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Ralston AL, Holt NR, Andrews AR, Huit TZ, Puckett JA, Woodruff N, Mocarski R, Hope DA. Mental Health and Marginalization Stress in Transgender and Gender Diverse Adults: Differences between Urban and Non-Urban Experiences. Psychol Sex Orientat Gend Divers 2024; 11:165-176. [PMID: 38577413 PMCID: PMC10989840 DOI: 10.1037/sgd0000595] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Background Transgender and gender diverse (TGD) individuals face high rates of psychological distress, including depression, anxiety, and suicide risk. Further, TGD individuals living outside of urban areas experience additional disparities compared to their urban counterparts. Minority stress theory states that minority stressors (termed marginalization stressors for this paper), such as experiences of discrimination and internalized transphobia, lead to psychological distress. The current study compared marginalization stressors across rural (population less than 2,500), urban cluster (population between 2,500 and 50,000), and urban (population greater than 50,000) samples and tested the degree to which these stressors account for differences across areas of residence. Methods Participants were 225 TGD individuals who completed an online survey that included measures of depression, anxiety, suicidal ideation marginalization stress, and protective factors. Results In the first model, mental health outcomes, marginalization stressors, and protective factors differed between areas. Urban cluster participants reported experiencing higher levels of depression, anxiety, and suicidal ideation and rural participants reported experiencing higher levels of depression suicidal ideation than urban participants. Both rural and urban cluster participants reported more experiences of several marginalization stressors. In the subsequent path model, indirect effects between area and marginalization stress variables were significant, but urban cluster participants still reported higher depression, anxiety, and suicidal ideation symptoms (p-values < .05). Discussion We demonstrate that marginalization stress processes appear to account for some of the differences between TGD individuals living in urban, rural, and urban cluster areas. The differences between areas largely persist, however, after controlling for marginalization stress, especially when comparing urban with urban cluster areas.
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DuBois LZ, Puckett JA, Jolly D, Powers S, Walker T, Hope DA, Mocarski R, Huit TZ, Lash BR, Holt N, Ralston A, Miles M, Capannola A, Tipton C, Eick G, Juster RP. Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States. Horm Behav 2024; 159:105473. [PMID: 38190769 DOI: 10.1016/j.yhbeh.2023.105473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024]
Abstract
The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.
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Affiliation(s)
- L Zachary DuBois
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Jae A Puckett
- Department of Psychology, Michigan State University, 316 Physics Road, East Lansing, MI 48824, United States.
| | - Dee Jolly
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Sally Powers
- Department of Psychological and Brain Sciences, University of Massachusetts at Amherst, 135 Hicks Way, Amherst, MA 01003, United States.
| | - Tian Walker
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States; Office of Graduate Studies, University of Nebraska-Lincoln, Lincoln, NE 68588, United States.
| | - Richard Mocarski
- Office of Research, San José State University, One Washington Square, San José, CA, United States.
| | - T Zachary Huit
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Brenna R Lash
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Natalie Holt
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Allura Ralston
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Makinna Miles
- College of Public Health and Human Sciences, Oregon State University, 160 SW 26th St, Corvallis, OR 97331, United States
| | - A Capannola
- Department of Child & Family Studies, The University of Tennessee at Knoxville, 1215 W. Cumberland Ave., Knoxville, TN 37996, United States.
| | - Clove Tipton
- Department of Sociology, The University of Tennessee at Knoxville, 901 McClung Tower, Knoxville, TN 37996, United States.
| | - Geeta Eick
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States
| | - Robert-Paul Juster
- Department of Psychiatry and Addiction, University of Montreal, Research Center of the Montreal Mental Health University Institute, 7331 Hochelaga, FS-145-12, Montreal, Quebec H1N 3V2, Canada.
