Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Let’s Get Physical: Sexual Orientation Disparities in Physical Activity,Sports Involvement,and Obesity Among a Population-Based Sample of Adolescents

Objectives. We examined sexual orientation disparities in physical activity, sports involvement, and obesity among a population-based adolescent sample.Methods. We analyzed data from the 2012 Dane County Youth Assessment for 13 933 students in grades 9 through 12 in 22 Wisconsin high schools. We conducted logistic regressions to examine sexual orientation disparities in physical activity, sports involvement, and body mass index among male and female adolescents.Results. When we accounted for several covariates, compared with heterosexual females, sexual minority females were less likely to participate in team sports (adjusted odds ratio [AOR] = 0.44; 95% confidence interval [CI] = 0.37, 0.53) and more likely to be overweight (AOR = 1.28; 95% CI = 1.02, 1.62) or obese (AOR = 1.88; 95% CI = 1.43, 2.48). Sexual minority males were less likely than heterosexual males to be physically active (AOR = 0.62; 95% CI = 0.46, 0.83) or to participate in team sports (AOR = 0.26; 95% CI = 0.20, 0.32), but the 2 groups did not differ in their risk of obesity.Conclusions. Sexual orientation health disparities in physical activity and obesity are evident during adolescence. Culturally affirming research, interventions, and policies are needed for sexual minority youths.Obesity is an increasing and serious health problem among adolescents.1,2 This is of major concern because obesity has many health and social consequences and it affects adolescents’ overall well-being.3,4 Obesity among adolescents also has a high likelihood of continuing into adulthood.5 Recent population-based and longitudinal research has demonstrated that there are disparities in obesity between sexual minority and heterosexual adolescents.6–8 Research has also documented sexual orientation disparities in physical activity and sports involvement in adolescence.9,10 Despite this increased attention, the overall empirical base remains limited, and findings also suggest some gender nuances that need further exploration. More population-based research is needed to investigate these disparities, consistent with federal health priorities.7,11There are sexual orientation–based disparities in physical activity and sports involvement among adolescents; however, there are mixed findings for females. One study reported that sexual minority females are less likely than heterosexual females to participate in moderate to vigorous physical activity and team sports,9 whereas another study found no such differences in physical activity.10 Findings are more consistent for sexual minority male adolescents, who are less likely than heterosexual males to engage in moderate to vigorous physical activity, to engage in recommended levels of physical activity, and to participate in team sports.9,10 More research is needed because of the paucity of studies and mixed results. This is especially important given that adolescents’ physical activity has been shown to relieve stress and protect against many mental and physical health conditions, including obesity,12,13 for which sexual minority adolescents are at greater risk.Research on sexual orientation disparities in obesity suggests that there are some gender nuances. Many studies have found that sexual minority female adolescents have higher risk of obesity than heterosexual females (e.g., higher body mass index [BMI], defined as weight in kilograms divided by the square of height in meters).6,8,10,14 These sexual orientation disparities in obesity among adolescent females parallel those among sexual minority adult women.15,16Findings of elevated obesity risk among sexual minority male adolescents are mixed. Some studies show that sexual minority males, specifically bisexual males, have higher odds of obesity than heterosexuals,14 whereas other studies have documented no differences.10 By contrast, some studies have found that heterosexual males have increases in BMI during adolescence compared with sexual minority males.6,8 These mixed findings for sexual minority males might be attributed to physical maturation and developmental changes in adolescence that some of the cross-sectional studies could not examine.10,14 Specifically, one study found that sexual minority