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1.  A Mixed Methods Study of the Sexual Health Needs of New England Transmen Who Have Sex with Nontransgender Men 
AIDS Patient Care and STDs  2010;24(8):501-513.
The sexual health of transmen—individuals born or assigned female at birth and who identify as male—remains understudied. Given the increasing rates of HIV and sexually transmitted diseases (STDs) among gay and bisexual men in the United States, understanding the sexual practices of transmen who have sex with men (TMSM) may be particularly important to promote sexual health or develop focused HIV prevention interventions. Between May and September 2009, 16 transmen who reported sexual behavior with nontransgender men completed a qualitative interview and a brief interviewer-administered survey. Interviews were conducted until redundancy in responses was achieved. Participants (mean age, 32.5, standard deviation [SD] = 11.1; 87.5% white; 75.0% “queer”) perceived themselves at moderately high risk for HIV and STDs, although 43.8% reported unprotected sex with an unknown HIV serostatus nontransgender male partner in the past 12 months. The majority (62.5%) had used the Internet to meet sexual partners and “hook-up” with an anonymous nontransgender male sex partner in the past year. A lifetime STD history was reported by 37.5%; 25.0% had not been tested for HIV in the prior 2 years; 31.1% had not received gynecological care (including STD screening) in the prior 12 months. Integrating sexual health information “by and for” transgender men into other healthcare services, involving peer support, addressing mood and psychological wellbeing such as depression and anxiety, Internet-delivered information for transmen and their sexual partners, and training for health care providers were seen as important aspects of HIV and STD prevention intervention design and delivery for this population. “Embodied scripting” is proposed as a theoretical framework to understand sexual health among transgender populations and examining transgender sexual health from a life course perspective is suggested.
PMCID: PMC2958438  PMID: 20666586
2.  Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center 
AIDS care  2013;26(7):857-864.
The sexual health of female-to-male (FTM) transgender men remains understudied. De-identified electronic medical records of 23 FTMs (mean age = 32, 48% racial/ethnic minority) who screened for sexually transmitted diseases (STDs) between July and December 2007 at a Boston, Massachusetts area health center were analyzed. Almost half (48%) were on testosterone and 39% had undergone chest surgery; none had undergone genital reconstruction. The majority (57%) were bisexual, and 30% reported sex with nontransgender males only in the prior three months. One individual was HIV-infected (4.3%) and two (8.7%) had a history of STDs (all laboratory-confirmed). Overall, 26% engaged in sexual risk behavior in the prior three months (i.e., unprotected sex with a nontransgender male, condom breakage, or anonymous sex). The majority (61%) had a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) diagnosis (52% depression, 52% anxiety, and 26% adjustment disorder), and regular alcohol use was common (65%). Alcohol use, psychosocial distress histories, and sex with males only (versus with males and females) were associated with sexual risk in the past three months. Transgender men have concomitant psychosocial health vulnerabilities which may contribute to sexual risk behaviors. Future research is needed to understand the myriad social, behavioral, and biological factors that contribute to HIV and STD vulnerability for FTMs.
PMCID: PMC4634528  PMID: 24206043
transgender; FTM; HIV; STD; psychosocial; sexual risk
3.  Mental Health Disparities Within the LGBT Population: A Comparison Between Transgender and Nontransgender Individuals 
Transgender Health  2016;1(1):12-20.
Purpose: This study assessed within a Midwestern LGBT population whether, and the extent to which, transgender identity was associated with elevated odds of reported discrimination, depression symptoms, and suicide attempts.
Methods: Based on survey data collected online from respondents who self-identified as lesbian, gay, bisexual, and/or transgender persons over the age of 19 in Nebraska in 2010, this study performed bivariate t- or chi-square tests and multivariate logistic regression analysis to examine differences in reported discrimination, depression symptoms, suicide attempts, and self-acceptance of LGBT identity between 91 transgender and 676 nontransgender respondents.
Results: After controlling for the effects of selected confounders, transgender identity was associated with higher odds of reported discrimination (OR=2.63, p<0.01), depression symptoms (OR=2.33, p<0.05), and attempted suicides (OR=2.59, p<0.01) when compared with nontransgender individuals. Self-acceptance of LGBT identity was associated with substantially lower odds of reporting depression symptoms (OR=0.46, p<0.001).
Conclusion: Relative to nontransgender LGB individuals, transgender individuals were more likely to report discrimination, depression symptoms, and attempted suicides. Lack of self-acceptance of LGBT identity was associated with depression symptoms among transgender individuals.
PMCID: PMC5685247
depression symptoms; discrimination; LGBT; LGBT identity acceptance; transgender
4.  Physical and Mental Health of Transgender Older Adults: An At-Risk and Underserved Population 
The Gerontologist  2013;54(3):488-500.
Purpose: This study is one of the first to examine the physical and mental health of transgender older adults and to identify modifiable factors that account for health risks in this underserved population. Design and Methods: Utilizing data from a cross-sectional survey of lesbian, gay, bisexual, and transgender older adults aged 50 and older (N = 2,560), we assessed direct and indirect effects of gender identity on 4 health outcomes (physical health, disability, depressive symptomatology, and perceived stress) based on a resilience conceptual framework. Results: Transgender older adults were at significantly higher risk of poor physical health, disability, depressive symptomatology, and perceived stress compared with nontransgender participants. We found significant indirect effects of gender identity on the health outcomes via fear of accessing health services, lack of physical activity, internalized stigma, victimization, and lack of social support; other mediators included obesity for physical health and disability, identity concealment for perceived stress, and community belonging for depressive symptomatology and perceived stress. Further analyses revealed that risk factors (victimization and stigma) explained the highest proportion of the total effect of gender identity on health outcomes. Implications: The study identifies important modifiable factors (stigma, victimization, health-related behaviors, and social support) associated with health among transgender older adults. Reducing stigma and victimization and including gender identity in nondiscrimination and hate crime statutes are important steps to reduce health risks. Attention to bolstering individual and community-level social support must be considered when developing tailored interventions to address transgender older adults’ distinct health and aging needs.
PMCID: PMC4013724  PMID: 23535500
Gender identity; LGBT; Minority health; Resilience
5.  Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Côte d'Ivoire, Togo and Burkina Faso 
Journal of the International AIDS Society  2016;19(3Suppl 2):20774.
Transgender women are at high risk for the acquisition and transmission of HIV. However, there are limited empiric data characterizing HIV-related risks among transgender women in sub-Saharan Africa. The objective of these analyses is to determine what factors, including sexual behaviour stigma, condom use and engagement in sex work, contribute to risk for HIV infection among transgender women across three West African nations.
Data were collected via respondent-driven sampling from men who have sex with men (MSM) and transgender women during three- to five-month intervals from December 2012 to October 2015 across a total of six study sites in Togo, Burkina Faso and Côte d'Ivoire. During the study visit, participants completed a questionnaire and were tested for HIV. Chi-square tests were used to compare the prevalence of variables of interest between transgender women and MSM. A multilevel generalized structural equation model (GSEM) was used to account for clustering of observations within study sites in the multivariable analysis, as well as to estimate mediated associations between sexual behaviour stigma and HIV infection among transgender women.