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Puckett JA, Huit TZ, Hope DA, Mocarski R, Lash BR, Walker T, Holt N, Ralston A, Miles M, Capannola A, Tipton C, Juster RP, DuBois LZ. Transgender and Gender-Diverse People's Experiences of Minority Stress, Mental Health, and Resilience in Relation to Perceptions of Sociopolitical Contexts. Transgend Health 2024; 9:14-23. [PMID: 38312451 PMCID: PMC10835148 DOI: 10.1089/trgh.2022.0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose The sociopolitical context in which transgender and gender-diverse (TGD) people live has significant effects on mental health. We examined whether perceptions of context (TGD people's perceptions of how TGD people were viewed) differed across four United States (U.S.) states and associations with mental health and identity pride, the mediational effects of minority stressors, and potential buffering effects of resilience. Methods TGD individuals in Oregon, Michigan, Nebraska, and Tennessee (n=158; ages 19-70, mean=33.06) completed questionnaires assessing their perceptions of how TGD people were viewed in their local area and in the U.S., as well as scales assessing minority stressors, pride, resilience, and mental health. Data were collected during Fall 2019 to Spring 2020. Results Oregon participants viewed perceptions in their state the most positively, with no state-level differences in terms of broader U.S. perceptions. Tennessee participants experienced more expectations of rejection; however, there were no differences across the states in other minority stress variables, identity pride, resilience, or mental health. Participants who viewed their area as having more negative views of TGD people reported higher levels of discrimination, expectations of negative events, internalized stigma, and anxiety, as well as less pride. The effects of perceptions of local context on mental health were partially explained by enacted stigma and internalized stigma. Resilience did not buffer the effects of perceptions of the local context on mental health or pride. Conclusion Context is important to shaping exposure to minority stressors and mental health, potentially through increasing enacted and internalized stigma.
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Affiliation(s)
- Jae A Puckett
- Department of Psychology, Michigan State University, East Lansing, Michigan, USA
| | - T Zachary Huit
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
- Office of Graduate Studies, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Richard Mocarski
- Office of Research, San José State University, San José, California, USA
| | - Brenna R Lash
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Tian Walker
- Department of Anthropology, University of Oregon, Eugene, Oregon, USA
| | - Natalie Holt
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Allura Ralston
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Makinna Miles
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - A Capannola
- Department of Child and Family Studies, The University of Tennessee at Knoxville, Knoxville, Tennessee, USA
| | - Clove Tipton
- Department of Sociology, The University of Tennessee at Knoxville, Knoxville, Tennessee, USA
| | - Robert-Paul Juster
- Department of Psychiatry and Addiction, University of Montreal, Montreal, Canada
| | - L Zachary DuBois
- Department of Anthropology, University of Oregon, Eugene, Oregon, USA
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Holt NR, Hope DA, Mocarski R, Woodruff N. The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults. Curr Psychiatry Rep 2023; 25:105-111. [PMID: 36773177 PMCID: PMC9918830 DOI: 10.1007/s11920-023-01410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE OF REVIEW We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients. RECENT FINDINGS Barriers and facilitators at all socioecological levels impact TGD adults' mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. More work-both advocacy and research-is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps.
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Affiliation(s)
- Natalie R Holt
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Richard Mocarski
- Office of Research, San Jose State University, San Jose, CA, USA
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Dietsch AM, Mocarski R, Hope DA, Woodruff N, McKelvey M. Revisiting the Rainbow: Culturally Responsive Updates to a Standard Clinical Resource. Am J Speech Lang Pathol 2023; 32:377-380. [PMID: 36356220 DOI: 10.1044/2022_ajslp-22-00215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Cultural responsivity is essential for efficacious and affirming clinical relationships. This may be especially important with historically marginalized clients, such as transgender and gender-diverse (TGD) people seeking behaviorally based affirming communication services. We recommend modifications to standard tools for diagnostics and training that otherwise might undermine our efforts to create an inclusive and affirming environment. METHOD Modifications to the Rainbow Passage, a standardized paragraph utilized for eliciting speech samples in clinical settings, focused on nongendered terminology and the elimination of content with religious connotations. RESULTS The recommended edits to the Rainbow Passage maintain similar length, cadence, and phonetic balance while considering cultural and health care context for TGD people and other clients. CONCLUSION Simple linguistic changes to a standardized paragraph maintain clinical benefits and facilitate SLP efforts toward cultural responsivity, client engagement, and good clinical outcomes.