males had higher obesity risk than heterosexual males in early adolescence, but their risk of obesity became lower than for heterosexual males later in adolescence.6 The authors postulated that, compared with heterosexual males, sexual minority males reach puberty maturation earlier in adolescence but make less substantial weight gains later in adolescence.6Sexual orientation health disparities have been explained through the minority stress model: sexual minority youths experience unique stressors and stigma related to their sexual identity (e.g., homophobic bullying), which lead to poorer health.17 Sexual minority adolescents might therefore be less likely to be physically active or involved in team sports because of potential minority stressors that they often experience at school, especially bias and heightened discrimination experienced in the context of sports or in their communities.18–20 More recently, the negative effects of minority stress and stigma on physical health disparities have been documented,21,22 including their effects on obesity for sexual minority women.23 However, the minority stress model is not sufficient in explaining how sexual minority adolescent females, but not males, are at greater risk for obesity compared with their heterosexual peers.Another potential explanation of these obesity disparities is related to cultural norms and sexual minority females’ experiences of internalizing ideals for femininity and appearance8 and sexual minority males’ ideals for muscularity and body image.24 For instance, compared with heterosexual women, sexual minority women are more likely to be satisfied with their bodies and attracted to women with greater body mass,25,26 whereas sexual minority men are less likely to be satisfied with their bodies compared with heterosexual men and are more likely to be attracted to muscular men.25,27 Therefore, these 2 groups might engage (or not engage) in differing body weight management and dieting behaviors compared with their heterosexual peers; concomitantly, these behaviors might render differing risks for obesity.Sexual minority adolescents’ lack of physical activity and sports involvement might be influenced by traditional gender norms associated with athleticism and sports, which has implications for their athletic self-esteem and involvement. For adolescent males, team sports are a means to define masculinity28; however, adolescent males often engage in homophobic banter to prove their masculinity and heterosexuality and to enforce traditional gender norms.29,30 Sexual prejudice is pervasive in athletic settings,19,20 making sports contexts unwelcoming and unsafe for many sexual minority males. Traditional feminine gender norms and homophobia also affect sexual minority females’ involvement in sports.31 However, sexual minority adolescent females have unique gendered experiences in relation to sports. Because women’s athleticism can be a stereotype for being a lesbian,32 sexual minority females might avoid sports involvement. Expecting or experiencing exclusion in sports settings might also affect sexual minority adolescents’ athletic self-esteem, consequently preventing them from engaging in future sports or physical activity.9 In fact, athletic self-esteem has been found to contribute to sexual orientation disparities in sports involvement and physical activity.9Emerging evidence of sexual orientation disparities in physical activity, sports involvement, and obesity among adolescents, in addition to potential gender nuances in these disparities, points to the need for more population-based research in this area. We therefore examined sexual orientation disparities among a large adolescent population-based sample and tested for gender differences. While accounting for variables commonly associated with physical activity and obesity among adolescents,4,33 we hypothesized that sexual minority adolescents would be less likely to report physical activity and sports involvement than would their heterosexual peers. We also hypothesized that sexual minority females would be at higher risk for being overweight and obese than their heterosexual peers. Because of mixed findings in existing sexual orientation disparities research among adolescent males, we hypothesized that sexual minority males would be at equal risk for being overweight and obese than their heterosexual male peers.     

