Under-Representation of Transgender Identities in Research: The Limitations of Traditional Quantitative Survey Data.

Purpose: Research indicates that the portrayal and representation of transgender individuals within society, or lack thereof, impact the way in which they are able to reconcile their gender identity. Quantitative research methodology often requires that participants select one identity label from a limited list for each identity characteristic (e.g., race, sexual orientation, and relationship status). The process of choosing from limited items that do not represent one's identities limits our understanding of the nuances of identity and may create minority stress for the participant. Methods: This study included 325 diverse transgender adults who participated in a national anonymous online survey as part of a broader study focused on minority stress and mental health. Participants answered questions about gender, sexual orientation, relationship status, race, and religion, and were given the option to select multiple response options and to write in additional identities that were not listed. Results: Descriptive results indicated that 95 unique gender identities written in were not captured by the 14 gender labels provided, over 43% of participants selected multiple sexual orientations, and participants wrote in additional options for every identity variable. Conclusion: The nuance of transgender identities may not be adequately captured by standard demographic research methodologies and research would benefit from ongoing revision of demographic response options informed by the literature. Through the process of acknowledging and validating less visible identities, transgender individuals will be better represented and understood by researchers.

Clinical phenotype in infants with negative Zika virus immunoglobulin M testing born to mothers with confirmed Zika virus infection during pregnancy.

BACKGROUND: Recommended testing for both infants with Zika-associated birth defects (i.e., microcephaly and selected brain or eye anomalies) and infants without birth defects whose mothers had laboratory evidence of possible Zika virus (ZIKV) infection during pregnancy includes nucleic acid amplification testing (NAAT) and immunoglobulin M (IgM) testing within days after birth. Brain and eye defects highly specific for congenital ZIKV infection have been described; sporadic reports have documented negative ZIKV testing in such infants. METHODS: Infants from the U.S. Zika Pregnancy and Infant Registry and Zika Birth Defects Surveillance with Zika-associated birth defects and maternal and infant laboratory testing for ZIKV and two congenital infections (i.e., cytomegalovirus [CMV] and toxoplasmosis) were reviewed for phenotype and laboratory results. Infants with at least one defect considered highly specific for congenital ZIKV infection were designated as having congenital Zika syndrome (CZS) clinical phenotype for this study. RESULTS: Of 325 liveborn infants with Zika-associated birth defects and laboratory evidence of maternal ZIKV infection, 33 (10%) had CZS clinical phenotype; 172 (53%) had ZIKV IgM testing with negative or no ZIKV NAAT. ZIKV IgM was negative in the remaining 121 infants, and for 90%, testing for CMV and toxoplasmosis was missing/incomplete. Among 11 infants testing negative for ZIKV IgM, CMV, and toxoplasmosis, 2 infants had CZS clinical phenotype. CONCLUSIONS: These data add support to previous reports of negative ZIKV IgM testing in infants with clear maternal and phenotypic evidence of congenital ZIKV infection. Follow-up care consistent with the diagnosis is recommended regardless of infant ZIKV test results.

Functional Outcomes among a Cohort of Children in Northeastern Brazil Meeting Criteria for Follow-Up of Congenital Zika Virus Infection.

Following the large outbreak of Zika virus in the Western Hemisphere, many infants have been born with congenital Zika virus infection. It is important to describe the functional outcomes seen with congenital infections to allow for their recognition and appropriate interventions. We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil, who were approximately 24 months old, to assess functional outcomes. All children met either anthropometric criteria or laboratory criteria suggestive of possible congenital Zika virus infection. We collected results of previous medical evaluations, interviewed parents, and performed physical examinations and functional assessments, for example, the Hammersmith Infant Neurological Examination (HINE). We compared patterns of neurologic outcomes and developmental delay at age 24 months by whether children met anthropometric or laboratory criteria, or both. Among children meeting both criteria, 60% (26/43) were multiply affected (had severe motor impairment, severe developmental delay, and suboptimal HINE scores), compared with 5% (3/57) meeting only laboratory criteria and none (0/20) meeting only anthropometric criteria. Of the remaining 91 children, 49% (45) had developmental delay, with more severe delay seen in children meeting both criteria. Although children meeting physical and laboratory criteria for potential congenital Zika virus infection were more severely affected, we did identify several children with notable adverse neurologic outcomes and developmental delay with no physical findings but potential laboratory evidence of Zika virus infection. Given this, all children who were potentially exposed in utero to Zika virus should be monitored in early childhood for deficits to allow for early intervention.