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Affiliation(s)
- Angela M Dietsch
- Department of Special Education and Communication Disorders, University of Nebraska-Lincoln
| | | | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln
| | | | - Miechelle McKelvey
- Department of Communication Disorders, University of Nebraska at Kearney
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Puckett JA, Holt NR, Lash B, Zachary Huit T, Ralston AL, Hope DA, Mocarski R, Zachary DuBois L. Transgender and gender diverse adults' self-reported mental health diagnoses, engagement in mental health services, and perceptions of therapists. Psychother Res 2023; 33:84-95. [PMID: 35767823 DOI: 10.1080/10503307.2022.2091961] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice. METHOD The sample included 158 TGD adults (Mage = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms. RESULTS Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction. CONCLUSIONS Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.
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Affiliation(s)
- Jae A Puckett
- Department of Psychology, Michigan State University, East Lansing
| | - Natalie R Holt
- Clinical Psychology Fellow, VA Quality Scholars, VA Tennessee Valley Healthcare System, Nashville
| | - Brenna Lash
- Department of Psychology, University of Nebraska-Lincoln, Lincoln
| | - T Zachary Huit
- Department of Psychology, University of Nebraska-Lincoln, Lincoln
| | - Allura L Ralston
- Department of Psychology, University of Nebraska-Lincoln, Lincoln
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, Lincoln
| | - Richard Mocarski
- Associate Vice President for Research, San José State University, San José
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Holt NR, Obasi SN, Nisley C, LeBlanc-Ralston AL, Lash B, Huit TZ, Hope DA, Woodruff N, Mocarski R. Transgender and Gender Diverse Community Perspectives on Barriers and Benefits of the Psychosocial Assessment for Gender-Affirming Medical Care. J Health Care Poor Underserved 2023; 34:569-584. [PMID: 37464518 DOI: 10.1353/hpu.2023.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Transgender and gender diverse (TGD) individuals often must undergo a psychosocial assessment and receive a letter of support from a mental health care provider to access gender-affirming medical care (GAMC). This study describes TGD individuals' perceptions of barriers and benefits of the assessment process and uses thematic analysis to explore TGD individuals' opinions on how mental health care should or should not be related to gender-affirming medical care. Two hundred and eighteen TGD participants completed an online survey. Participants endorsed benefits and negative impacts associated with the psychosocial assessment and provided qualitative responses to explain their support or opposition to involvement of mental health care and assessment in accessing GAMC. Nearly all participants identified both benefits (e.g., "experienced validation") and barriers (e.g., "experienced an increase in psychological distress") to the psychosocial assessment. Results are considered in the context of the historical marginalization and gatekeeping of TGD people by the medical system.
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DuBois LZ, SturtzSreetharan C, MacFife B, Puckett JA, Jagielski A, Dunn T, Anderson T, Hope DA, Mocarski R, Juster RP. Trans and Gender Diverse People's Experience Wearing Face Masks During the COVID-19 Pandemic: Findings from Data Across 4 States in the USA. Sex Res Social Policy 2022; 20:1-9. [PMID: 36589257 PMCID: PMC9792916 DOI: 10.1007/s13178-022-00781-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 06/17/2023]
Abstract
Introduction Social isolation and reduced access to public life in response to SARS-CoV-2 (COVID-19) challenges health and well-being for many. Marginalized communities, including transgender and gender diverse (TGD) people, have been disproportionally impacted. Experiences of TGD people should be centered in pandemic-related research to better inform policy. Methods A diverse sample of TGD people (N = 158) were recruited from Michigan, Nebraska, Oregon, and Tennessee to participate in the Trans Resilience and Health Study. Participants ranged from 19 to 70 years old (M = 33.06; SD = 12.88) with 27.2% identifying as trans men/men, 26% identifying as trans women/women, and remaining identifying with terms like genderqueer and nonbinary. Thirty percent identified as people of color. Participants completed a monthly COVID-19-related questionnaire April 2020-March 2021 including open-ended questions to learn what contributed to resilience during this time. Thematic analyses of responses enabled identification of salient themes. Results Analyses revealed pandemic-related changes in social experiences of marginalization and mask-wearing. Twenty-six participants mentioned face masks as contributing to resilience while also elaborating the influence of masks on experiences of misgendering. Participants identifying as trans women reported decreased misgendering while trans men and nonbinary participants reported increased misgendering. Conclusions and Policy Implications Mask-wearing helps reduce transmission of COVID-19. For some trans women, masks also reduce the threat of misgendering and possibly other forms of enacted stigma. However, increased risk for misgendering, as noted by trans men in our study, should be considered and increased supports should be provided.
