Children in the U.S. whose activity choices, interests, and pretend play before age 11 fall outside those typically expressed by their biological sex face increased risk of being physically, psychologically, and sexually abused, and of suffering from posttraumatic stress disorder (PTSD) by early adulthood, according to a new study led by researchers at Harvard School of Public Health (HSPH). It is the first study to use a population-based sample to look at gender nonconformity as a risk factor for abuse. The study was published online February 20, 2012 and will appear in the March 2012 print issue of Pediatrics.

"The abuse we examined was mostly perpetrated by parents or other adults in the home. Parents need to be aware that discrimination against gender nonconformity affects one in ten kids, affects kids at a very young age, and has lasting impacts on health," said lead author Andrea Roberts, a research associate in the Department of Society, Human Development, and Health at HSPH. PTSD has been linked to risky behavior such as engaging in unprotected sex, and also to physical symptoms such as cardiovascular problems and chronic pain.

The researchers, led by Roberts and senior author S. Bryn Austin, associate professor in the Department of Society, Human Development, and Health at HSPH, and in the Division of Adolescent and Young Adult Medicine at Children's Hospital Boston, examined questionnaire data gathered from nearly 9,000 young adults (average age 23) who enrolled in the longitudinal Growing Up Today study in 1996. Respondents were asked in 2007 to recall their childhood experiences, including favorite toys and games, roles they took while playing, media characters they imitated or admired, and feelings of femininity and masculinity. They also were asked about physical, sexual, or emotional abuse they experienced and were screened for PTSD.

Men who ranked in the top 10th percentile of childhood gender nonconformity reported a higher prevalence of sexual and physical abuse before age 11 and psychological abuse between ages 11 and 17 compared with those below the median of nonconformity. Women in the top 10th percentile reported a higher prevalence of all forms of abuse as children compared with those below the median of nonconformity. Rates of PTSD were almost twice as high among young adults who were gender nonconforming in childhood than among those who were not.

The researchers also found that most children who were gender nonconforming were heterosexual in adulthood (85%), a finding reported for the first time in this study. "Our findings suggest that most of the intolerance toward gender nonconformity in children is targeted toward heterosexuals," said Roberts.

More research is needed to understand why gender nonconforming kids experience greater risk of abuse, and to develop interventions to prevent abuse, the researchers said. They recommend that pediatricians and school health providers consider abuse screening for this vulnerable population.

States that prescribe abstinence-only sex education programs in public schools have significantly higher teenage pregnancy and birth rates than states with more comprehensive sex education programs, researchers from the University of Georgia have determined. The researchers looked at teen pregnancy and birth data from 48 U.S. states to evaluate the effectiveness of those states' approaches to sex education, as prescribed by local laws and policies. "Our analysis adds to the overwhelming evidence indicating that abstinence-only education does not reduce teen pregnancy rates," said Kathrin Stanger-Hall, assistant professor of plant biology and biological sciences in the Franklin College of Arts and Sciences. Hall is first author on the resulting paper, which has been published online in the journal PLoS ONE.

The study is the first large-scale evidence that the type of sex education provided in public schools has a significant effect on teen pregnancy rates, Hall said. "This clearly shows that prescribed abstinence-only education in public schools does not lead to abstinent behavior," said David Hall, second author and assistant professor of genetics in the Franklin College. "It may even contribute to the high teen pregnancy rates in the U.S. compared to other industrialized countries."

Along with teen pregnancy rates and sex education methods, Hall and Stanger-Hall looked at the influence of socioeconomic status, education level, access to Medicaid waivers and ethnicity of each state's teen population. Even when accounting for these factors, which could potentially impact teen pregnancy rates, the significant relationship between sex education methods and teen pregnancy remained: the more strongly abstinence education is emphasized in state laws and policies, the higher the average teenage pregnancy and birth rates. "Because correlation does not imply causation, our analysis cannot demonstrate that emphasizing abstinence causes increased teen pregnancy. However, if abstinence education reduced teen pregnancy as proponents claim, the correlation would be in the opposite direction," said Stanger-Hall.