In total, 2456 participants meeting eligibility criteria were recruited, of which 453 individuals identified as being female/transgender. Transgender women were more likely than MSM to report selling sex to a male partner within the past 12 months (p<0.01), to be living with HIV (p<0.01) and to report greater levels of sexual behaviour stigma as compared with MSM (p<0.05). In the GSEM, sexual behaviour stigma from broader social groups was positively associated with condomless anal sex (adjusted odds ratio (AOR)=1.33, 95% confidence interval (CI)=1.09, 1.62) and with selling sex (AOR=1.23, 95% CI=1.02, 1.50). Stigma from family/friends was also associated with selling sex (AOR=1.42, 95% CI=1.13, 1.79), although no significant associations were identified with prevalent HIV infection.
These data suggest that transgender women have distinct behaviours from those of MSM and that stigma perpetuated against transgender women is impacting HIV-related behaviours. Furthermore, given these differences, interventions developed for MSM will likely be less effective among transgender women. This situation necessitates dedicated responses for this population, which has been underserved in the context of both HIV surveillance and existing responses.
PMCID: PMC4949310  PMID: 27431465
HIV; transgender women; stigma; sub-Saharan Africa; epidemiology; sexual risk behaviours; structural equation modelling
6.  HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis 
PLoS Medicine  2017;14(11):e1002422.
Sub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant vulnerability to HIV. This analysis aimed to assess HIV prevalence as well as psychosocial and behavioral drivers of HIV infection among transgender women compared with cisgender (non-transgender) men who have sex with men (cis-MSM) in 8 sub-Saharan African countries.
Methods and findings
Respondent-driven sampling targeted cis-MSM for enrollment. Data collection took place at 14 sites across 8 countries: Burkina Faso (January–August 2013), Côte d’Ivoire (March 2015–February 2016), The Gambia (July–December 2011), Lesotho (February–September 2014), Malawi (July 2011–March 2012), Senegal (February–November 2015), Swaziland (August–December 2011), and Togo (January–June 2013). Surveys gathered information on sexual orientation, gender identity, stigma, mental health, sexual behavior, and HIV testing. Rapid tests for HIV were conducted. Data were merged, and mixed effects logistic regression models were used to estimate relationships between gender identity and HIV infection. Among 4,586 participants assigned male sex at birth, 937 (20%) identified as transgender or female, and 3,649 were cis-MSM. The mean age of study participants was approximately 24 years, with no difference between transgender participants and cis-MSM. Compared to cis-MSM participants, transgender women were more likely to experience family exclusion (odds ratio [OR] 1.75, 95% CI 1.42–2.16, p < 0.001), rape (OR 1.95, 95% CI 1.63–2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12–1.52, p < 0.001). Transgender women were more likely to report condomless receptive anal sex in the prior 12 months (OR 2.44, 95% CI 2.05–2.90, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49–2.19, p < 0.001). Overall HIV prevalence was 25% (235/926) in transgender women and 14% (505/3,594) in cis-MSM. When adjusted for age, condomless receptive anal sex, depression, interpersonal stigma, law enforcement stigma, and violence, and the interaction of gender with condomless receptive anal sex, the odds of HIV infection for transgender women were 2.2 times greater than the odds for cis-MSM (95% CI 1.65–2.87, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments.
In this study in sub-Saharan Africa, we found that HIV burden and stigma differed between transgender women and cis-MSM, indicating a need to address gender diversity within HIV research and programs.
In a cross-sectional analysis of data from African countries, Tonia Poteat and colleagues report on risk factors for infection and HIV prevalence in transgender women and men who have sex with men.
Author summary
Why was this study done?
Sub-Saharan Africa includes countries with the most broadly generalized HIV epidemics.
Transgender women have unmet HIV prevention and treatment needs around the world; however, study of their specific needs across sub-Saharan Africa has been limited.
What did the researchers do and find?
We merged HIV test results and survey data from studies initially focused on gay men and other men who have sex with men (MSM) in 8 countries in sub-Saharan Africa, then specifically assessed transgender women separately from cisgender MSM.
We identified 937 transgender women among the total sample of 4,586 individuals.
We found that transgender women were more likely than cisgender MSM to test positive for HIV as well as report experiences of stigma, depressive symptoms, and condomless sex.
What do these findings mean?
Gender identities are as complex across sub-Saharan Africa as they are in other regions.
These data highlight the limitations of an essentialist gender binary framework for HIV prevention and treatment programs in sub-Saharan Africa.
Advancing HIV prevention and treatment in sub-Saharan Africa necessitates specifically studying the appropriate content and implementation of programs that reach transgender women.
PMCID: PMC5675306  PMID: 29112689
7.  Alcohol Sales and Risk of Serious Assault 
PLoS Medicine  2008;5(5):e104.
Alcohol is a contributing cause of unintentional injuries, such as motor vehicle crashes. Prior research on the association between alcohol use and violent injury was limited to survey-based data, and the inclusion of cases from a single trauma centre, without adequate controls. Beyond these limitations was the inability of prior researchers to comprehensively capture most alcohol sales. In Ontario, most alcohol is sold through retail outlets run by the provincial government, and hospitals are financed under a provincial health care system. We assessed the risk of being hospitalized due to assault in association with retail alcohol sales across Ontario.
Methods and Findings
We performed a population-based case-crossover analysis of all persons aged 13 years and older hospitalized for assault in Ontario from 1 April 2002 to 1 December 2004. On the day prior to each assault case's hospitalization, the volume of alcohol sold at the store in closest proximity to the victim's home was compared to the volume of alcohol sold at the same store 7 d earlier. Conditional logistic regression analysis was used to determine the associated relative risk (RR) of assault per 1,000 l higher daily sales of alcohol. Of the 3,212 persons admitted to hospital for assault, nearly 25% were between the ages of 13 and 20 y, and 83% were male. A total of 1,150 assaults (36%) involved the use of a sharp or blunt weapon, and 1,532 (48%) arose during an unarmed brawl or fight. For every 1,000 l more of alcohol sold per store per day, the relative risk of being hospitalized for assault was 1.13 (95% confidence interval [CI] 1.02–1.26). The risk was accentuated for males (1.18, 95% CI 1.05–1.33), youth aged 13 to 20 y (1.21, 95% CI 0.99–1.46), and those in urban areas (1.19, 95% CI 1.06–1.35).
The risk of being a victim of serious assault increases with alcohol sales, especially among young urban men. Akin to reducing the risk of driving while impaired, consideration should be given to novel methods of preventing alcohol-related violence.
In a population-based case-crossover analysis, Joel Ray and colleagues find that the risk of being a victim of serious assault increases with retail alcohol sales, especially among young urban men.
Editors' Summary
Alcohol has been produced and consumed around the world since prehistoric times. In the Western world it is now the most commonly consumed psychoactive drug (a substance that changes mood, behavior, and thought processes). The World Health Organization reports that there are 76.3 million persons with alcohol use disorders worldwide. Alcohol consumption is an important factor in unintentional injuries, such as motor vehicle crashes, and in violent criminal behavior. In the United Kingdom, for example, a higher proportion of heavy drinkers than light drinkers cause violent criminal offenses. Other figures suggest that people (in particular, young men) have an increased risk of committing a criminally violent offense within 24 h of drinking alcohol. There is also some evidence that suggests that the victims as well as the perpetrators of assaults have often been drinking recently, possibly because alcohol impairs the victim's ability to judge potentially explosive situations.