The Effect of a “Maintain,Don’t Gain” Approach to Weight Management on Depression Among Black Women: Results From a Randomized Controlled Trial

Objectives. We evaluated the effect of a weight gain prevention intervention (Shape Program) on depression among socioeconomically disadvantaged overweight and obese Black women.Methods. Between 2009 and 2012, we conducted a randomized trial comparing a 12-month electronic health–based weight gain prevention intervention to usual primary care at 5 central North Carolina community health centers. We assessed depression with the Patient Health Questionnaire (PHQ-8). We analyzed change in depression score from baseline to 12- and 18-month follow-up across groups with mixed models. We used generalized estimating equation models to analyze group differences in the proportion above the clinical threshold for depression (PHQ-8 score ≥ 10).Results. At baseline, 20% of participants reported depression. Twelve-month change in depression scores was larger for intervention participants (mean difference = −1.85; 95% confidence interval = −3.08, −0.61; P = .004). There was a significant reduction in the proportion of intervention participants with depression at 12 months with no change in the usual-care group (11% vs 19%; P = .035). All effects persisted after we controlled for weight change and medication use. We saw similar findings at 18 months.Conclusions. The Shape Program, which includes no mention of mood, improved depression among socioeconomically disadvantaged Black women.Depression is one of the most common and disabling, yet treatable, mental health conditions in the United States.1,2 Women are twice as likely as men to be affected,3 and more than 1 in 7 (14.9%) Black women will experience major depression in their lifetime.4 Observational evidence suggests that, although the prevalence of major depression is lower among Blacks than Whites, its severity is greater for Blacks.5 This is likely a result of racial disparities in access to depression treatment.6 Indeed, compared with their White counterparts, Black adults with depression are less likely to receive treatment for depression (39.7% vs 54.0%).6 Of those who do seek treatment, Blacks are less likely than Whites to receive care that corresponds to clinical practice guidelines.6,7 These racial disparities are magnified by socioeconomic disadvantage.8 Depression is 3 times more common for those with incomes below the federal poverty level, compared with those with higher incomes.9 As a consequence, the challenge remains how to effectively treat socioeconomically disadvantaged Black women with depression.Obesity is also disproportionately prevalent among Black women relative to other racial/ethnic groups.10 The high burden of obesity among Black women not only indicates a higher prevalence of obesity-related chronic diseases (e.g., diabetes, heart disease),11 but it may also have an impact on psychosocial outcomes such as depression.12 As such, interventions focusing on behavioral weight control may present a useful opportunity to address both obesity and depression.Behavioral weight loss interventions typically include frequent contact with a weight loss counselor; self-monitoring of diet, exercise, and weight; and lessons that cover various topics such as problem solving, relapse prevention, and stress management. Indeed, across numerous studies, behavioral weight loss interventions have been shown to promote reductions in depression.13,14 Such findings are generally believed to be related to weight loss15 and mediated by improvements in body satisfaction; that is, for many, weight loss might enhance body satisfaction and, thus, improve depression outcomes.16,17 However, this finding has most frequently been demonstrated in predominantly socioeconomically advantaged White women, who tend to exhibit strong relations between body size and mood.16,18 In contrast, Black women have greater social acceptance of overweight, less body weight dissatisfaction, and higher body weight ideals compared with White women.19–22 Thus, it is unclear whether Black women would experience a similar reduction in depression as a result of obesity treatment.Although weight loss is indicated for those with obesity, promoting clinically meaningful weight change among Black women has been a major challenge.23 Across various studies, Black women achieve less weight loss relative to White women.24–26 The reason for this racial disparity in weight loss outcomes is unclear, but may be influenced in part by differences in sociocultural norms related to weight, diet, and physical activity.27 As a result, interventions that focus on preventing weight gain may be a useful alternative treatment approach among overweight and obese Black women.27We recently conducted a study titled the Shape Program, a 12-month randomized controlled trial with follow-up at 18 months, evaluating an electronic health weight gain prevention intervention among Black women compared with usual care in the primary care setting.27 The Shape intervention was found to be effective in staving off weight gain at 12 and 18 months.28 It is unclear whether a weight gain prevention approach, as was tested in Shape, would be helpful for treating depression among Black women. As such, we sought to examine the potential spillover benefits produced by this “maintain, don’t gain” approach on depression, compared with usual care.     

Effect of Depression on Risky Drinking and Response to a Screening,Brief Intervention,and Referral to Treatment Intervention

We assessed alcohol consumption and depression in 234 American Indian/Alaska Native women (aged 18–45 years) in Southern California. Women were randomized to intervention or assessment alone and followed for 6 months (2011–2013). Depression was associated with risk factors for alcohol-exposed pregnancy (AEP). Both treatment groups reduced drinking (P < .001). Depressed, but not nondepressed, women reduced drinking in response to SBIRT above the reduction in response to assessment alone. Screening for depression may assist in allocating women to specific AEP prevention interventions.Women who consume alcohol and do not practice effective contraception are at risk for an alcohol-exposed pregnancy (AEP). AEPs can lead to fetal alcohol spectrum disorders, the leading known cause of developmental disabilities.1–3 Prepregnancy drinking, particularly heavy episodic or binge drinking, is a robust predictor of AEP.4 Depression has been linked to problem alcohol consumption in women5–7 and appears to predate8,9 and perhaps predict10 alcohol problems. Among American Indian/Alaska Native (AI/AN) women, studies have linked depression to problem drinking.11–13 However, risk factors for an AEP and interventions to reduce risk for AEP have not been well studied in AI/AN women.14 This is further complicated by variability among AI/AN populations in the prevalence of alcohol consumption11,15–20 and depression.13,21–23One approach to prevention of AEPs is screening, brief intervention, and referral to treatment (SBIRT).24,25 We previously tested the effectiveness of an SBIRT intervention in AI/AN women and found that whether women received an assessment followed by the SBIRT intervention or assessment alone, they reported a significant reduction in alcohol use. We examined depression as a predictor of vulnerability to having an AEP and explored whether depressed AI/AN women respond differently than nondepressed women to an SBIRT intervention.     