The paper indicates that states with the lowest teen pregnancy rates were those that prescribed comprehensive sex and/or HIV education, covering abstinence alongside proper contraception and condom use. States whose laws stressed the teaching of abstinence until marriage were significantly less successful in preventing teen pregnancies. These results come at an important time for legislators. A new evidence-based Teen Pregnancy Prevention Initiative was signed into federal law in December 2009 and awarded $114 million for implementation. However, federal abstinence-only funding was renewed for 2010 and beyond by including $250 million of mandatory abstinence-only funding as part of an amendment to the Senate Finance Committee's health-reform legislation. With two types of federal funding programs available, legislators of individual states now have the opportunity to decide which type of sex education -- and which funding option -- to choose for their state and possibly reconsider their state's sex education policies for public schools, while pursuing the ultimate goal of reducing teen pregnancy rates.

Stanger-Hall and Hall conducted this large-scale analysis to provide scientific evidence to inform this decision. "Advocates for continued abstinence-only education need to ask themselves: If teens don't learn about human reproduction, including safe sexual health practices to prevent unintended pregnancies and sexually transmitted diseases, as well as how to plan their reproductive adult life in school, then when should they learn it and from whom?" said Stanger-Hall.

Concordia study finds link between self acceptance, stress hormones and bullying

Young adults who are lesbian, gay or bisexual (LGB) are at far higher risk for severe mental health problems than their heterosexual peers. New research from Concordia University suggests that the stress of being rejected or victimized because of sexual orientation may disrupt hormonal responses in lesbians, gays and bisexuals.

Recently published as a doctoral thesis in clinical psychology, this investigation examined environmental risks and protective factors that counterbalanced them in LGB youth. "Compared to their heterosexual peers, suicide rates are up to 14 times higher among lesbian, gay and bisexual high school and college students," says Michael Benibgui, who led this investigation as part of his PhD thesis at Concordia's Department of Psychology and Centre for Research in Human Development.

"Depression and anxiety are widespread," he continues. "To learn why this occurs, we studied the physiological impact of homophobic social environments on a group of healthy young LGB adults."

Self loathing, stress hormones and bullying linked

The study examined the link between living in a homophobic environment and 'internalized homophobia,' e.g., feeling negatively about oneself because of one's sexual identity as LGB.

Individuals who experienced more LGB-related stress – arguments about sexual identity, bullying or discrimination – had higher internalized homophobia and showed increased production of the stress hormone cortisol compared to peers in more positive environments.

What's more, LGB youth who showed more internalized homophobia and abnormal cortisol activity also experienced increased symptoms of depression, anxiety and suicidal thoughts. "This study is among the first to clearly link the experience of homophobia with abnormal cortisol activity," says Benibgui.

Benibgui says abnormal cortisol activity in LGB youth, combined with the vicious cycle of stress, could be further influenced by a complex set of biological, psychological and social factors. "This study shows a clear relation between abnormal cortisol levels and environmental stressors related to homophobia," he says.

Protective factors of social networks

Benibgui also identified protective factors that can help safeguard mental health in young gays, lesbians and bisexuals. His research confirms that social support from parents and peers have protective effects. "LGB young adults who experienced more homophobic discrimination, yet felt accepted and supported by their peers, showed very few symptoms of depression," he says.

These findings underline the impact – both physical and mental – that homophobia may have on LGB young adults. "The effect on mental health of bullying in schools has received much attention," says Benibgui. "Our study supports the notion that homophobic bullying can lead to physical and mental health problems."

Preventative interventions are needed to protect vulnerable lesbian, gay or bisexual youth, Benibgui stresses, to discourage homophobic and heterosexist behaviors from peers and communities.

Paul Hastings, a former Concordia psychology professor who supervised Benibgui's thesis research, says that this study should push the conversation about the impact of homophobia.

