2018. Among cisgender lesbian women, 3.4 % scored in the clinically significant range on the Restraint, 1.6 % on the Eating Concern, 9.1 % on the Weight Concern, 13.9 % on the Shape Concern, and 3.9 % on the Global Score scales of the EDE-Q. We found that 13.5 % of participants reported any occurrence (≥1/28 days) of dietary restriction, 8.7 % for objective binge episodes, 5.3 % for excessive exercise, .4% for self-induced vomiting, and .4% for laxative misuse. Participants reported a current (1.8 %) or lifetime (7.1 %) diagnosis of an eating disorder by a clinician. These EDE-Q descriptive data capture eating disorder attitudes and disordered eating behaviors among cisgender lesbian women and may aid clinicians and researchers in interpreting the EDE-Q in this specific population.

Development of an affirming and customizable electronic survey of sexual and reproductive health experiences for transgender and gender nonbinary people

To address pervasive measurement biases in sexual and reproductive health (SRH) research, our interdisciplinary team created an affirming, customizable electronic survey to measure experiences with contraceptive use, pregnancy, and abortion for transgender and gender nonbinary people assigned female or intersex at birth and cisgender sexual minority women. Between May 2018 and April 2019, we developed a questionnaire with 328 items across 10 domains including gender identity; language used for sexual and reproductive anatomy and events; gender affirmation process history; sexual orientation and sexual activity; contraceptive use and preferences; pregnancy history and desires; abortion history and preferences; priorities for sexual and reproductive health care; family building experiences; and sociodemographic characteristics. Recognizing that the words people use for their sexual and reproductive anatomy can vary, we programmed the survey to allow participants to input the words they use to describe their bodies, and then used those customized words to replace traditional medical terms throughout the survey. This process-oriented paper aims to describe the rationale for and collaborative development of an affirming, customizable survey of the SRH needs and experiences of sexual and gender minorities, and to present summary demographic characteristics of 3,110 people who completed the survey. We also present data on usage of customizable words, and offer the full text of the survey, as well as code for programming the survey and cleaning the data, for others to use directly or as guidelines for how to measure SRH outcomes with greater sensitivity to gender diversity and a range of sexual orientations.

Screening gender minority people for harmful alcohol use

This study identifies how to screen for harmful alcohol use among gender minority (e.g., transgender and gender-expansive) people using brief screening methods and identifies which screening methods perform best among gender-expansive, transfeminine, and transmasculine subgroups, as screening recommendations are not currently available. Using 2018 Annual Questionnaire data from The PRIDE Study, area under the curve (AUC) values were compared to identify which screening methods ("4 or more" or "5 or more" drinks on one occasion in the past year, or one or more items from the Alcohol Use Disorders Identification Test [AUDIT]) best predicted (i) harmful alcohol use and (ii) one or more past year alcohol dependence symptoms or consequences. Among 1892 participants, "5 or more" drinks on one occasion (AUC ranges: 0.82-0.86) performed better than "4 or more" drinks (AUC ranges: 0.78-0.81) in predicting harmful drinking. The screening methods "4 or more" drinks, "5 or more" drinks, and the consumption items of the AUDIT (AUDIT-C) using a cutoff score of 3 all maximized sensitivity and specificity to predict alcohol dependence symptoms or consequences in gender minority people overall (AUC: 0.77-0.78). Screening for "5 or more" drinks on one occasion within the past year performed as well as or better than other screening methods to detect both harmful drinking and alcohol dependence-related symptoms or consequences. This single-item screening method can identify if more extensive alcohol use assessment is warranted with gender minority people.

Friend or Ally: Whether Cross-Group Contact Undermines Collective Action Depends on What Advantaged Group Members Say (or Don’t Say)

Previous research shows that positive contact with members of advantaged groups can undermine collective action among the disadvantaged. The present work provides the first experimental evidence of this effect and introduces a moderator which highlights the fundamental role of communication about perceptions of the legitimacy of intergroup inequality. Study 1 ( N = 267) focused on the lesbian/gay/bisexual/transgendered community’s struggle for same-sex marriage in California. In Study 2 ( N = 81), cross-group contact was initiated between members of two universities that differ in social status. Results revealed that positive cross-group contact undermined public collective action among the disadvantaged when the advantaged-group partner described their group’s advantaged position as legitimate or when they did not communicate their feelings about intergroup inequality (leaving them ambiguous). In contrast, when the advantaged-group partner clearly described the intergroup inequality as illegitimate, cross-group contact did not undermine participation in public collective action.