Why Was This Study Done?
The researchers wanted to know more about the relationship between alcohol and intentional violence. The recognition of a clear link between driving when impaired by alcohol and motor vehicle crashes has led many countries to introduce public awareness programs that stigmatize drunk driving. If a clear link between alcohol consumption by the people involved in violent crime could also be established, similar programs might reduce alcohol-related assaults. The researchers tested the hypothesis that the risk of being hospitalized due to a violent assault increases when there are increased alcohol sales in the immediate vicinity of the victim's place of residence.
What Did the Researchers Do and Find?
The researchers did their study in Ontario, Canada for three reasons. First, Ontario is Canada's largest province. Second, the province keeps detailed computerized medical records, including records of people hospitalized from being violently assaulted. Third, most alcohol is sold in government-run shops, and the district has the infrastructure to allow daily alcohol sales to be tracked. The researchers identified more than 3,000 people over the age of 13 y who were hospitalized in the province because of a serious assault during a 32-mo period. They compared the volume of alcohol sold at the liquor store nearest to the victim's home the day before the assault with the volume sold at the same store a week earlier (this type of study is called a “case-crossover” study). For every extra 1,000 l of alcohol sold per store per day (a doubling of alcohol sales), the overall risk of being hospitalized for assault increased by 13%. The risk was highest in three subgroups of people: men (18% increased risk), youths aged 13 to 20 y (21% increased risk), and those living in urban areas (19% increased risk). At peak times of alcohol sales, the risk of assault was 41% higher than at times when alcohol sales were lowest.
What Do These Findings Mean?
These findings indicate that the risk of being seriously assaulted increases with the amount of alcohol sold locally the day before the assault and show that the individuals most at risk are young men living in urban areas. Because the study considers only serious assaults and alcohol sold in shops (i.e., not including alcohol sold in bars), it probably underestimates the association between alcohol and assault. It also does not indicate whether the victim or perpetrator of the assault (or both) had been drinking, and its findings may not apply to countries with different drinking habits. Nevertheless, these findings support the idea that the consumption of alcohol contributes to the occurrence of medical injuries from intentional violence. Increasing the price of alcohol or making alcohol harder to obtain might help to reduce the occurrence of alcohol-related assaults. The researchers suggest that a particularly effective approach may be to stigmatize alcohol-related brawling, analogous to the way that driving under the influence of alcohol has been made socially unacceptable.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Bennetts and Seabrook
The US National Institute on Alcohol Abuse and Alcoholism provides information on all aspects of alcohol abuse, including an article on alcohol use and violence among young adults
Alcohol-related assault is examined in the British Crime Survey
Alcohol Concern, the UK national agency on alcohol misuse, provides fact sheets on the health impacts of alcohol, young people's drinking, and alcohol and crime
The Canadian Centre for Addiction and Mental Health in Toronto provides information about alcohol addiction (in English and French)
PMCID: PMC2375945  PMID: 18479181
8.  A Systematic Review of Interventions to Reduce Problematic Substance Use Among Transgender Individuals: A Call to Action 
Transgender Health  2017;2(1):45-59.
Persons who are transgender (i.e., individuals who are assigned one sex at birth, but who do not identify with that sex) are at elevated risk for developing problematic substance use. Recent studies indicate that transgender persons have high rates of alcohol use, illicit drug use, and nonmedical use of prescription drugs and evince more severe misuse of these substances compared with nontransgender individuals. Despite the high rates of substance use among transgender persons and the multiple conceptual and narrative recommendations for substance use treatments, there is a lack of consensus or awareness of empirically tested interventions and programs effective for this population. Thus, it is critical to examine current substance use interventions for transgender individuals to identify gaps in the field and to immediately put forth efforts to reduce problematic substance use. This systematic review is the first to attempt a comprehensive identification and synthesis of the available evidence on interventions for reducing problematic substance use among transgender persons. Reflective of the state of the field regarding transgender care for substance use, we found a deficiency of studies to include in this systematic review (n=2). Perhaps the most important conclusion of this review is that well-designed, theoretically informed culturally sensitive research focused on developing and rigorously testing interventions for substance use among transgender individuals is alarmingly scarce. This review discusses barriers to intervention design and synthesizes treatment recommendations for future work.
PMCID: PMC5549596  PMID: 28861547
alcohol; drug use; substance use interventions; substance use treatment; systematic review; transgender individuals
9.  A Person-Centered Approach to Examining Heterogeneity and Subgroups Among Survivors of Sexual Assault 
Journal of abnormal psychology  2015;124(3):685-696.
This study identified subgroups of female sexual assault survivors based on characteristics of their victimization experiences, validated the subgroup structure in a second cohort of women recruited identically to the first, and examined subgroups' differential associations with sexual risk/safety behavior, heavy episodic drinking (HED), psychological distress symptomatology, incarceration, transactional sex, and experiences with controlling and violent partners. The community sample consisted of 667 female survivors of adolescent or adult sexual assault who were 21 to 30 years old (M=24.78, SD=2.66). Eligibility criteria included having unprotected sex within the past year, other HIV/STI risk factors, and some experience with HED, but without alcohol problems or dependence. Latent class analyses (LCA) were used to identify subgroups of women with similar victimization experiences. Three groups were identified and validated across two cohorts of women using multiple-group LCA: Contact or Attempted assault (17% of the sample), Incapacitated assault (52%), and Forceful Severe assault (31%). Groups did not differ in their sexual risk/safety behavior. Women in the Forceful Severe category had higher levels of anxiety, depression, and trauma symptoms, higher proportions of incarceration and transactional sex, and more experiences with controlling and violent partners than did women in the other two groups. Women in the Forceful Severe category also reported a higher frequency of HED than women in the Incapacitated category. Different types of assault experiences appear to be differentially associated with negative outcomes. Understanding heterogeneity and subgroups among sexual assault survivors has implications for improving clinical care and contributing to recovery.
PMCID: PMC4573799  PMID: 26052619
Sexual Assault; Person-Centered Classification; Subgroups; Revictimization
10.  Characteristics of Transgender Individuals Entering Substance Abuse Treatment 
Addictive behaviors  2014;39(5):969-975.
Little is known about the needs or characteristics of transgender individuals in substance abuse treatment settings. Transgender (n=199) and non-transgender (cisgender, n=13440) individuals were compared on psychosocial factors related to treatment, health risk behaviors, medical and mental health status and utilization, and substance use behaviors within a database that documented individuals entering substance abuse treatment in San Francisco, CA from 2007–2009 using logistic and linear regression analyses (run separately by identified gender). Transgender men (assigned birth sex of female) differed from cisgender men across many psychosocial factors, including having more recent employment, less legal system involvement, greater incidence of living with a substance abuser, and greater family conflict, while transgender women (assigned birth sex of male) were less likely to have minor children than cisgender women. Transgender women reported greater needle use and HIV testing rates were greater among transgender women. Transgender men and women reported higher rates of physical health problems, mental health diagnoses, and psychiatric medications but there were no differences in service utilization. There were no differences in substance use behaviors except that transgender women were more likely to endorse primary methamphetamine use. Transgender individuals evidence unique strengths and challenges that could inform targeted services in substance abuse treatment.