"This study is one part of a much larger and greatly needed dialogue on the impacts that prejudice, discrimination and victimization have on healthy development and well-being in young people," says Dr. Hastings, an international member of the Centre for Research in Human Development and now a professor at the University of California, Davis. "We need to promote acceptance and respect for the diversity of our population – including sexual diversity – at all levels: government, community, schools and homes."

Women experiencing physical abuse from intimate partners spent 42 percent more on health care per year than non-abused women, according to a long-term study of more than 3,000 women. And the costs don't end when the abuse does. The study revealed that women who suffered physical abuse five or more years earlier still spent 19 percent more per year on health care than women who were never abused. "Along with all the physical and emotional pain it causes, domestic violence also comes with a substantial financial price," said Amy Bonomi, co-author of the study and associate professor of human development and family science at Ohio State University.

The study is the largest to date to examine health care costs and utilization based on the timing and type of domestic violence that women suffer, Bonomi said. The study, co-authored with researchers from the Group Health Cooperative and the University of Washington in Seattle, was published online this week in the journal Health Services Research. It will appear in an upcoming print edition.

The research examined data from 3,333 randomly selected women who belonged to Group Health, a health care system in the Pacific Northwest. Women in the study were surveyed about whether they experienced any physical or emotional abuse from intimate partners and if so, when it occurred. Researchers then studied patterns of health care use and costs by the women over an 11-year period, from 1992 through 2002.

"We were able to track health care costs for quite a long time, giving us a good picture of how much domestic violence is actually costing our health care system," Bonomi said. Women experiencing ongoing physical abuse had the highest health care costs -- 42 percent higher than non-abused women. "It's likely that these women need more health care because they are seeking care for immediate injuries and associated health problems," Bonomi said. Women who had been physically abused within the last five years, but not currently, had 24 percent higher yearly health costs. Abuse that occurred more than five years ago resulted in 19 percent higher costs.

The study separately examined women who experienced psychological abuse, which included verbal threats and chronic controlling behavior. Those suffering psychological abuse within the past five years, but not currently, had yearly health care costs that were 33 percent higher than those of non-abused women. "It's possible that it takes additional time for women with psychological abuse to seek care for their experiences," Bonomi said.

Another striking finding was that all abused women, whether they experienced physical or psychological abuse, used significantly more mental health services than non-abused women, Bonomi said. Women suffering ongoing physical abuse were about 2.5 times more likely to visit a mental health provider in the past year than were non-abused women. The rate for psychologically abused women was two times higher. "This lends support to the idea that mental health providers should always ask women about their abuse history when they first come in for treatment," Bonomi said.

But mental health was just one of several areas in which abused women used more services. Physically abused women used significantly more primary care, pharmacy, specialty care, laboratory and radiology services. For psychologically abused women, more services were needed in specialty care, pharmacy, and radiology.

Group Health, the health care system whose members were surveyed for the study, provides health and insurance services to more than 500,000 people in the Pacific Northwest.

No such gender disparity exists for younger women

Younger women have equivalent access to kidney transplants compared with their male counterparts, but older women receive transplants much less frequently than older men, according to a study appearing in the March 2009 issue of the Journal of the American Society Nephrology (JASN). The results suggest that steps are needed to ensure that women are provided with equal opportunities to receive kidney transplants as they age.

Researchers have reported that women have less access to kidney transplants than men, but this recent study indicates that this disparity does not affect all women. Dorry Segev, MD, of the Johns Hopkins Medical Institutions in Baltimore, MD, and his colleagues discovered this by studying the United States Renal Data System, which collects, analyzes, and distributes information about end-stage kidney disease in this country. Their analysis included 563,197 patients with end-stage kidney disease diagnosed between 2000 and 2005.

The investigators found that while young women in this group had equivalent access to transplantation when compared with their male counterparts, access for older women decreased significantly. Specifically, women aged 18 to 45 years had access to transplantation that was equivalent to men, women aged 46 to 55 years had 3% less access, women aged 56 to 65 years had 15% less access, women aged 66 to 75 had 29% less access, and women over 75 years had 59% less access.