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Affiliation(s)
- L. Zachary DuBois
- Department of Anthropology, University of Oregon, 355 Condon Hall, Eugene, OR 97403 USA
| | - Cindi SturtzSreetharan
- School of Human Evolution and Social Change, Arizona State University, SHESC Bldg 266 ASU, P.O. Box 872402, Tempe, AZ 85287 USA
| | - Bex MacFife
- Department of Sociology, University of Oregon, 1415 Kincaid St, Eugene, OR 97403 USA
| | - Jae A. Puckett
- Department of Psychology, Michigan State University, 316 Physics Rd., East Lansing, MI 48824 USA
| | - Alex Jagielski
- Department of Anthropology, University of Oregon, 355 Condon Hall, Eugene, OR 97403 USA
| | - Terra Dunn
- Department of Psychology, Michigan State University, 316 Physics Rd., East Lansing, MI 48824 USA
| | - Taylor Anderson
- Department of Psychology, Michigan State University, 316 Physics Rd., East Lansing, MI 48824 USA
| | - Debra A. Hope
- Department of Psychology, University of Nebraska-Lincoln, 1100 Seaton Hall, Lincoln, NE 68588 USA
| | - Richard Mocarski
- Office of Research, San José State University, One Washington Square, 525a Clark Hall, San José, CA 95126 USA
| | - Robert-Paul Juster
- Department of Psychiatry and Addiction, University of Montreal, 7331 Hochelaga, FS-145-12, Montreal, QC H1N 3V2 Canada
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Puckett JA, Price SF, Mocarski R, Mustanski B, Newcomb ME. Transgender and gender diverse individuals' daily experiences of rumination. Am J Orthopsychiatry 2022; 92:540-551. [PMID: 35834218 PMCID: PMC9946683 DOI: 10.1037/ort0000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Transgender and gender diverse (TGD) people face a myriad of daily stressors because of the hegemonic gender norms embedded within U.S. society. Due to these minority stressors, TGD people report elevated anxiety, depression, stress, and suicidality, among other health issues. One mechanism through which stigma may lead to these negative mental health outcomes is through increased rumination. In this intensive daily diary study with 181 TGD individuals (ages 16-40), we gathered qualitative data on their ruminative thoughts over the course of 56 days. There were a total of 2,431 responses across participants, with individuals providing a range of 1-53 responses (M = 15 responses). Using an experiential framework and an inductive approach to thematic analysis, we generated the following themes: (a) interpersonal relationships as a site of struggle, (b) fear and worry in response to contextual factors, (c) the weight of basic needs and safety, (d) gender as experienced through self and others, (e) intersections of health and rumination, and (f) the occasional reprieve. Using a deductive approach, we also placed these data within the context of Bronfenbrenner's Person-Process-Context-Time model to provide a conceptual model for future research in this area. These ruminative experiences revealed significant adversities and challenges weighing on participants' minds that spanned many areas of life. These findings also highlight the nuanced nature of rumination for TGD individuals and areas that may be overlooked in current assessments of this construct. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Obasi SN, Myers RK, Holt N, Mocarski R, Hope DA, Woodruff N. Educational preparedness to care for transgender and gender diverse adults: Perspectives of mental health professionals. J Gay Lesbian Soc Serv 2022; 35:204-217. [PMID: 37635934 PMCID: PMC10448943 DOI: 10.1080/10538720.2022.2056782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Ensuring that mental health professionals are appropriately trained to provide affirming and sensitive care to transgender and gender diverse (TGD) adults is one mechanism that may reduce the marginalization sometimes experienced by TGD adults in mental health contexts. In this study, mental health professionals (n=142) completed an online survey documenting the sources and types of training received to provide TGD-sensitive care; and, shared a self-assessment of their comfort, competence, and ability to provide TGD-sensitive care. Findings revealed that the majority of the mental health professionals in the study (approximately 81%) received specific training to work with TGD clients from a variety of sources. These mental health professionals also self-reported high levels of comfort, competence, and ability to offer TGD-sensitive care which were statistically significantly associated with the number of hours of TGD-specific training they had received.