PMCID: PMC4130569  PMID: 24561017
11.  The Effectiveness of Community Action in Reducing Risky Alcohol Consumption and Harm: A Cluster Randomised Controlled Trial 
PLoS Medicine  2014;11(3):e1001617.
In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.
The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.
Methods and Findings
We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000–20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department–based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001–2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = −3.37 to −0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.
This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12607000123448
Please see later in the article for the Editors' Summary
Editors' Summary
People have consumed alcoholic beverages throughout history, but alcohol use is now an increasing global public health problem. According to the World Health Organization's 2010 Global Burden of Disease Study, alcohol use is the fifth leading risk factor (after high blood pressure and smoking) for disease and is responsible for 3.9% of the global disease burden. Alcohol use contributes to heart disease, liver disease, depression, some cancers, and many other health conditions. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crimes and road traffic crashes. The impact of alcohol use on disease and injury depends on the amount of alcohol consumed and the pattern of drinking. Most guidelines define long-term risky drinking as more than four drinks per day on average for men or more than two drinks per day for women (a “drink” is, roughly speaking, a can of beer or a small glass of wine), and short-term risky drinking (also called binge drinking) as seven or more drinks on a single occasion for men or five or more drinks on a single occasion for women. However, recent changes to the Australian guidelines acknowledge that a lower level of alcohol consumption is considered risky (with lifetime risky drinking defined as more than two drinks a day and binge drinking defined as more than four drinks on one occasion).
Why Was This Study Done?
In 2010, the World Health Assembly endorsed a global strategy to reduce the harmful use of alcohol. This strategy emphasizes the importance of community action–a process in which a community defines its own needs and determines the actions that are required to meet these needs. Although community action is highly acceptable to community members, few studies have looked at the effectiveness of community action in reducing risky alcohol consumption and alcohol-related harm. Here, the researchers undertake a cluster randomized controlled trial (the Alcohol Action in Rural Communities [AARC] project) to quantify the effectiveness of community action in reducing risky alcohol consumption and harms in rural communities in Australia. A cluster randomized trial compares outcomes in clusters of people (here, communities) who receive alternative interventions assigned through the play of chance.
What Did the Researchers Do and Find?
The researchers pair-matched 20 rural Australian communities according to the proportion of their population that was Aboriginal (rates of alcohol-related harm are disproportionately higher among Aboriginal individuals than among non-Aboriginal individuals in Australia; they are also higher among young people and males, but the proportions of these two groups across communities was comparable). They randomly assigned one member of each pair to the experimental group and implemented 13 interventions in these communities by negotiating with key individuals in each community to define and implement each intervention. Examples of interventions included general practitioner training in screening for alcohol use disorders and in implementing a brief intervention, and a school-based interactive session designed to reduce alcohol harm among young people. The researchers quantified the effectiveness of the interventions using routinely collected data on alcohol-related crime and road traffic crashes, and on hospital inpatient admissions for alcohol dependence or abuse (which were expected to increase in the experimental group if the intervention was effective because of more people seeking or being referred for treatment). They also examined drinking habits and experiences of alcohol-related harm, such as verbal abuse, among community members using pre- and post-intervention surveys. After implementation of the interventions, the rates of alcohol-related crime, road traffic crashes, and hospital admissions, and of risky and hazardous/harmful alcohol consumption (measured using a validated tool called the Alcohol Use Disorders Identification Test) were not statistically significantly different in the experimental and control communities (a difference in outcomes that is not statistically significantly different can occur by chance). However, the reported average weekly consumption of alcohol was 20% lower in the experimental communities after the intervention than in the control communities (equivalent to 1.9 fewer standard drinks per week per respondent) and there was less alcohol-related verbal abuse post-intervention in the experimental communities than in the control communities.
What Do These Findings Mean?
These findings provide little evidence that community action reduced risky alcohol consumption and alcohol-related harms in rural Australian communities. Although there was some evidence of significant reductions in self-reported weekly alcohol consumption and in experiences of alcohol-related verbal abuse, these findings must be interpreted cautiously because they are based on surveys with very low response rates. A larger or differently designed study might provide statistically significant evidence for the effectiveness of community action in reducing risky alcohol consumption. However, given their findings, the researchers suggest that legislative approaches that are beyond the control of individual communities, such as alcohol taxation and restrictions on alcohol availability, may be required to effectively reduce alcohol harms. In other words, community action alone may not be the most effective way to reduce alcohol-related harm.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides detailed information about alcohol; its fact sheet on alcohol includes information about the global strategy to reduce the harmful use of alcohol; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
More information about the Alcohol Action in Rural Communities project is available
PMCID: PMC3949675  PMID: 24618831
12.  Reporting Bias in the Association Between Age at First Alcohol Use and Heavy Episodic Drinking 
Given the weight placed on retrospective reports of age at first drink in studies of later drinking-related outcomes, it is critical that its reliability be established and possible sources of systematic bias be identified. The overall aim of the current study is to explore the possibility that the estimated magnitude of association between early age at first drink and problem alcohol use may be inflated in studies using retrospectively reported age at alcohol use onset.
The sample was comprised of 1,716 participants in the Missouri Adolescent Female Twin Study who reported an age at first drink in at least 2 waves of data collection (an average of 4 years apart). Difference in reported age at first drink at Time 2 vs. Time 1 was categorized as 2 or more years younger, within 1 year (consistent), or 2 or more years older. The strength of the association between age at first drink and peak frequency of heavy episodic drinking (HED) at Time 1 was compared with that at Time 2. The association between reporting pattern and peak frequency of HED was also examined.
A strong association between age at first drink and HED was found for both reports, but it was significantly greater at Time 2. Just over one-third of participants had a 2 year or greater difference in reported ageat first drink. The majority of inconsistent reporters gave an older age at Time 2 and individuals with this pattern of reporting engaged in HED less frequently than consistent reporters.
The low rate of HED in individuals reporting an older age at first drink at Time 2 suggests that the upward shift in reported age at first drink among early initiates is most pronounced for light drinkers. Heavy drinkers may therefore be overrepresented among early onset users in retrospective studies, leading to inflated estimates of the association between early age at initiation and alcohol misuse.
PMCID: PMC3128178  PMID: 21438885
age at first drink; heavy episodic drinking; reporting bias
13.  Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women 
JAMA pediatrics  2016;170(5):481-486.
Transgender youth, including adolescent and young adult transgender women assigned a male sex at birth who identify as girls, women, transgender women, transfemale, male-to-female, or another diverse transfeminine gender identity, represent a vulnerable population at risk for negative mental health and substance use outcomes. Diagnostic clinical interviews to assess prevalence of mental health, substance dependence, and comorbid psychiatric disorders in young transgender women remain scarce.
