Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations.

OBJECTIVE: Two-step questions to assess gender identity are recommended for optimizing care delivery for gender-diverse individuals. As gender identity fields are increasingly integrated into electronic health records, guidance is needed on how to analyze these data. The goal of this study was to assess potential approaches for analyzing 2-step gender identity questions and the impact of each on suicidal ideation. MATERIALS AND METHODS: A regional Youth Risk Behavior Survey in one Northeastern school district used a 2-step question to assess gender identity. Three gender measurement strategies (GMSs) were used to operationalize gender identity, (1) combining all gender-diverse youth (GDY) into one category, (2) grouping GDY based on sex assigned at birth, and (3) categorizing GDY based on binary and nonbinary identities. Mixed-effects logistic regression was used to compare odds of suicidal ideation between gender identity categories for each GMS. RESULTS: Of the 3010 participants, 8.3% were GDY. Subcategories of GDY had significantly higher odds (odds ratio range, 1.6-2.9) of suicidal ideation than cisgender girls regardless of GMS, while every category of GDY had significantly higher odds (odds ratio range, 2.1-5.0) of suicidal ideation than cisgender boys. CONCLUSIONS: The field of clinical informatics has an opportunity to incorporate inclusive items like the 2-step gender identity question into electronic health records to optimize care and strengthen clinical research. Analysis of the 2-step gender identity question impacts study results and interpretation. Attention to how data about GDY are captured will support for more nuanced, tailored analyses that better reflect unique experiences within this population.

Intersectional Differences in Protective School Assets by Sexuality, Gender, Race/Ethnicity, and Socioeconomic Status.

BACKGROUND: School assets-such as connectedness, caring relationships with adults, high behavioral expectations from adults, and meaningful participation-are associated with positive outcomes for adolescents. However, little is known about how school assets differ among adolescents with intersecting marginalized identities. METHODS: We used the 2013-2014 California Healthy Kids Survey (N = 320,462 students) to examine differences in school assets with respect to sexuality, gender, race/ethnicity, and socioeconomic status using adjusted multilevel linear regression models. RESULTS: Sexual minority, gender minority, racial/ethnic minority, and low socioeconomic status adolescents had significantly lower protective school assets. For all outcomes, the differences between sexual minority and heterosexual adolescents were more pronounced among nontransgender girls than nontransgender boys; however, these differences were not consistently present among racial/ethnic minority students. For school connectedness and meaningful participation, differences for racial/ethnic minorities versus white adolescents were more pronounced among nontransgender girls than nontransgender boys. Differences between transgender adolescents and nontransgender boys were more pronounced for white adolescents compared to some other racial/ethnic minority students. Overall, adolescents with certain multiple marginalized identities had lower school assets. CONCLUSIONS: Interventions are needed to strengthen school assets among marginalized students, thereby helping mitigate health and education inequities.

Cases of Sexual Assault Prevented in an Athletic Coach-Delivered Gender Violence Prevention Program.

Sexual violence (SV) is pervasive and economically burdensome in the USA. According to the CDC, SV prevention could avert $122,461 in costs per victim of rape, totaling an estimated $3.1 trillion. Coaching Boys into Men (CBIM) is an evidence-based dating abuse and SV prevention program found to reduce dating abuse and SV perpetration among male high school athletes and dating abuse among middle school athletes. This secondary data analysis of CBIM's high school (N = 1520) and middle school (N = 973) RCTs estimated the incidence of dating abuse, sexual harassment, and sexual assault that CBIM could prevent as well as the potential cost savings. Ten items measured dating abuse, with a subset measuring sexual assault and sexual harassment, among participants who had ever dated a female. Perpetration measures were dichotomized as present or absent. Maximum likelihood estimates of Poisson-distributed event rates allowed for possible multiple incidents of perpetration per athlete. Among high school athletes, CBIM was associated with a relative reduction of 85 incidents of dating abuse (95%CI 24, 146), 48 incidents of sexual harassment (95%CI 3.8, 92), and 20 incidents of sexual assault (95%CI 1.7, 38) per 1,000 athletes. Results among middle school athletes demonstrated similar, albeit non-significant, trends. Based on the reduction of sexual assaults among high school athletes alone, CBIM may have resulted in $2.4 million reduction in costs per 1000 athletes exposed. CBIM may be associated with significant sexual assault-related cost reductions. Given the low costs and time needed to implement the program, sexual and dating violence prevention programs like CBIM may result in substantial economic benefits.

"This Could Mean Death for My Child": Parent Perspectives on Laws Banning Gender-Affirming Care for Transgender Adolescents.