Mediation by Peer Violence Victimization of Sexual Orientation Disparities in Cancer-Related Tobacco,Alcohol, and Sexual Risk Behaviors: Pooled Youth Risk Behavior Surveys

Objectives. We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.Results. PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.Conclusions. Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.The Institute of Medicine recently reviewed the research literature on health disparities between lesbian, gay, bisexual, and transgender individuals and heterosexuals across the life span.1 It identified the significant role of stigma in the health of lesbian, gay, bisexual, and transgender individuals and areas in need of research, including disparities in cancer between sexual minorities (lesbian, gay, and bisexual persons) and heterosexuals. Behaviors that increase cancer risk (e.g., tobacco and alcohol use, unprotected sexual intercourse) may be initiated during adolescence. For sexual minorities, peer violence victimization (PVV) may partly explain disparities in cancer-related risk behaviors because such disparities between sexual minorities and heterosexuals have been attributed to the differential burden of stigma experienced by sexual minorities.1Certain behaviors place one at risk for cancer, and sexual orientation disparities exist in those cancer-related risk behaviors. Tobacco and alcohol use are risk factors for various types of cancers, such as lung, esophageal, oropharyngeal, and colon.2–8 More sexual minority adults and youths than their heterosexual peers report tobacco and alcohol use.9–18Several sexual risk behaviors (number of partners, early age of first intercourse, concurrent sexual partners, lack of condom use, and substance use during intercourse) are known to increase vulnerability to infection with, for example, human papillomavirus (HPV)19–29 and hepatitis B.30,31 Women who have sex with women have elevated rates of such sexual risk behaviors relative to women who only have sex with men.32–34 Women who only have sex with women are less likely to be screened for sexually transmitted infections,33,35,36 despite the risk of HPV transmission during female-to-female sexual intercourse.37 HPV in men is important because it is linked to anal, oral, and penile cancers.24,38 The risk of cancer-related sexual behaviors may be elevated among sexual minority men, because of the links between anal intercourse, HPV, and anal cancer,39 especially among men who are HIV positive.40 Hepatitis B has been linked to liver cancer41 and increased risk of anal HPV among men.31     

Association of Depressive Symptoms and Substance Use With Risky Sexual Behavior and Sexually Transmitted Infections Among African American Female Adolescents Seeking Sexual Health Care