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Affiliation(s)
- Sharon N. Obasi
- Department of Counseling, School Psychology and Family Science, University of Nebraska at Kearney, Kearney, Nebraska, USA
| | - Robyn King Myers
- Department of Counseling, School Psychology and Family Science, University of Nebraska at Kearney, Kearney, Nebraska, USA
| | - Natalie Holt
- Department of Psychology, University of Nebraska – Lincoln, Lincoln, Nebraska, USA
| | - Richard Mocarski
- Office of Sponsored Programs, University of Nebraska at Kearney, Kearney, Nebraska, USA
| | - Debra A. Hope
- Department of Psychology, University of Nebraska – Lincoln, Lincoln, Nebraska, USA
| | - Nathan Woodruff
- Trans Collaborations Local Community Board, Lincoln, Nebraska, USA
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Price SF, Puckett JA, Mocarski R. The Impact of the 2016 Presidential Elections on Transgender and Gender Diverse People. Sex Res Social Policy 2021; 18:1094-1103. [PMID: 34925634 PMCID: PMC8673739 DOI: 10.1007/s13178-020-00513-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/01/2020] [Indexed: 05/30/2023]
Abstract
BACKGROUND With Trump's presidency came a rise in the oppression of transgender and gender diverse (TGD) people, as the nation witnessed a removal of protections for TGD people. METHOD We examined the daily experiences of 181 TGD individuals (ages 16-40, M age = 25.6) through their reflections about daily stressors over the course of 8 weeks (data collected fall 2015-summer 2017), some of which reflected shifts during the election period. RESULTS During 2016 presidential election, participants reported a rise in marginalization stress and the subsequent impact on safety, mental health, and well-being. There were three emergent themes: External Rejection and Stigma from Dominant Culture; Supporting the TGD Community; and Fear for the Self and Development of Proximal Stressors. CONCLUSION In line with marginalization stress theory, participants vocalized the progression from exterior stigmatization to proximal stressors and their heightened sense of vigilance and fear of the dominant culture.
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Affiliation(s)
- Sarah F Price
- College of Communication and Information Sciences, University of Alabama, 901 University Blvd, Tuscaloosa, AL 35401
| | - Jae A Puckett
- Department of Psychology, Michigan State University, 316 Physics Road, East Lansing, MI 48824
| | - Richard Mocarski
- Division of Research, University of Nebraska at Kearney, 2134 Warner Hall, Kearney, NE 68845
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Holt NR, Ralston AL, Hope DA, Mocarski R, Woodruff N. A Systematic Review of Recommendations for Behavioral Health Services for Transgender and Gender Diverse Adults: The Three-Legged Stool of Evidence-Based Practice is Unbalanced. Clin Psychol (New York) 2021; 28:186-201. [PMID: 34456519 PMCID: PMC8386449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is a growing literature of clinical recommendations for transgender and gender diverse (TGD) affirming behavioral health care, yet it is unknown to what extent these recommendations are rooted in evidence-based practice (EBP). This systematic review included 65 articles published between 2009 and 2018 with recommendations for behavioral health services with TGD adults, emphasizing general clinical care. Coded variables included type of article, participant demographics, aspects of EBP, and whether care was informed by objective assessment. Most articles did not equally draw from all components of EBP. Recommendations for specific clinical problems are increasingly available and address diversity within TGD communities. More research, including clinical trials adapting established interventions, is needed to inform state-of-the-art TGD-affirmative behavioral health care.