These disparities existed for both access to the deceased donor waiting list as well as access to live donations. However, the gender disparities were limited to referral to the waiting list—once a woman was on the transplant list, her chances of receiving a transplant were equivalent to a man's. This is very different from other disparities in transplantation such as race disparities, in which African Americans are less likely to be referred to the waiting list and are also less likely to receive a transplant once on the list.

Dr. Segev and his team also found that for every age group analyzed in this study, women had a similar or slightly higher survival benefit from transplantation compared with men, indicating that there is no reason to deny women transplants as they age.

These findings could help researchers develop ways to reduce disparities in kidney allocation. "Knowing that the gender disparity is limited to older women indicates that efforts should be made to identify specific differences between older men and older women—rather than general differences between all men and women—in an effort to minimize the gender disparity in access to transplantation," said Dr. Segev.

UC-Davis researcher urges healthcare providers to look for signs of intimate partner violence

SACRAMENTO, Calif. -- Seven years ago, Elizabeth Miller was a volunteer physician in a community-based clinic in Boston, Mass., which offered confidential services to teens. She is still haunted by the memory of a 15-year old girl who asked her for a pregnancy test. It was negative, but two weeks later the girl was treated for a severe head injury in a nearby emergency room. The girl’s boyfriend had pushed her down a flight of stairs.

“I assumed all she needed was to be educated about her contraceptive options,” Miller recalled. “Later, I wondered what I had missed. Could I have asked a question that would have identified that she was in an abusive relationship"”

That nagging question inspired Miller, now a pediatrician with UC Davis Children’s Hospital, to dedicate her career to trying to understand the unique characteristics of adolescent partner violence.

In a new qualitative clinical study published in the September-October issue of the journal Ambulatory Pediatrics, Miller and her research colleagues report that a quarter of the teenage girls interviewed for the study – all of whom had histories of abusive relationships – say their partners were actively trying to get them pregnant. The study, available online today, is the first in the general adolescent health literature to document the role of abusive partners in promoting teen pregnancy.

“Physicians are trained to think about domestic violence in adult terms,” said Miller, a physician trained in both adult and pediatric medicine who specializes in treating adolescents. “Our study suggests that health-care providers who come in contact with teens, especially those seeking pregnancy testing and emergency contraception, should ask about the possibility of abuse in the relationship and specifically whether the young woman’s partner may be trying to get her pregnant.”

Miller’s study is based on interviews with 61 girls from a variety of racial and ethnic backgrounds with a known history of intimate partner violence living in the poorest neighborhoods in Boston. The analysis included 53 girls between the ages of 15 and 20 who reported being sexually active and involved in relationships that included recurring patterns of physical, sexual or emotional abuse from a male partner. Twenty-six percent of these girls reported that their partners were actively trying to get them pregnant by manipulating condom use, sabotaging birth control use and making explicit statements about wanting them to become pregnant.

“We were floored by what these girls told us,” Miller recalled. “You think of forced sex as an aspect of abusive relationships, but this takes that abuse a step further to reproductive control of a young woman’s body.”

Despite the small sample size, Miller describes the current study as a critically important first step toward understanding the nuances of control in intimate relationships and its role in teen pregnancy.

“Our study suggests that those providing care, especially reproductive care, to adolescent girls need to ask questions that reveal the complexities of partner violence, specifically whether a partner is actively trying to get her pregnant when she doesn’t want to be,” Miller said. “Historically, assessments in clinical settings have focused on physical and sexual violence – and for good reasons. However, our data argues for including questions, for instance, about whether a boyfriend is flushing birth control pills down the toilet or saying he used a condom when he didn’t. And pregnancy prevention programs should include discussions about reproductive control as a form of abuse in relationships.”