To report the prevalence of mental health, substance dependence, and comorbid psychiatric disorders assessed via clinical diagnostic interview in a high-risk community-recruited sample of young transgender women.
Observational study reporting baseline finding from a diverse sample of 298 sexually active, young transgender women aged 16 through 29 years (mean age, 23.4 years; 49.0%black, 12.4%Latina, 25.5%white, and 13.1%other minority race/ethnicity) and enrolled in Project LifeSkills, an ongoing randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015.
Transfeminine gender identity.
Age- and site-adjusted prevalence and comorbidities of mental health and substance dependence disorders assessed via the Mini-International Neuropsychiatric Interview, including 1 or more diagnoses, 2 or more comorbid diagnoses, major depressive episode (current and lifetime), past 30-day suicidal risk (no/low risk vs moderate/high risk), past 6-month generalized anxiety disorder and posttraumatic stress disorder, and past 12-month alcohol dependence and nonalcohol psychoactive substance use dependence.
Of the 298 transgender women, 41.5%of participants had 1 or more mental health or substance dependence diagnoses; 1 in 5 (20.1%) had 2 or more comorbid psychiatric diagnoses. Prevalence of specific disorders was as follows: lifetime and current major depressive episode, 35.4%and 14.7%, respectively; suicidality, 20.2%; generalized anxiety disorder, 7.9%; posttraumatic stress disorder, 9.8%; alcohol dependence, 11.2%; and nonalcohol psychoactive substance use dependence, 15.2%.
Prevalence of psychiatric diagnoses was high in this community-recruited sample of young transgender women. Improving access to routine primary care, diagnostic screening, psychotherapy, and pharmacologic treatments, and retention in care in clinical community-based, pediatric, and adolescent medicine settings are urgently needed to address mental health and substance dependence disorders in this population. Further research will be critical, particularly longitudinal studies across development, to understand risk factors and identify optimal timing and targets for psychosocial interventions.
PMCID: PMC4882090  PMID: 26999485
14.  Connecting the Dots: Examining Transgender Women’s Utilization of Transition-Related Medical Care and Associations with Mental Health, Substance Use, and HIV 
Findings on access to general healthcare for transgender people have emerged, but little is known about access to transition-related medical care for transwomen (i.e., hormones, breast augmentation, and genital surgery). Transgender women have low access to general medical care and are disproportionately at risk for substance use, mental illness, and HIV. We conducted an analysis to determine if utilization of transition-related medical care is a protective factor for health risks to transgender women and to investigate if care differs by important demographic factors and HIV status. A secondary analysis was conducted using data from a 2010 HIV surveillance study using respondent-driven sampling to recruit 314 transwomen in San Francisco. Survey-corrected logistic regression models were used to estimate odds ratios for six psychosocial health problems—binge drinking, injection drug use, anxiety, depression, suicidal ideation, and high-risk intercourse—comparing various levels of utilization of transition-related medical care. Odds ratios were also calculated to determine if utilization of transition-related medical care was related to less overlap of risk domains. We found that Latina and African American transwomen had significantly lower estimated utilization of breast augmentation and genital surgery, as did transwomen who identified as transgender rather than female. Overall, utilization of transition-related medical care was associated with significantly lower estimated odds of suicidal ideation, binge drinking, and non-injection drug use. Findings suggest that utilization of transition-related medical care may reduce risk for mental health problems, especially suicidal ideation, and substance use among transwomen. Yet, important racial/ethnic and gender identity disparities in utilization of transition-related medical care need to be addressed.
PMCID: PMC4338120  PMID: 25476958
Healthcare utilization; Transition; Transgender women; HIV; Substance use; Mental health
15.  Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(3):e1001609.
Ana Maria Buller and colleagues review 19 studies and estimate the associations between the experience and perpetration of intimate partner violence and various health conditions and sexual risk behaviors among men who have sex with men.
Please see later in the article for the Editors' Summary
Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant problem. Little is known about the association between IPV and health for MSM. We aimed to estimate the association between experience and perpetration of IPV, and various health conditions and sexual risk behaviours among MSM.
Methods and Findings
We searched 13 electronic databases up to 23 October 2013 to identify research studies reporting the odds of health conditions or sexual risk behaviours for MSM experiencing or perpetrating IPV. Nineteen studies with 13,797 participants were included in the review. Random effects meta-analyses were performed to estimate pooled odds ratios (ORs). Exposure to IPV as a victim was associated with increased odds of substance use (OR = 1.88, 95% CIOR 1.59–2.22, I2 = 46.9%, 95% CII2 0%–78%), being HIV positive (OR = 1.46, 95% CIOR 1.26–1.69, I2 = 0.0%, 95% CII2 0%–62%), reporting depressive symptoms (OR = 1.52, 95% CIOR 1.24–1.86, I2 = 9.9%, 95% CII2 0%–91%), and engagement in unprotected anal sex (OR = 1.72, 95% CIOR 1.44–2.05, I2 = 0.0%, 95% CII2 0%–68%). Perpetration of IPV was associated with increased odds of substance use (OR = 1.99, 95% CIOR 1.33–2.99, I2 = 73.1%). These results should be interpreted with caution because of methodological weaknesses such as the lack of validated tools to measure IPV in this population and the diversity of recall periods and key outcomes in the identified studies.
MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in unprotected anal sex. MSM who perpetrate IPV are more likely to engage in substance use. Our results highlight the need for research into effective interventions to prevent IPV in MSM, as well as the importance of providing health care professionals with training in how to address issues of IPV among MSM and the need to raise awareness of local and national support services.
Please see later in the article for the Editors' Summary
Editors' Summary
Intimate partner violence (IPV, also called domestic violence) is a common and widespread problem. Globally, nearly a third of women are affected by IPV at some time in their life, but the prevalence of IPV (the proportion of the population affected by IPV) varies widely between countries. In central sub-Saharan Africa, for example, nearly two-thirds of women experience IPV during their lifetime, whereas in East Asia only one-sixth of women are affected. IPV is defined as physical, sexual, or emotional harm that is perpetrated on an individual by a current or former partner or spouse. Physical violence includes hitting, kicking, and other types of physical force; sexual violence means forcing a partner to take part in a sex act when the partner does not consent; and emotional abuse includes threatening a partner by, for example, stalking them or preventing them from seeing their family. The adverse effects of IPV for women include physical injury, depression and suicidal behaviour, and sexual and reproductive health problems such as HIV infection and unwanted pregnancies.
Why Was This Study Done?
IPV affects men as well as women. Men can be subjected to IPV either by a female partner or by a male partner in the case of men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). Recent reviews suggest that the prevalence of IPV in same-sex couples is as high as the prevalence of IPV for women in opposite-sex relationships: reported lifetime prevalences of IPV in homosexual male relationships range between 15.4% and 51%. Little is known, however, about the adverse health effects of IPV on MSM. It is important to understand how IPV affects the health of MSM so that appropriate services and interventions can be provided to support MSM who experience IPV. In this systematic review (a study that identifies all the research on a given topic using predefined criteria) and meta-analysis (a study that combines the results of several studies using statistical methods), the researchers investigate the associations between the experience and perpetration of IPV and various health conditions and sexual risk behaviours among MSM.