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Holt NR, King RE, Mocarski R, Woodruff N, Hope DA. Specialists in Name or Practice? The Inclusion of Transgender and Gender Diverse Identities in Online Materials of Gender Specialists. J Gay Lesbian Soc Serv 2020; 33:1-15. [PMID: 34140762 PMCID: PMC8204661 DOI: 10.1080/10538720.2020.1763225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Recommendations for health care providers working with transgender and gender diverse (TGD) individuals emphasize affirming clients' identities, such as using correct pronouns and name, however it is unknown how often gender specialists adhere to such recommendations. Websites and intake forms of gender specialists were coded for use of affirming language, asking for pronouns and chosen name, and mention of TGD specialties and resources. Most websites identified the provider's specialty to work with TGD individuals, though much fewer provided additional resources concerning TGD issues and only half of intake forms included affirming language. Given previous research that has demonstrated providers working in states with legal protections for TGD individuals use affirming language more often than providers in locales without protections, association with state legal climate is also examined.
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Affiliation(s)
- Natalie R Holt
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-03011
| | - Robyn E King
- Department of Counseling and School Psychology, University of Nebraska at Kearney, Kearney, Nebraska
| | - Richard Mocarski
- Department of Communication, University of Nebraska at Kearney, Kearney, Nebraska
| | - Nathan Woodruff
- Trans Collaborations Local Community Board, Lincoln, Nebraska
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-03011
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Meyer HM, Mocarski R, Holt NR, Hope DA, King RE, Woodruff N. Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains. Qual Health Res 2020; 30:409-422. [PMID: 31328642 DOI: 10.1177/1049732319860265] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient-health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.
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Affiliation(s)
| | | | | | - Debra A Hope
- University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Robyn E King
- University of Nebraska at Kearney, Kearney, Nebraska, USA
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Holt NR, Huit TZ, Shulman GP, Meza JL, Smyth JD, Woodruff N, Mocarski R, Puckett JA, Hope DA. Trans Collaborations Clinical Check-In (TC 3): Initial Validation of a Clinical Measure for Transgender and Gender Diverse Adults Receiving Psychological Services. Behav Ther 2019; 50:1136-1149. [PMID: 31735248 PMCID: PMC7405917 DOI: 10.1016/j.beth.2019.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 01/07/2023]
Abstract
One key aspect of evidence-based psychological services is monitoring progress to inform treatment decision making, often using a brief self-report measure. However, no such measure exists to support measurement-based care, given the distinct needs of transgender and gender diverse people (TGD), a group facing large documented health disparities and marginalization in health care. The purpose of the present study was to develop and provide initial psychometric validation of a short, behavioral health progress monitoring self-report measure, the Trans Collaborations Clinical Check-in (TC3). TGD communities, providers identified as TGD-affirmative, and relevant academic experts contributed to item and scale development. The final 18-item version was administered to 215 TGD adults (75 transfeminine, 76 transmasculine, 46 nonbinary, 18 unknown; mean age of 30 with a range of 19 to 73), who were recruited for an online study, with other questionnaires assessing negative affect, well-being, gender dysphoria, gender minority stressors, and resilience. Higher scores on the TC3 (indicating better adjustment and comfort with gender) were generally associated with lower depression, anxiety, minority stress, and gender dysphoria and greater life satisfaction, body congruence, and positive aspects of being TGD such as pride in identity and community belongingness. These results support the validity of the TC3 as a brief measure to be used as a clinical tool for TGD people receiving mental health services. Additional research is needed on the reliability and validity of the TC3 across multiple time points to determine utility as a progress monitoring measure. The TC3 should also be further validated with more culturally diverse samples.
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Mocarski R, King R, Butler S, Holt NR, Huit TZ, Hope DA, Meyer HM, Woodruff N. The Rise of Transgender and Gender Diverse Representation in the Media: Impacts on the Population. Commun Cult Crit 2019; 12:416-433. [PMID: 31709008 PMCID: PMC6824534 DOI: 10.1093/ccc/tcz031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 03/24/2019] [Accepted: 05/21/2019] [Indexed: 06/01/2023]
Abstract
In recent years, the transgender and gender diverse (TGD) population has gained a stronger voice in the media. Although these voices are being heard, there are limits on the types of TGD representation displayed in media. The current study interviewed 27 TGD individuals. These interviews exposed how participants view the rise of TGD media representation. The main themes that emerged were TGD awareness and TGD identity discovery and role modeling. Clearly, there is a disconnect between transnormativity in the media and transnormativity in reality.