Objectives. We examined how depression and substance use interacted to predict risky sexual behavior and sexually transmitted infections (STIs) among African American female adolescents.Methods. We measured depressive symptoms, substance use, sexual behavior, and STIs in 701 African American female adolescents, aged 14 to 20 years, at baseline and at 6-month intervals for 36 months in Atlanta, Georgia (2005–2007). We used generalized estimating equation models to examine effects over the 36-month follow-up period.Results. At baseline, more than 40% of adolescents reported significant depressive symptoms; 64% also reported substance use in the 90 days before assessment. Depression was associated with recently incarcerated partner involvement, sexual sensation seeking, unprotected sex, and prevalent STIs (all P < .001). In addition, adolescents with depressive symptoms who reported any substance use (i.e., marijuana, alcohol, Ecstasy) were more likely to report incarcerated partner involvement, sexual sensation seeking, unprotected sex, and have an incident STI over the 36-month follow-up (all P < .05).Conclusions. African American female adolescents who reported depressive symptoms and substance use were more likely to engage in risky behavior and acquire incident STIs. This population might benefit from future prevention efforts targeting the intersection of depression and substance use.Although self-exploration and identity seeking are healthy aspects of adolescence, certain adverse behaviors, such as substance use and risky sexual behavior, have also been associated with adolescence. HIV, other sexually transmitted infections (STIs), and adolescent pregnancy are significant contributors to female adolescents’ morbidity and mortality in the United States.1 Adolescents aged 15 to 24 years account for approximately 50% of new STI cases each year,2 and it is estimated that 24.1% of adolescent girls aged 14 to 19 years have 1 of 5 commonly reported STIs (herpes simplex virus, trichomonaisis, chlamydia, gonorrhea, and human papilloma virus).3 Minority adolescents are disproportionately at higher risk for HIV and other STIs relative to their White counterparts.4 For example, African American adolescents account for 65% of HIV diagnoses among individuals aged 13 to 24 years.5 Among African American female adolescents aged 14 to 19 years, a national study found that 44% had at least 1 STI.3 Because African American female adolescents are at heightened risk for engaging in risky sexual behavior and STI acquisition, it is important to gain a better understanding of factors that may be associated with these risks. Two such factors are depressive symptoms and substance use or abuse.6–15In a national survey, 4.3% of youths, aged 12 to 17 years, reported current depression, and girls, regardless of age, were more likely to report depression than boys (6.7% vs 4.0%).16 In addition, 1 study found that among adolescents in mental health treatment, girls were more likely to use condoms inconsistently and were more than 9 times likely to contract an STI than were boys.17 The National Longitudinal Study of Adolescent Health found that 19.7% of African American female adolescents reported recent and chronic depressive symptoms compared with 13% among White female adolescents.18 Other studies found rates of depressive symptoms ranging from 40% to 55% among African American female adolescents.6,7,19 Previous research among African American female adolescents reported that depressive symptoms were associated with inconsistent condom use,6,10,12 multiple sexual partners,7,9,10 risky male sexual partners,6 sexual contact while high on alcohol or drugs,6,7,9,11 low frequency of sexual communication,6,7 fear of communication about condoms,6,7 self-reported previous or current STI,7,8,10 and biologically confirmed STIs.6With regards to substance use, a national survey revealed that among African American female 9th to 12th graders, 31.3% reported current alcohol use (vs 35.7% for White and 39.7% for Hispanic), 11.5% reported 5 or more drinks in a sitting (vs 21.1% for White and 22.6% for Hispanic), 27.1% reported current marijuana use (vs 18% for White and 27.4% for Hispanic), and 2.1% reported ever using Ecstasy (vs 4.6% for White and 10.1% for Hispanic).20 Another study found that approximately 27% of African American female adolescents reported having 3 or more drinks in a sitting.13 Substance use often co-occurred with sexual risk behaviors,20 placing adolescents at increased risk for less condom use. Among young African American women, substance use was associated with inconsistent condom use,13,15 sexual sensation seeking,13 multiple sexual partners,13,15 risky sexual partners,15 having sexual intercourse while high on alcohol or drugs,13 and STIs.13–15Previous studies established the relationship between depression, substance use, and risky sexual behavior, and although limited, some studies examined the longitudinal effects of depressive symptoms and substance use on sexual risk-taking among African American female adolescents.7,11–13,15 However, to our knowledge, there is scant research available on the interaction of depressive symptoms and substance use to longitudinally predict sexual risk-taking and STIs among this population. A previous study found that substance use mediated the relationship between depression and substance use, but this effect was only significant for male adolescents and not for female adolescents.8 In addition, this previous study sample included adolescents from multiple ethnicities; thus, the findings might not be applicable to African American adolescents.Because of the impact of these 2 factors on sexual risk-taking, combined with increased HIV/STI vulnerability among African American female adolescents, we aimed to expand upon the existing literature on depression, substance use, and risky sexual behavior in African American female adolescents. To advance the current knowledge and inform HIV/STI prevention efforts among this group, we examined the longitudinal effects of depression and substance use on risky sexual behavior and STI contraction, as well as the interaction between these 2 factors among a clinic-based sample of African American female adolescents over an extended period (36-month follow-up).     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

Breaking the Blue Wall of Silence: Risk Factors for Experiencing Police Sexual Misconduct Among Female Offenders