What Did the Researchers Do and Find?
The researchers identified 19 studies that investigated associations between IPV and various health conditions or sexual risk behaviours (for example, unprotected anal sex, a risk factor for HIV infection) among MSM. The associations were expressed as odds ratios (ORs); an OR represents the odds (chances) that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The researchers estimated pooled ORs from the data in the individual studies using meta-analysis. The pooled lifetime prevalence of experiencing any IPV (which was measured in six studies) was 48%. Exposure to IPV as a victim was associated with an increased risk of substance (alcohol or drug) use (OR = 1.88, data from nine studies), reporting depressive symptoms (OR = 1.52, data from three studies), being HIV positive (OR = 1.46, data from ten studies), and engagement in unprotected sex (OR = 1.72, data from eight studies). Perpetration of IPV was associated with an increased risk of substance abuse (OR = 1.99, data from six studies).
What Do These Findings Mean?
These findings suggest that MSM frequently experience IPV and that exposure to IPV is associated with several adverse health conditions and sexual risk behaviours. There were insufficient data to estimate the lifetime prevalence of IPV perpetration among MSM, but these findings also reveal an association between IPV perpetration and substance use. The accuracy of these findings is limited by heterogeneity (variability) between the studies included in the meta-analyses, by the design of these studies, and by the small number of studies. Despite these and other limitations, these findings highlight the need to undertake research to identify interventions to prevent IPV among MSM and to learn more about the health effects of IPV among MSM. They highlight the importance of health care professionals being aware that IPV is a problem for MSM and of training these professionals to assess MSM for IPV. Finally, these results highlight the need to improve the availability and effectiveness of support services to which health care professionals can refer MSM experiencing or perpetrating IPV.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides detailed information on intimate partner violence
The US Centers for Disease Control and Prevention provides information about IPV and a fact sheet on understanding IPV that includes links to further resources
The UK National Health Service Choices website has a webpage about domestic violence, which includes descriptions of personal experiences
The US National Domestic Violence Hotline provides confidential help and support to people experiencing IPV, including MSM; its website includes personal stories of IPV
The US Gay Men's Domestic Violence Project/GLBTQ Domestic Violence Project provides support and services to MSM experiencing IPV; its website includes some personal stories
The UK not-for-profit organization Respect runs two advice lines: the Men's Advice Line provides advice and support for men experiencing domestic violence and abuse and the Respect Phoneline provides advice for domestic violence perpetrators and for professionals who would like further information about services for those using violence/abuse in their intimate partner relationships
The UK not-for-profit organization ManKind Initiative also provides support for male victims of IPV
The UK not-for-profit organization Broken Rainbow UK provides help and support for lesbians and MSM experiencing IPV
MedlinePlus provides links to other resources about domestic violence (in English and Spanish)
The UK charity Galop gives advice and support to people who have experienced biphobia, homophobia, transphobia, sexual violence, or domestic abuse
PMCID: PMC3942318  PMID: 24594975
16.  Using a Two-Step Method to Measure Transgender Identity in Latin America/the Caribbean, Portugal, and Spain 
Archives of sexual behavior  2014;43(8):1503-1514.
Few comparative data are available internationally to examine health differences by transgender identity. A barrier to monitoring the health and well-being of transgender people is the lack of inclusion of measures to assess natal sex/gender identity status in surveys. Data were from a cross-sectional anonymous online survey of members (n > 36,000) of a sexual networking website targeting men who have sex with men in Spanish- and Portuguese-speaking countries/ territories in Latin America/the Caribbean, Portugal, and Spain. Natal sex/gender identity status was assessed using a two-step method (Step 1: assigned birth sex, Step 2: current gender identity). Male-to-female (MTF) and female-to-male (FTM) participants were compared to non-transgender males in age-adjusted regression models on socioeconomic status (SES) (education, income, sex work), masculine gender conformity, psychological health and well-being (lifetime suicidality, past-week depressive distress, positive self-worth, general self-rated health, gender related stressors), and sexual health (HIV-infection, past-year STIs, past-3 month unprotected anal or vaginal sex). The two-step method identified 190 transgender participants (0.54%; 158 MTF, 32 FTM). Of the 12 health-related variables, six showed significant differences between the three groups: SES, masculine gender conformity, lifetime suicidality, depressive distress, positive self-worth, and past-year genital herpes. A two-step approach is recommended for health surveillance efforts to assess natal sex/gender identity status. Cognitive testing to formally validate assigned birth sex and current gender identity survey items in Spanish and Portuguese is encouraged.
PMCID: PMC4199875  PMID: 25030120
transgender; gender identity; HIV; health; surveillance
17.  Medication adherence among transgender women living with HIV 
AIDS care  2016;28(8):976-981.
Medication adherence is linked to health outcomes among adults with HIV infection. Transgender women living with HIV (TWLWH) in the U.S. report suboptimal adherence to medications and are found to have difficulty integrating HIV medication into their daily routine, but few studies explore factors associated with medication adherence among transgender women. Thus, the purpose of this paper is to examine demographic and clinical factors related to self-reported medication adherence among transgender women. This secondary analysis is based on data collected from the Symptom and Genetic Study that included a convenience sample of 22 self-identified transgender women, 201 non-transgender men, and 72 non-transgender women recruited in northern California. Self-reported medication adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire. Gender differences in demographic and clinical variables were assessed, as were differences between transgender women reporting high and low adherence. Transgender women had lower adherence to medications compared to non-transgender males and non-transgender females (p=.028) and were less likely to achieve viral suppression (p=.039). Within the transgender group, Black/African Americans reported better adherence than participants who were Whites/Caucasian or other races (p=.009). Adherence among transgender women was unrelated to medication count and estrogen therapy, but consistent with other reports on the HIV population as a whole; transgender women with high adherence were more likely to achieve viral suppression compared to the transgender women with low adherence. Despite the high incidence of HIV infection in the transgender population, few studies focus on TWLWH, either in regard to their adherence to antiretroviral therapies or to their healthcare in general. To address ongoing health disparities, more studies are needed focusing on the transgender population’s continuum of care in HIV therapies.
PMCID: PMC4917432  PMID: 26908228
HIV; transgender; gender identity; medication adherence; health disparities
18.  Transgender Noninclusive Healthcare and Delaying Care Because of Fear: Connections to General Health and Mental Health Among Transgender Adults 
Transgender Health  2017;2(1):17-28.
Purpose: There are many barriers to reliable healthcare for transgender people that often contribute to delaying or avoiding needed medical care. Yet, few studies have examined whether noninclusive healthcare and delaying needed medical care because of fear of discrimination are associated with poorer health among transgender adults. This study aims to address these gaps in the knowledge base.
Methods: This study analyzed secondary data from a statewide survey of 417 transgender adults in the Rocky Mountain region of the United States. Independent variables included noninclusive healthcare from a primary care provider (PCP) and delay of needed medical care because of fear of discrimination. Dependent variables assessed general health and mental health.