OBJECTIVES: Numerous U.S. state legislatures have proposed bills to ban gender-affirming medical interventions for minors. Parents and caregivers play a critical role in advocating for and supporting their transgender and gender-diverse youth (TGDY). We aimed to understand parent and caregiver perspectives about this potential legislation and perceived effects on their TGDY's mental health. METHODS: We developed and launched a social-media based, anonymous online survey in February 2020 to assess parent and caregiver perspectives on proposed laws to ban gender-affirming medical interventions for minors. Participants were asked to respond to two open-ended questions about these laws; responses were coded to identify key themes. RESULTS: We analyzed responses from 273 participants from 43 states. Most identified as white (86.4%) female (90.0%) mothers (93.8%), and 83.6% of their TGDY had received gender-affirming medical interventions before age 18 years. The most salient theme, which appeared in the majority of responses, described parent and caregiver fears that these laws would lead to worsening mental health and suicide for their TGDY. Additional themes included a fear that their TGDY would face increased discrimination, lose access to gender-affirming medical interventions, and lose autonomy over medical decision-making due to government overreach. CONCLUSIONS: In this convenience sample, parents and caregivers overwhelmingly expressed fear that the proposed legislation will lead to worsening mental health and increased suicidal ideation for their TGDY. They implored lawmakers to hear their stories and to leave critical decisions about gender-affirming medical interventions to families and their medical providers.

Effect of a Community-Based Gender Norms Program on Sexual Violence Perpetration by Adolescent Boys and Young Men: A Cluster Randomized Clinical Trial.

Importance: Engaging adolescent boys and young men in preventing violence against women is a potentially impactful public health strategy. Objective: To evaluate the effectiveness of a community-based, gender-transformative program (ie, Manhood 2.0) on perpetration of gender-based violence by adolescent boys and young men. Design, Setting, and Participants: In this unblinded cluster randomized clinical trial, neighborhoods were designated as the unit of clustering (1:1 allocation). Three-month (ie, time point 2 [T2]) and 9-month (ie, time point 3 [T3]) follow-ups were conducted. The trial took place in 20 Pittsburgh, Pennsylvania, neighborhoods and 1 centrally located site with concentrated disadvantage. Pittsburgh-based adolescent boys and young men (ages 13 to 19 years) were recruited between July 27, 2015, and June 5, 2017, through youth-serving organizations and community-based alternatives to residential placement for juvenile justice-involved youth. Intention-to-treat analysis was conducted from June 2018 to November 2019. Interventions: Manhood 2.0, an international program adapted for adolescent boys and young men in US urban communities, encourages these individuals to challenge gender norms that foster violence against women and unhealthy sexual relationships. Individuals in the control population received job-readiness training. Each program was 18 hours. Main Outcomes and Measures: The primary outcome was change in participant-level perpetration of sexual violence (SV) or adolescent relationship abuse (ARA) at T3. Results: Among 866 participants, 465 individuals (54%) enrolled in 11 intervention clusters and 401 individuals (46%) enrolled in 10 control clusters. In the intervention group, 325 participants (70%) were analyzed at T2 and 334 participants (72%) were analyzed at T3; in the control group, 262 participants (65%) were analyzed at T2 and 301 participants (75%) were analyzed at T3. Mean (SD) age was 15.5 (1.6) years; 609 participants (70%) self-identified as non-Hispanic Black, and 178 (20%) self-identified as Hispanic, multiracial, or other race/ethnicity other than White. Among individuals in the intervention group, 296 participants (64%) reported any SV or ARA perpetration at baseline, and 173 participants (52%) reported any SV or ARA perpetration at T3. Among individuals in the control group, 213 participants (53%) reported any SV or ARA perpetration at baseline, and 124 participants (41%) reported any SV or ARA perpetration at T3). The difference in reduction between groups was not significant. There was no evidence of an intervention effect for the primary outcome (adjusted odds ratio [OR], 1.32; 95% CI, 0.86-2.01; P = .20). Conclusions and Relevance: The findings from this evaluation of a community-based gender-transformative program for adolescent boys and young men did not show a significant intervention effect in reducing SV or ARA perpetration between Manhood 2.0 and a job-readiness control program. Combining gender-transformative approaches with job-readiness programs may be relevant for violence prevention in low-resource urban settings. Attention to improving implementation and strategies to sustain such community-based efforts are needed. Trial Registration: ClinicalTrials.gov Identifier: NCT02427061.

An Athletic Coach-Delivered Middle School Gender Violence Prevention Program: A Cluster Randomized Clinical Trial.