Objectives. We assessed the prevalence of and risk factors for trading sex with a police officer among women recruited from drug courts in St Louis, Missouri.Methods. In 2005 to 2008, we recruited women into an HIV intervention study, which surveyed participants about multiple sociodemographic, lifestyle, and risk factors. Regression analyses assessed risk factors for trading sex, a form of police sexual misconduct (PSM).Results. Of the 318 participants, 78 (25%) reported a lifetime history of PSM. Among women who experienced PSM, 96% had sex with an officer on duty, 77% had repeated exchanges, 31% reported rape by an officer, and 54% were offered favors by officers in exchange for sex; 87% said officers kept their promise. Only 51% of these respondents always used a condom with an officer. Multivariable models identified 4 or more arrests (adjusted odds ratio [AOR] = 2.8; 95% confidence interval [CI] = 1.29, 5.97), adult antisocial personality (AOR = 9.0; 95% CI = 2.08, 38.79), and lifetime comorbid cocaine and opiate use (AOR = 2.9 [1.62, 5.20]) as risk factors; employment (AOR = 0.4; 95% CI = 0.22, 0.77) lowered the risk of PSM.Conclusions. Community-based interventions are critical to reduce risk of abuse of vulnerable women by police officers charged with protecting communities.Female offenders represent a growing population of high-risk, vulnerable women in the United States. The number of women who are incarcerated or under correctional supervision increased from approximately 600 000 in 1990 to just more than 1.3 million in 2009.1 Many women involved in the criminal justice system experience stressful life events, suffer from mental disorders, and struggle with substance use problems.2,3Stressful and traumatic life events are common experiences for female offenders. Childhood physical or sexual abuse is such an event and is reported by a large proportion of female offenders4–6; according to the Bureau of Justice Statistics, 37% of women in state prisons, 23% of women in federal prisons, 37% of women in jail, and 28% of female probationers were victims of physical or sexual abuse as a minor. These rates exceed the range of 6% to 14% for men in respective facilities and estimates of 12% to 17% for women in the general adult population.5 Household dysfunction during childhood (e.g., family violence, parental separation or divorce, foster care or adoption placement) is more common among female offenders than women in the general population.6 In addition, the prevalence of other stressful life events, such as adolescent pregnancy and motherhood, among criminal justice samples is higher than national rates.6–8In addition to their experiences with stressful life events, female offenders have high rates of mental health problems, which have been reported among drug court participants,2,9–11 jail detainees,3 felons entering prison,12 prisoners,4,13,14 and offenders in prison substance abuse treatment programs.15,16 Comorbidities, particularly mental disorders and substance use disorders, are common in this population.14,17–19 For example, Teplin et al. found that more than 80% of jail detainees met criteria for 1 or more lifetime psychiatric disorders.3 Lifetime prevalence was highest for substance abuse or dependence (70.2%), posttraumatic stress disorder (33.5%), and major depressive episode (16.9%). Another study among drug-dependent female inmates in a substance abuse treatment program reported rates of 43% and 32% for antisocial personality and depression, respectively.15 Interestingly, the pattern of comorbidity differed such that women with a greater number of drug dependencies had higher rates of antisocial personality and depression than did women dependent on fewer drugs. Studies on gender differences among drug court populations have shown that female drug court participants are more likely than their male counterparts to have mental health problems; specifically, women are more likely than men to report feelings of depression and anxiety11 and to require referrals for mental health issues.2 Women who took more risks were also more likely to engage in gambling.20 Finally, the rate of female offenders’ mental disorder diagnoses exceeds that of the general population, with population prevalence estimates of 6% to 16% for major depressive disorder17,18 and less than 1% for antisocial personality disorder.21Police sexual violence, including rape, has been explored in a few studies in the criminological literature. Methods of these studies varied and included assessing police officers’ perspectives22 and reviewing publicly available records.23 In a study of 40 St Louis, Missouri–area police officers, 11 incidents of firsthand knowledge of a “sexual shakedown” were reported; this involved a demand for sexual services from an unwilling citizen who yielded to perceived police authority. However, these 11 incidents represented only a very small proportion of the 8306 total incidents of firsthand knowledge of police sexual misconduct (PSM). The most common type of PSM was nonsexual contact, such as a sexually motivated traffic stop, with 3481 reported incidents.22To understand the complex environmental factors that could affect behavioral change associated with an HIV prevention field trial focused on female offenders, we convened a series of focus groups at a St Louis correctional facility. Quite serendipitously, women shared with us that the sexual abuse experienced as a child with male relatives extended into their adulthood with other men in authority, specifically police officers.24To better understand the life events that affect female drug court participants, we added structured questions to focus on PSM, a neglected area of study masked by a “blue wall of silence”: an unwritten rule among some groups of police officers whereby officers ignore one another’s misconduct.22,23,25 We compared the experiences of female drug court participants who reported they had traded sex for favors with a police officer with those who did not and assessed sociodemographic characteristics, stressful life events, psychiatric history, and substance use as risk factors for this behavior.     