Results: Transgender individuals who delayed healthcare because of fear of discrimination had worse general health in the past month than those who did not delay or delayed care for other reasons (B=−0.26, p<0.05); they also had 3.08 greater odds of having current depression, 3.81 greater odds of a past year suicide attempt, and 2.93 greater odds of past year suicidal ideation (p<0.001). After controlling for delayed care because of fear of discrimination, having a noninclusive PCP was not significantly associated with either general health or mental health.
Conclusion: This study suggests a significant association between delaying healthcare because of fear of discrimination and worse general and mental health among transgender adults. These relationships remain significant even when controlling for provider noninclusivity, suggesting that fear of discrimination and consequent delay of care are at the forefront of health challenges for transgender adults. The lack of statistical significance for noninclusive healthcare may be related to the measurement approach used; future research is needed to develop an improved tool for measuring transgender noninclusive healthcare.
PMCID: PMC5436369  PMID: 28861545
discrimination; health; healthcare; mental health; minority stress model; transgender
19.  Gender Identity, Sexual Orientation, and Eating-related Pathology in a National Sample of College Students 
This study examined associations of gender identity and sexual orientation with self-reported eating disorder (SR-ED) diagnosis and compensatory behaviors (CB) in trans- and cis-gender college students.
Data came from 289,024 students from 223 U.S. universities participating in The American College Health Association – National College Health Assessment II (median age 20 years). Rates of self-reported past year SR-ED diagnosis and past month use of diet pills and vomiting or laxatives were compared among transgender students (n=479) and cisgender sexual minority male (n=5,977) and female (n=9,445), unsure male (n=1,662) and female (n=3,395), and heterosexual male (n=91,599) and female (n=176,467) students using chi-squared tests. Logistic regression models were used to estimate the odds of eating-related pathology outcomes after adjusting for covariates.
Rates of past year SR-ED diagnosis and past month use of diet pills and vomiting or laxatives were highest among transgender students and lowest cisgender heterosexual men. Compared to cisgender heterosexual women, transgender students had greater odds of past year SR-ED diagnosis (OR: 4.62, 95% CI: 3.41-6.26) and past month use of diet pills (OR: 2.05, 95% CI: 1.48-2.83) and vomiting or laxatives (OR: 2.46, 95% CI: 1.83-3.30). Although cisgender sexual minority men and unsure men and women also had elevated rates of SR-ED diagnosis than heterosexual women, the magnitudes of these associations were lower than for transgender individuals (ORs: 1.40-1.54).
Transgender and cisgender sexual minority young adults have elevated rates of CB and SR-ED diagnosis. Appropriate interventions for these populations are urgently needed.
PMCID: PMC4545276  PMID: 25937471
Eating Disorders; Compensatory Behaviors; Gender Identity; Sexual Orientation; College Students
20.  Does our legal minimum drinking age modulate risk of first heavy drinking episode soon after drinking onset? Epidemiological evidence for the United States, 2006–2014 
PeerJ  2016;4:e2153.
Background. State-level ‘age 21’ drinking laws conform generally with the United States National Minimum Drinking Age Act of 1984 (US), and are thought to protect young people from adverse drinking experiences such as heavy episodic drinking (HED, sometimes called ‘binge drinking’). We shed light on this hypothesis while estimating the age-specific risk of transitioning from 1st full drink to 1st HED among 12-to-23-year-old newly incident drinkers, with challenge to a “gender gap” hypothesis and male excess described in HED prevalence reports.
Methods. The study population consisted of non-institutionalized civilians in the United States, with nine independently drawn nationally representative samples of more than 40,000 12-to-23-year-olds (2006–2014). Standardized audio computer-assisted self-interviews identified 43,000 newly incident drinkers (all with 1st HED evaluated within 12 months of drinking onset). Estimated age-specific HED risk soon after first full drink is evaluated for males and females.
Results. Among 12-to-23-year-old newly incident drinkers, an estimated 20–30% of females and 35–45% of males experienced their 1st HED within 12 months after drinking onset. Before mid-adolescence, there is no male excess in such HED risk. Those who postponed drinking to age 21 are not spared (27% for ‘postponer’ females; 95% CI [24–30]; 42% for ‘postponer’ males; 95% CI [38–45]). An estimated 10–18% females and 10–28% males experienced their 1st HED in the same month of their 1st drink; peak HED risk estimates are 18% for ‘postponer’ females (95% CI [15–21]) and 28% for ‘postponer’ males (95% CI [24–31]).
Conclusions. In the US, one in three young new drinkers transition into HED within 12 months after first drink. Those who postpone the 1st full drink until age 21 are not protected. Furthermore, ‘postponers’ have substantial risk for very rapid transition to HED. A male excess in this transition to HED is not observed until after age 14.
PMCID: PMC4924122  PMID: 27366651
Heavy episodic drinking; Newly incident drinkers; Adolescents; United States
Heavy episodic drinking (HED) is associated with sexual risk behavior and HIV seroconversion among men who have sex with men (MSM), yet few studies have examined heavy drinking typologies in this population.
We analyzed data from 4,075 HIV-uninfected MSM (aged 16 to 88) participating in EXPLORE, a 48-month behavioral intervention trial, to determine the patterns and predictors of HED trajectories. Heavy episodic drinking was defined as the number of days in which ≥5 alcohol drinks were consumed in the past 6 months. Longitudinal group-based mixture models were used to identify HED trajectories, and multinomial logistic regression was used to determine correlates of membership in each group.
We identified five distinct HED trajectories: non-heavy drinkers (31.9%); infrequent heavy drinkers (i.e., <10 heavy drinking days per 6 month period, 54.3%); regular heavy drinkers (30-45 heavy drinking days per 6 months, 8.4%); drinkers who increased HED over time (average 33 days in the past six months to 77 days at end of follow-up, 3.6%); and very frequent heavy drinkers (>100 days per 6 months, 1.7%). Intervention arm did not predict drinking trajectory patterns. Younger age, self-identifying as white, lower educational attainment, depressive symptoms, and stimulant use were also associated with reporting heavier drinking trajectories. Compared to non-heavy drinkers, participants who increased HED more often experienced a history of childhood sexual abuse. Over the study period, depressive symptomatology increased significantly among very frequent heavy drinkers.
Socioeconomic factors, substance use, depression, and childhood sexual abuse were associated with heavier drinking patterns among MSM. Multi-component interventions to reduce HED should seek to mitigate the adverse impacts of low educational attainment, depression, and early traumatic life events on the initiation, continuation or escalation of frequent HED among MSM.
PMCID: PMC4331451  PMID: 25684055
alcohol; men who have sex with men; depression; substance use; educational attainment
22.  Transgender sexual health in China: a cross-sectional online survey in China 
Sexually transmitted infections  2016;sextrans-2015-052350 10.1136/sextrans-2015-052350.
Transgender individuals are at increased risk for HIV infection around the world, yet few studies have focused on transgender individuals in China. We conducted an online cross-sectional survey of men who have sex with men (MSM) and transgender individuals to examine sociodemographics, intimate partner violence (IPV) and sexual behaviours in China.