Improving the Gender-Affirmation Process for Transgender and Gender-Nonconforming Individuals: Associations Among Time Since Transition Began, Body Satisfaction, and Sexual Distress.

Sexual distress is associated with a variety of negative outcomes. Unique contributors to sexual distress exist among transgender individuals. The current study examined the impacts of gender-affirming interventions (i.e., hormone therapy [HT], gender-affirmation surgery [GAS]) and body satisfaction on sexual distress among 317 transgender adults recruited nationally to participate in an anonymous online survey. As expected, individuals who had received HT and/or GAS reported better body satisfaction compared to those who wanted these interventions but had not yet received them. Sexual distress did not differ by transition status. As hypothesized, time since transition began was positively associated with body satisfaction, and there was an indirect relationship between time since transition began and sexual distress through body satisfaction. These results replicated findings in the extant literature suggesting that body satisfaction is improved by GAS. Furthermore, this was the first study of which we are aware to examine the role of time since transition began with respect to body satisfaction and the resulting impact on sexual distress. Results from this study may have clinical implications that could help improve the gender-affirmation experience for transgender individuals.

Heartland virus infection in a heart transplant recipient from the Heartland.

Tick-borne infections represent a significant health risk each year in the United States. Immunocompromised patients are typically at risk of more severe disease manifestations than their immunocompetent counterparts. Here we report a case of a newly emerging phlebovirus, Heartland virus, in a heart transplant recipient.

The Role of Distal Minority Stress and Internalized Transnegativity in Suicidal Ideation and Nonsuicidal Self-Injury Among Transgender Adults.

Transgender people are at elevated risk for nonsuicidal self-injury (NSSI) and suicidal ideation compared to the general population. Transgender (trans) refers to a diverse group of people who experience incongruence between their gender identity and sex assigned at birth. The present study is guided by the minority stress model and the psychological mediation framework, which postulate that sexual minority groups experience elevated stress as a result of anti-minority prejudice, contributing to negative mental health outcomes. This study utilized these theories to investigate the role of internalized transnegativity-internalization of negative societal attitudes about one's trans identity-in the relationships of distal trans stress to suicidal ideation and NSSI. A U.S. national sample of trans adults (N = 237) completed a battery of online measures. Structural equation modeling (SEM) was used to compare models with mediation and moderation effects. Results suggested that internalized transnegativity acts as both a mediator and a moderator in the relationship between distal trans stress and suicidal ideation. Log likelihood comparisons suggested moderation models had the superior fit for these data. Results suggest that clinical interventions should directly target individuals' internalized transnegativity as well as societal-level transnegativity.

Considerations for Culturally Sensitive Research With Transgender Adults: A Qualitative Analysis.

Transgender (trans) individuals have historically been left out of research, and previous work has often conflated gender identity with sexual orientation. Furthermore, language used in psychology measures is often heteronormative and uses binary gendered language (e.g., "him"/"her"). The aim of the current study was to provide empirically derived guidance on conducting culturally sensitive research with transgender participants using qualitative data. We recruited trans individuals, ages 18 to 44, to participate in an anonymous, qualitative, national online survey as part of a quantitative study on the relationships among minority stress, sexual behavior, and mental health. The qualitative portion included four open-ended feedback questions. We identified four overarching themes regarding experiences with our survey: (a) emotional reaction; (b) insight gained; (c) being outside the box; and (d) value of the work. Research with trans adults should be more inclusive of diverse gender identities, sexual identities, and sexual behaviors. Steps in this direction may include soliciting feedback from community members regarding survey language and response options, allowing participants to contextualize their responses using open-ended questions, and clarifying language to distinguish between sexual behavior and sexual identity. A list of seven preliminary guidelines was proposed to aid scientists in conducting culturally sensitive research with trans individuals.

A descriptive analysis of alcohol behaviors across gender subgroups within a sample of transgender adults.