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Affiliation(s)
- Richard Mocarski
- Division of Research, University of Nebraska at Kearney, Kearney, NE, USA
| | - Robyn King
- Counseling and School Psychology, University of Nebraska at Kearney, Kearney, NE, USA
| | - Sim Butler
- Communication Studies, The University of Alabama, Tuscaloosa, AL, USA
| | - Natalie R Holt
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - T Zachary Huit
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Heather M Meyer
- Marketing, University of Nebraska at Kearney, Kearney, NE, USA
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Holt NR, Hope DA, Mocarski R, Meyer H, King R, Woodruff N. The provider perspective on behavioral health care for transgender and gender nonconforming individuals in the Central Great Plains: A qualitative study of approaches and needs. Am J Orthopsychiatry 2019; 90:136-146. [PMID: 30920242 PMCID: PMC6940540 DOI: 10.1037/ort0000406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transgender and gender nonconforming (TGNC) individuals interact with mental health care systems at high rates and experience substantial barriers to care. Rural TGNC individuals face additional disparities in accessing appropriate mental health services. Little research has focused on the mental health care providers who work with TGNC individuals in underserved areas. The current study sought to describe the mental health care services delivered by providers perceived as affirming by TGNC community members in the Central Great Plains. We conducted qualitative interviews with 10 providers to understand how providers seek cultural competency and conceptualize and work with their TGNC clients given the barriers to care. Providers held diverse theoretical orientations and described challenges to working with TGNC clients, including the impact of stigma and marginalization and financial and structural barriers to care. Emphasis was placed on individualizing care, helping clients to manage stigma and build resiliency, connecting clients to resources (when available) and support systems, and navigating the intersections of physical health care and mental health care, such as writing letters for medical transition. Providers largely educated themselves on TGNC topics and had previous experience working with marginalized populations. Overall, the providers' approaches to working with TGNC clients mapped onto models of cultural competency, but few providers described their work in the context of an evidence-based model. Implications for increasing the quality and availability of mental health care services for TGNC individuals in underserved areas are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | - Richard Mocarski
- Mocarski, Department of Communication, University of Nebraska at Kearney
| | - Heather Meyer
- Department of Marketing, University of Nebraska at Kearney
| | - Robyn King
- Department of Counseling and School Psychology, University of Nebraska at Kearney
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Holt NR, Hope DA, Mocarski R, Woodruff N. First Impressions Online: The Inclusion of Transgender and Gender Nonconforming Identities and Services in Mental Healthcare Providers' Online Materials in the USA. INT J TRANSGENDERISM 2018; 20:49-62. [PMID: 31217753 PMCID: PMC6583891 DOI: 10.1080/15532739.2018.1428842] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. AIMS The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. METHODS Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client's pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. RESULTS While provider websites were found through Google searches for a "gender therapist," only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client's pronouns than intake forms from States without legal protections. DISCUSSION Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections.
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Affiliation(s)
- Natalie R. Holt
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Debra A. Hope
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Richard Mocarski
- Office of Sponsored Programs and Research Development, University of Nebraska at Kearney, Kearney, Nebraska, USA
| | - Nathan Woodruff
- Trans Collaborations Local Community Board, Lincoln, Nebraska, USA
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Shulman GP, Holt NR, Hope DA, Mocarski R, Eyer J, Woodruff N. A Review of Contemporary Assessment Tools for Use with Transgender and Gender Nonconforming Adults. Psychol Sex Orientat Gend Divers 2017; 4:304-313. [PMID: 29201935 DOI: 10.1037/sgd0000233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There is increasing recognition of the need for culturally sensitive services for individuals who identify as transgender or gender non-conforming (TGNC), and only recently have empirical studies appeared in the literature that inform best practices for TGNC people. Competent, culturally appropriate clinical services and research depend upon methodologically sound assessment of key constructs, but it is unclear whether appropriate self-report or clinician-rated assessment tools for adults exist. This paper reviewed existing published measures to identify areas of strength as well as existing gaps in the available research. The search strategy for this systematic review identified any published paper describing a self-report or clinician-rated scale for assessing transgender-related concerns. Each measure was reviewed for information on its scope, reliability, validity, strengths, limitations, and source. The majority of these questionnaires were developed with the TGNC communities and targeted important factors that affect quality of life for TGNC people. Limitations included limited evidence for validity, reliability, and sensitivity to change. Overall, the field is moving in the direction of TGNC-affirming assessment, and promising measures have been created to monitor important aspects of quality of life for TGNC people. Future research should continue to validate these measures for use in assessing clinical outcomes and the monitoring of treatment progress.