Importance: Adolescent relationship abuse (ARA) and sexual violence (SV) reported among adolescents point to the need for prevention among middle school-age youths. Objective: To test an athletic coach-delivered relationship abuse and sexual violence prevention program among middle school male athletes. Design, Setting, and Participants: An unblinded cluster randomized clinical trial from spring 2015 to fall 2017 at 41 middle schools (38 clusters). The study included 973 male middle school athletes (ages 11-14 years; grades 6-8; participation rate 50%) followed up for 1 year (retention 86%). Interventions: Coaching Boys Into Men (CBIM) is a prevention program that trains athletic coaches to talk to male athletes about (1) respectful relationship behaviors, (2) promoting more gender-equitable attitudes, and (3) positive bystander intervention when harmful behaviors among peers are witnessed. Main Outcomes and Measures: The primary outcome was change in positive bystander behaviors (ie, intervening in peers' disrespectful or harmful behaviors); secondary outcomes were changes in recognition of what constitutes abusive behavior, intentions to intervene, gender-equitable attitudes, and reduction in recent ARA/SV perpetration (at end of sports season and 1-year follow up). Results: Of the 973 participants, 530 were white (54.5%), 282 were black (29.0%), 14 were Hispanic (1.4%), and the remainder were multiracial, other race/ethnicity, or not reported. Positive bystander behaviors increased at end of sports season and at 1-year follow-up (relative risk, 1.51; 95% CI, 1.06-2.16 and 1.53; 95% CI, 1.10-2.12, respectively) as did recognition of abuse (mean risk difference, 0.14; 95% CI, 0.01-0.27 and 0.14; 95% CI, 0.00-0.28, respectively). At 1-year follow-up, among those who ever dated, athletes on teams receiving CBIM had lower odds of reporting recent ARA/SV perpetration (odds ratio, 0.24; 95% CI, 0.09-0.65). Gender attitudes and intentions to intervene did not differ between study arms. In exploratory intensity-adjusted and per protocol analyses, athletes on teams receiving CBIM were more likely to report positive bystander behaviors and to endorse equitable gender attitudes and less likely to report ARA and sexual harassment perpetration 1 year later. Conclusions and Relevance: An athletic coach-delivered program for middle school male athletes is an effective strategy for reducing relationship abuse among younger adolescents. Trial Registration: ClinicalTrials.gov Identifier: NCT02331238.

Male Adolescents' Gender Attitudes and Violence: Implications for Youth Violence Prevention.

INTRODUCTION: This study analyzed the associations among male adolescents' gender attitudes, intentions to intervene, witnessing peers' abusive behaviors, and multiple forms of adolescent violence perpetration. This community-based evaluation aims to inform future youth violence prevention efforts through the identification of potential predictors of interpersonal violence perpetration. METHODS: Cross-sectional data were from baseline surveys conducted with 866 male adolescents, aged 13-19 years, from community settings in 20 lower-resource neighborhoods in Pittsburgh, PA (August 2015 - June 2017), as part of a cluster RCT to evaluate a sexual violence prevention program. Participants completed in-person, anonymous electronic surveys about gender attitudes, bystander intentions, witnessing peers' abusive behaviors, violence perpetration, and demographics. The analysis was conducted between 2018 and 2019. RESULTS: The youth identified mostly as African American (70%) or Hispanic, multiracial, or other (21%). Most (88%) were born in the U.S., and 85% were in school. Youth with more equitable gender attitudes had lower odds of self-reported violence perpetration across multiple domains, including dating abuse (AOR=0.46, 95% CI=0.29, 0.72) and sexual harassment (AOR=0.50, 95% CI=0.37, 0.67). The relationship between intentions to intervene and violence perpetration was inconclusive. Witnessing peers engaged in abusive behaviors was associated with increased odds of multiple types of violence perpetration, such as dating abuse (witnessed 3 or more behaviors, AOR=2.41, 95% CI=1.31, 4.44). CONCLUSIONS: This is the first U.S.-based study to elicit information from male adolescents in community-based settings (rather than schools or clinics) about multiple types of interpersonal violence perpetration. Findings support violence prevention strategies that challenge harmful gender and social norms while simultaneously increasing youths' skills in interrupting peers' disrespectful and harmful behaviors.

Housing and food stress among transgender adults in the United States.