OBJECTIVE: Transgender (trans) adults are identified as an at-risk group for problem alcohol use. Descriptive empirical data examining alcohol behaviors among trans adults is limited. The present study investigates alcohol behaviors - quantity, frequency, alcohol-related problems, and drinking to cope motives - across sex assigned at birth, gender expression, and gender identity subgroups within a sample of trans adults. METHOD: A total of 317 trans participants were recruited to complete a cross-sectional battery of online measures assessing alcohol use behaviors, alcohol-related problems, and drinking to cope. Gender identity was assessed through two methods: (1) an open-ended question in which participants wrote-in their primary gender identity; and (2) participants rated the extent to which they identified with 14 gender identity categories. RESULTS: This sample had high rates of alcohol use, alcohol-related problems, and drinking to cope motives relative to the general population. Significant and meaningful differences in drinking frequency, alcohol-related problems and drinking motives were found according to gender expression, but not sex assigned at birth or gender identity. CONCLUSIONS: Future work should examine alcohol behaviors among trans individuals, including investigation of predictors and causal pathways, to inform prevention and intervention work aimed at reducing trans people's risk for alcohol-related problems.

Sexual Assault Disclosure and Sexual Functioning: The Role of Trauma Symptomatology.

INTRODUCTION: Previous research has demonstrated that a history of adult sexual assault (ASA) is associated with negative outcomes, including trauma symptomatology and fear of sexual intimacy. Disclosing sexual assault might be protective against such negative outcomes. AIM: To examine the indirect effect of trauma symptomatology on the association between disclosing ASA and current sexual functioning. METHODS: Participants included 652 women 21 to 30 years old with a history of ASA recruited from the community. Participants completed self-report measurements on a computer. MAIN OUTCOME MEASURES: Separate models were performed, with sexual functioning divided into sexual desire, orgasm, and pain during sex. RESULTS: ASA disclosure was indirectly associated with sexual orgasm and pain during sex by trauma symptomatology. However, there was no indirect effect of trauma symptomatology on the relation between ASA disclosure and sexual desire. CONCLUSION: Disclosing experiences of ASA could serve a protective function by lessening trauma symptomatology, thereby mitigating impacts on aspects of sexual functioning, such as orgasm and pain.

Effects of parental monitoring on alcohol use in the US and Sweden: A brief report.

OBJECTIVE: Adolescent alcohol use predicts a myriad of negative mental and physical health outcomes including fatality (Midanik, 2004). Research in parental influence on alcohol consumption finds parental monitoring (PM), or knowing where/whom your child is with, is associated with lower levels of alcohol use in adolescents (e.g., Arria et al., 2008). As PM interventions have had only limited success (Koutakis, Stattin, & Kerr, 2008), investigating moderating factors of PM is of importance. Country may serve as one such moderator (Calafat, Garcia, Juan, Becoña, & Fernández-Hermida, 2014). Thus, the purpose of the present report is to assess the relationship between PM and alcohol use in the US and Sweden. METHOD: High school seniors from the US (n=1181, 42.3% Male) and Sweden (n=2171, 44.1% Male) completed assessments of total drinks consumed in a typical week, problematic alcohol use, and perceived PM. RESULTS: Generalized linear mixed modeling (GLM, Cohen, Cohen, West, & Aiken, 2013; Hilbe, 2011) was used to examine whether country moderated the relationship between PM and alcohol use. Results revealed main effects of country and PM and a significant interaction between country and PM in predicting total drinks per week and PM in predicting problematic alcohol use (p<0.001). CONCLUSIONS: While PM is related to lower quantity of alcohol consumed and problematic alcohol use, greater PM appears to be more strongly related to fewer drinks per week and less problematic alcohol use in the US, as compared to Sweden.

Partner Pressure, Victimization History, and Alcohol: Women's Condom-Decision Abdication Mediated by Mood and Anticipated Negative Partner Reaction.

Highly intoxicated versus sober women were evaluated using multi-group path analyses to test the hypothesis that sexual victimization history would interact with partner pressure to forgo condom use, resulting in greater condom-decision abdication-letting the man decide whether or not to use a condom. After beverage administration, community women (n = 408) projected themselves into a scenario depicting a male partner exerting high or low pressure for unprotected sex. Mood, anticipated negative reactions from the partner, and condom-decision abdication were assessed. In both control and alcohol models, high pressure increased anticipated negative partner reaction, and positive mood was associated with increased abdication. In the alcohol model, victimization predicted abdication via anticipated negative partner reaction, and pressure decreased positive mood and abdication. In the control model, under high pressure, victimization history severity was positively associated with abdication. Findings implicate condom-decision abdication as an important construct in understanding how women's sexual victimization histories may exert sustained impact on sexual interactions.