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Hope DA, Mocarski R, Bautista CL, Holt NR. Culturally competent evidence-based behavioral health services for the transgender community: Progress and challenges. Am J Orthopsychiatry 2016; 86:361-5. [PMID: 27380149 DOI: 10.1037/ort0000197] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The presence of individuals who identify as transgender has emerged into public awareness in the United States in recent years. Celebrities who publicly transition have expanded the national conversation about gender variation beyond gender and women's studies classrooms and certain specialty health and mental health services. This increased public visibility has been accompanied by increased visibility in the mental health literature, including the publishing of competencies or guidelines for working with clients who identify as transgender by various professional organizations. However, rapid societal changes and increased understanding of the experience of being transgender in our society means literature can rapidly become dated. This commentary identifies key points that will move forward professional competency, both of the field and of individual practitioners, in the provision of psychological services. Topics discussed include (1) how mental health has contributed to trans stigma, (2) why more than good intentions are needed, (3) a research agenda for the development of high-quality evidence-based behavioral health care for the trans community, and (4) clinician recommendations. (PsycINFO Database Record
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Affiliation(s)
- Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln
| | | | | | - Natalie R Holt
- Department of Psychology, University of Nebraska-Lincoln
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Abstract
Through a critical rhetorical analysis using Bandura’s social cognitive theory as a lens to view The Biggest Loser ( TBL), this article illustrates the contradictions between the show’s health promotional aims and its entertainment aims, which show the problems the show creates for health promotion practitioners working on obesity. The social cognitive theory constructs of observational learning, psychological determinants, and environmental determinants emerged from this reading of TBL as central to how the show masquerades as a health promotion tool. This reading reveals that TBL promotes a neoliberal construction of health and obesity that challenges the worldview that many health promotion campaigns take and, therefore, complicates our own efforts to combat obesity. With this revealed, it is suggested that TBL be incorporated into health promotion campaigns only as a foil.
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Abstract
Mechanical failure of the cement-bone interface can contribute to clinical loosening of cemented total hip replacements. The conditions that cause loosening are poorly understood, in part, due to a lack of information on the mechanical behavior of the cement bone interface. The purpose of this study was to determine the mechanical behavior of the cement-bone interface due to mixed-mode (combined tension and shear) loading and to develop a failure model for the cement bone interface. Laboratory tests of machined cement-bone test specimens were performed with mixed-mode loading conditions (loading angles of 22.5 degrees, 45 degrees, and 67.5 degrees) to determine the mechanical response in the pre-yield and post-yield state. After accounting for the quantity of interdigitated bone as a covariate, the mixed-mode data were combined with previous tension (0 degrees) and shear data (90 degrees) to develop a failure model for the cement bone interface. The strength of the interface was positively correlated with the quantity of interdigitated bone (r2 = 0.70, 0.53, 0.49, for 22.5 degrees, 45 degrees, and 67.5 degrees, respectively). There was a significant increase in failure strength (P < 0.001) with increasing mixed-mode angle. When all data were incorporated into an elliptical failure criterion, the average error between the actual and predicted strength was 33%. These results can now be incorporated into constitutive models of the cement bone interface to determine the initiation and progression of interface failure in cemented total hip replacements.
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Affiliation(s)
- K A Mann
- Department of Orthopedic Surgery, Institute for Human Performance, Upstate Medical University, Syracuse, New York 13210, USA.
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