PURPOSE: The purpose of the study was to assess housing and food-related stress in transgender and cisgender adults in the United States. METHODS: Data from the 2014 and 2015 Behavioral Risk Factor Surveillance System were analyzed for 53,060 adults who responded to the Sexual Orientation and Gender Identity module and the Social Context module. We used multiple logistic regression to assess the association of gender identity with housing and food-related stress. RESULTS: There were no significant differences by gender identity in the odds of experiencing housing or food-related stress. A sensitivity analysis revealed that with a broader definition of food-related stress, transgender individuals had higher odds of experiencing food-related stress compared with cisgender individuals. The sample of transgender individuals who experienced food-related stress were young, single, racially diverse, sexual minorities, and the majority had a high school degree or less. Similarly, most transgender individuals who experienced housing-related stress were single, sexual minorities, and had a high school degree or less. CONCLUSIONS: More precise assessments of housing and food insecurity among probability-based samples of transgender individuals are needed to fully understand housing and food-related instability and the stress associated with these experiences.

School climate and physical adolescent relationship abuse: Differences by sex, socioeconomic status, and bullying.

Little is known about the association between school climate and adolescent relationship abuse (ARA). We used 2011-2012 data from surveys of California public school students (in the United States of America) who were in a dating relationship in the last year (n = 112 378) to quantify the association between different school climate constructs and physical ARA. Fifty-two percent of students were female, and all students were in 9th or 11th grade (approximately ages 14-17). Over 11% of students reported experiencing physical ARA in the last year. Increased school connectedness, meaningful opportunities for participation, perceived safety, and caring relationships with adults at school were each significantly associated with lower odds of physical ARA. Increased violence victimization and school-level bullying victimization were associated with higher odds of physical ARA. These school climate-ARA associations were significantly moderated by student sex, school socioeconomic status, and school-level bullying victimization. School climate interventions may have spillover benefits for ARA prevention.

Engendering healthy masculinities to prevent sexual violence: Rationale for and design of the Manhood 2.0 trial.

Violence against women and girls is an important global health concern. Numerous health organizations highlight engaging men and boys in preventing violence against women as a potentially impactful public health prevention strategy. Adapted from an international setting for use in the US, "Manhood 2.0" is a "gender transformative" program that involves challenging harmful gender and sexuality norms that foster violence against women while promoting bystander intervention (i.e., giving boys skills to interrupt abusive behaviors they witness among peers) to reduce the perpetration of sexual violence (SV) and adolescent relationship abuse (ARA). Manhood 2.0 is being rigorously evaluated in a community-based cluster-randomized trial in 21 lower resource Pittsburgh neighborhoods with 866 adolescent males ages 13-19. The comparison intervention is a job readiness training program which focuses on the skills needed to prepare youth for entering the workforce, including goal setting, accountability, resume building, and interview preparation. This study will provide urgently needed information about the effectiveness of a gender transformative program, which combines healthy sexuality education, gender norms change, and bystander skills to interrupt peers' disrespectful and harmful behaviors to reduce SV/ARA perpetration among adolescent males. In this manuscript, we outline the rationale for and evaluation design of Manhood 2.0. Clinical Trials #: NCT02427061.

A cluster-randomized trial of a middle school gender violence prevention program: Design, rationale, and sample characteristics.

INTRODUCTION: High rates of adolescent relationship abuse (ARA) and sexual violence (SV) reported among adolescents point to the need for prevention among middle school-age youth. This is a cluster randomized controlled trial to test an athletic coach-delivered ARA/SV prevention program in 41 middle schools (38 clusters). Trained coaches talk to their male athletes about 1) what constitutes harmful vs. respectful relationship behaviors, 2) dispelling myths that glorify male sexual aggression and promoting more gender-equitable attitudes, and 3) positive bystander intervention when aggressive male behaviors toward females are witnessed. METHODS: A total of 973 male athletes (ages 11-14, grades 6-8) are participating. Athletes complete surveys at the beginning and end of sports season (Time 2), and one year later (Time 3). The primary outcome is an increase in positive bystander behaviors (i.e., intervening in peers' disrespectful or harmful behaviors); secondary outcomes are changes in recognition of what constitutes abusive behavior, intentions to intervene, and gender equitable attitudes (Time 2 and 3) as well as reduction in abuse perpetration (Time 3). RESULTS: Participating schools have a greater proportion of non-White students and students on free/reduced lunch compared to schools that declined participation. Participants' self-reported ethnicities are 54.5% White, 29.0% Black, 1.4% Hispanic and the remainder, multi-racial, other, or not reported. CONCLUSIONS: This study will evaluate the effectiveness of a coach-delivered ARA/SV prevention program for middle school male athletes. Findings will add to the evidence base regarding developmentally appropriate violence prevention programs as well as the role of coaches in adolescent health promotion. Clinical Trials #: NCT02331238.