We recruited participants (born biologically male, ≥16 years old, ever engaged in anal sex with men and agreed to provide cell phone number) from three web platforms in 2014. Data on sociodemographics, IPV and sexual behaviours were collected. Logistic regressions were performed to compare the differences between transgender individuals and non-transgender MSM.
Overall, 1424 eligible participants completed our online survey. Of these participants, 61 (4.3%) were transgender individuals, including 28 (2.0%) identifying as women and 33 (2.3%) identifying as transgender. Compared with MSM, transgender individuals were more likely to have experienced IPV and sexual violence (economic abuse, physical abuse, threat to harm loved ones, threat to ‘out’, forced sex). In addition, transgender individuals were more likely to have engaged in commercial sex (21.3% vs 5.1%, aOR 4.80, 95% CI 2.43 to 9.51) and group sex (26.2% vs 9.2%, aOR 3.47, 95% CI 1.58 to 6.48) in the last 12 months.
Our study is consistent with the emerging literature demonstrating increased sexual risk behaviours and high levels of IPV among transgender individuals. Future research should further investigate transgender individuals’ experiences of IPV and explore ways to promote disclosure of gender identity to healthcare providers. Furthermore, transgender research in China should be expanded independently of MSM research.
PMCID: PMC5053843  PMID: 27052037
23.  Perceived Discrimination and Heavy Episodic Drinking among African American Youth: Differences by Age and Reason for Discrimination 
To examine whether associations between perceived discrimination and heavy episodic drinking (HED) varies by age and by discrimination type (e.g., racial, age, physical appearance) among African American youth.
National data from the Panel Study of Income Dynamics Transition to Adulthood Study were analyzed. Youth participated in up to four interviews (2005, 2007, 2009, 2011; n=657) between ages 18–25. Respondents reported past-year engagement in HED (4 or more drinks for females, 5 or more drinks for males), and frequency of discriminatory acts experienced (e.g., receiving poor service, being treated with less courtesy). Categorical latent growth curve models, including perceived discrimination types (racial, age, and physical appearance) as a time-varying predictors of HED, were run in MPlus. Controls for gender, birth cohort, living arrangement in adolescence, familial wealth, parental alcohol use, and college attendance were explored.
The average HED trajectory was curvilinear (increasing followed by flattening), while perceived discrimination remained flat with age. In models including controls, odds of HED were significantly higher than average around ages 20–21 with greater frequency of perceived racial discrimination; associations were not significant at other ages. Discrimination attributed to age or physical appearance was not associated with HED at any age.
Perceived racial discrimination may be a particularly salient risk factor for HED around the ages of transition to legal access to alcohol among African American youth. Interventions to reduce discrimination or its impact could be targeted before this transition to ameliorate the negative outcomes associated with HED.
PMCID: PMC4621488  PMID: 26499858
Discrimination; heavy episodic drinking; early adulthood; minority health
24.  Internet-Delivered Dialectical Behavioral Therapy Skills Training for Suicidal and Heavy Episodic Drinkers: Protocol and Preliminary Results of a Randomized Controlled Trial 
JMIR Research Protocols  2017;6(10):e207.
The need to develop effective and accessible interventions for suicidal individuals engaging in heavy episodic drinking (HED) cannot be understated. While the link between alcohol use and suicidality is a complex one that remains to be elucidated, emotion dysregulation may play a key role in alcohol-related suicide risk in these individuals.
In the current study, an 8-week Internet-delivered dialectical behavior therapy (DBT) skills training intervention was developed and preliminarily evaluated for suicidal individuals who engage in HED to regulate emotions. The aim of the study is to evaluate the feasibility and effectiveness of the therapist-assisted and Internet-delivered intervention, and to inform the design of a subsequent full-scale study.
The study was a pilot randomized controlled trial comparing participants receiving immediate-treatment (n=30) to waitlist controls (n=29) over a period of 16 weeks. Intervention effects will be assessed longitudinally using hierarchical linear modeling and generalized estimating equations, along with analyses of effect sizes and clinically significant change. The primary outcomes are suicidal ideation, alcohol problems, and emotion dysregulation. Secondary outcomes include alcohol-related consequences, reasons for living, skills use, and depression.
The trial is ongoing. A total of 60 individuals returned their informed consent and were randomized, of whom 59 individuals were intended to treat. A total of 50 participants in the study were retained through the 16-week enrollment.
There is a dearth of evidence-based treatment for individuals presenting with high risk and complex behaviors. Furthermore, computerized interventions may provide a beneficial alternative to traditional therapies. The particular clinical features and treatment needs of suicidal individuals who also engage in HED constitute key domains for further investigation that are needed to consolidate the design of appropriate interventions for this high-risk population.
Trial Registration NCT02932241; (Archived by WebCite at
PMCID: PMC5677770  PMID: 29070480
dialectical behavioral therapy; randomized controlled trial; eMental health; suicide; heavy episodic drinking; emotion dysregulation
25.  Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center 
AIDS care  2015;27(8):1031-1036.
The sexual health of transgender adolescents and young adults who present for health care in urban community health centers is understudied. A retrospective review of electronic health record (EHR) data was conducted from 180 transgender patients aged 12–29 years seen for one or more health-care visits between 2001 and 2010 at an urban community health center serving youth in Boston, MA. Analyses were restricted to 145 sexually active transgender youth (87.3% of the sample). Laboratory-confirmed HIV and sexually transmitted infections (STIs) seroprevalence, demographics, sexual risk behavior, and structural and psychosocial risk indicators were extracted from the EHR. Analyses were descriptively focused for HIV and STIs. Stratified multivariable logistic regression models were fit for male-to-female (MTF) and female-to-male (FTM) patients separately to examine factors associated with any unprotected anal and/or vaginal sex (UAVS). The mean age was 20.0 (SD = 2.9); 21.7% people of color, 46.9% white (non-Hispanic), 21.4% race/ethnicity unknown; 43.4% MTF, and 56.6% FTM; and 68.3% were on cross-sex hormones. Prevalence of STIs: 4.8% HIV, 2.8% herpes simplex virus, 2.8% syphilis, 2.1% chlamydia, 2.1% gonorrhea, 2.8% hepatitis C, 1.4% human papilloma virus. Only gonorrhea prevalence significantly differed by gender identity (MTF 2.1% vs. 0.0% FTM; p = 0.046). Nearly half (47.6%) of the sample engaged in UAVS (52.4% MTF, 43.9% FTM, p = 0.311). FTM more frequently had a primary sex partner compared to MTF (48.8% vs. 25.4%; p = 0.004); MTF more frequently had a casual sex partner than FTM (69.8% vs. 42.7% p = 0.001). In multivariable models, MTF youth who were younger in age, white non-Hispanic, and reported a primary sex partner had increased odds of UAVS; whereas, FTM youth reporting a casual sex partner and current alcohol use had increased odds of UAVS (all p < 0.05). Factors associated with sexual risk differ for MTF and FTM youth. Partner type appears pivotal to understanding sexual risk in transgender adolescents and young adults. HIV and STI prevention efforts, including early intervention efforts, are needed in community-based settings serving transgender youth that attend to sex-specific (biological) and gender-related (social) pathways.
PMCID: PMC4624263  PMID: 25790139
transgender; youth; HIV; STI

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