In-The-Moment Dissociation, Emotional Numbing, and Sexual Risk: The Influence of Sexual Trauma History, Trauma Symptoms, and Alcohol Intoxication.

OBJECTIVE: Prior research on the effects of sexual trauma has examined dissociation but not emotional numbing during sex and has relied exclusively on retrospective surveys. The present experiment examined associations among distal factors of childhood sexual abuse (CSA), adolescent/adult sexual assault (ASA), and trauma symptoms and the proximal factor of acute alcohol intoxication on in-the-moment dissociation, emotional numbing, and sexual risk intentions. METHOD: Young adult female drinkers (N = 436) at elevated sexual risk were randomized to receive alcohol (target peak breath alcohol concentration = .10%) or no alcohol. They then read an eroticized sexual scenario and reported on their dissociation and emotional numbing experiences, unprotected sex refusal self-efficacy, and unprotected sex intentions. RESULTS: Path analysis revealed that CSA was indirectly associated with increased unprotected sex intentions through increased ASA severity, increased trauma-related symptoms, increased emotional numbing, and decreased unprotected sex refusal self-efficacy. Further, alcohol intoxication was indirectly associated with increased unprotected sex intentions through increased emotional numbing and decreased unprotected sex refusal self-efficacy. CONCLUSIONS: Emotional numbing, but not dissociation, was associated with unprotected sex intentions and may be one potential target for interventions aimed at reducing HIV/STI-related risk among women with a history of sexual trauma.

Alcohol myopia and sexual abdication among women: examining the moderating effect of child sexual abuse.

INTRODUCTION: HIV and other STIs are major public health concerns for women, and risky sexual behaviors increase the risk of transmission. Risky sexual behaviors include sexual abdication, that is, willingness to let a partner decide how far to go sexually. Alcohol intoxication is a risk factor for risky sexual behavior, and the Inhibition Conflict Model of Alcohol Myopia may help explain this relationship. This model suggests that in order for intoxication to influence behavior there must be high conflict, meaning the strength of the instigatory cues and inhibitory cues are both high. Recent research indicates that the degree to which cues are experienced as high in instigation or inhibition is subject to individual difference factors. One individual difference factor associated with alcohol-related sexual risk taking is child sexual abuse (CSA) history. METHODS: The current study examined the influence of acute alcohol intoxication, CSA, and inhibition conflict on sexual abdication with 131 women (mean age 25) randomized into a 2 (alcohol, control)×2 (high conflict, low conflict) experimental design. RESULTS: Regression analyses yielded a significant 3-way interaction, F (1,122)=8.15, R(2)=.14, p<.01. When there was high conflict, intoxicated CSA women were more likely to abdicate than sober CSA women, however, sober CSA women were less likely to abdicate than sober NSA women, when there was low conflict, CSA history and alcohol intoxication had no influence on abdication. CONCLUSION: These results may help explain the association between alcohol and risky sexual decision making among women with CSA.

Avoiding experiences: sexual dysfunction in women with a history of sexual abuse in childhood and adolescence.

Women with a history of sexual abuse during childhood/adolescence experience a high rate of sexual dysfunction. Evidence also suggests that they often use avoidant coping strategies, such as substance abuse, dissociation, and emotional suppression, which are likely factors implicated with their psychopathology. There is a dearth of information on potential psychological mechanisms affecting the sexuality of these women. Therefore, it is relevant to investigate whether avoidance, an important cognitive mechanism associated with anxiety disorders, relates to sexual functioning in this population. In this study, participants with (N = 34) and without (N = 22) a history of sexual abuse prior to age 16 years completed questionnaires on severity of sexual abuse, sexual functioning, and a tendency to avoid experiences. A three-step hierarchical regression investigated the effects of childhood/adolescent sexual abuse and avoidance tendencies on different aspects of sexual functioning. A significant interaction between childhood/adolescent sexual abuse and avoidance tendencies was found for orgasm function, with the combination of sexual abuse and avoidance tendencies explaining lower orgasm function. These findings suggest that, for women with a history of early sexual abuse, the tendency to avoid interpersonal closeness and avoid emotional involvement predicts orgasm functioning.