“This study demonstrates for the first time that abusive boys and men often actively promote pregnancy including contraceptive nonuse in their relationships,” said Jay Silverman, director of Violence Preventions Programs for the Harvard School of Public Health and senior author on the study. “The implications are clear – when we see girls who cannot consistently use contraception, who are requesting frequent emergency contraception or who seek repeat pregnancy testing, we need to be asking very directly about abuse from male partners and find ways to support them and promote their safety.”

Miller added that she and her colleagues will next look at the phenomenon of reproductive control in a larger study and at the population level. They just completed a clinic-based survey of 825 youth in the Boston area designed to address the prevalence of intimate partner violence and related behaviors among boys and girls seeking confidential care, and they are in the process of designing a national study to address these same issues.

Miller has also designed a study that would test interventions for partner violence in family planning clinics among women ages 16 to 24 years, and she is planning a study of dating violence intervention to be conducted in school-based clinics in California and Massachusetts. These interventions involve identifying intimate partner violence through screening questions and include a protocol for providing referrals to appropriate resources, such as advocacy groups, shelters, counseling and agencies that can address safety.

“Our work is aimed at documenting the severity and prevalence of intimate partner violence in teens,” Miller said. “Ultimately, we want to reduce teen pregnancy and the devastating effects of partner violence.”

Groundbreaking international legal principles on sexual orientation, gender identity, and international law have been released by 29 international human rights experts, led by University of Nottingham academic, Professor Michael O'Flaherty.

The "Yogyakarta Principles" call for worldwide action against violence, discrimination and abuse, by governments, the UN human rights system, national human rights institutions, non-governmental organisations, and others. The 29 principles contained in the Yogyakarta Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity establish the first ever set of principles on sexual orientation and gender identity, and are based upon a comprehensive analysis of current international human rights laws.

The principles identify the legal obligations of all States to ensure the universal reach of human rights protections. They were launched to coincide with the UN Human Rights Council's session in Geneva, where, in 2006, 54 States called for the Council to act against egregious violations of the rights of lesbian, gay, bisexual, and transgender people. "States have the primary obligation to respect, protect, and promote human rights," said Professor O'Flaherty, who is also a member of the UN Human Rights Committee, "Ending violence and abuse against people because of their sexual orientation or gender identity must become a global priority for governments."

The Yogyakarta Principles address a broad range of human rights standards. They were developed in response to well-documented patterns of abuse targeted toward persons because of their actual or perceived sexual orientation and gender identity.

Worldwide, human rights defenders point to violations including extrajudicial executions, violence and torture, repression of free speech and assembly, and discrimination in work, health, education, access to justice, and immigration.

The Principles were adopted by a group of distinguished experts in international law following a meeting in Yogyakarta, Indonesia. Among the group of experts are a former United Nations High Commissioner for Human Rights, UN independent experts, current and former members of human rights treaty bodies, judges, academics and human rights defenders.

The full text of the Yogyakarta Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity is available at: http://yogyakartaprinciples.org

A survey of 4,193 men living in New York City conducted by the New York City Department of Health and Mental Hygiene found that nearly 10 percent of male participants who identified themselves as straight reported having sex with at least one man during the previous year.

The study, "Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men," is published in the Sept. 19, 2006, issue of Annals of Internal Medicine.

Compared to men who identified themselves as gay, these men were more likely to belong to a minority racial or ethnic group, be foreign-born, have a lower educational level, and live outside Manhattan. Seventy percent reported being married. This group also was less likely to have been tested for HIV infection during the previous year and less likely to have used a condom during the last sexual encounter than men who identified themselves as gay.

"Doctors need to ask patients about specific sexual practices instead of relying on self-reported sexual orientation to assess risk for unsafe sexual practices and risk for sexually transmitted diseases," said Preeti Pathela, DrPH, lead author of the study. "Public health prevention messages should target risky sexual activities, such as unprotected receptive anal sex, and should not be framed to appeal solely to gay-identified men."

This study is one of the largest U.S. population-based surveys to report on the contrast between a man's self-identified sexual identity and his actual sexual behaviors.

EurekAlert!
19 September 2006