Gender-Equitable Attitudes,Bystander Behavior,and Recent Abuse Perpetration Against Heterosexual Dating Partners of Male High School Athletes

Objectives. We assessed the relationship between gender attitudes, identified as a critical component of violence prevention, and abuse toward dating partners among adolescent male athletes.Methods. Our sample comprised 1699 athletes from 16 high schools in northern California who were surveyed between December 2009 and October 2010 in the larger Coaching Boys Into Men trial. We used logistic regression to assess the association between gender-equitable attitudes, bystander behavior, and recent abuse incidents.Results. Athletes with more gender-equitable attitudes and greater intention to intervene were less likely (adjusted odds ratio [AOR] = 0.36; 95% confidence interval [CI] = 0.28, 0.46; and AOR = 0.60; 95% CI = 0.48, 0.75, respectively) and athletes who engaged in negative bystander behavior were more likely (AOR = 1.22, 95% CI = 1.10, 1.35) to perpetrate abuse against their female dating partners.Conclusions. Despite the shift among bystander intervention programs toward gender neutrality, our findings suggest a strong association between gender attitudes and dating violence. Programs designed for adolescents should include discussion of gender attitudes and target bystander behavior, because these components may operate on related but distinct pathways to reduce abuse.Adolescent relationship abuse among heterosexual youths is common, with 20% to 25% of adolescents reporting this exposure.1,2 Adolescent relationship abuse is a gendered exposure. Although adolescent boys report experiencing aggression or physical violence from their female dating partners,3 women and girls are more likely to experience such violence, particularly sexual assault, and to experience poor health as a result.4,5 This disparity has been attributed to social norms supportive of male dominance in sexual and dating relationships, normalization of the use of violence as a means of conflict resolution, and the perception that peers support aggressive and abusive behavior.6,7Gender-equitable norms (socially prescribed definitions of masculinity and equitable power in sexual relationships) have been recognized by the global health community as a critical component of violence prevention.8,9 A small body of literature has empirically tested the association of such attitudes with adolescent relationship abuse10,11 and adult intimate partner violence.12 Although attitudes that degrade women and legitimize violence have been shown to be modifiable in men,12–16 limited attention has been paid to addressing norms in the context of dating violence among adolescents.Recent work in the field has focused on the social context of violence by attempting to alter the behavior of men and boys when they witness peers perpetrating physical–sexual abuse, rather than targeting the behavior of individual perpetrators. This bystander intervention approach aims to help witnesses better recognize abusive behaviors and take responsibility to stop them.17–19 Early bystander intervention programs incorporated conversations about masculinity and power into their curricula, the most notable of which was designed for male high school and college athletes.20 The athletic context provided a unique opportunity to implement gender-transformative programming within a culture influenced by discourses of masculinity and power, and the program encouraged athletes to model respectful behavior for peers in the greater school community. Today, discussions of gender norms are largely absent from bystander intervention programs so as not to target individual perpetrators.20 Such gender-neutral programs consider the impact of power imbalances on violence, but the underlying causes of these imbalances are less clearly articulated.In light of the shift in bystander intervention programs toward gender neutrality,20 despite evidence that sexual violence and harassment are influenced by social norms regarding relationships and masculinity,21 we empirically examined the relationships between gender-equitable attitudes, bystander behavior, and abuse toward heterosexual dating partners among a sample of male high school athletes.     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.     

Syndemic Theory and HIV-Related Risk Among Young Transgender Women: The Role of Multiple,Co-Occurring Health Problems and Social Marginalization

Objectives. We assessed whether multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status (i.e., can be characterized as a syndemic) among young transgender women and the relationship of indicators of social marginalization to psychosocial factors.Methods. Participants (n = 151) were aged 15 to 24 years and lived in Chicago or Los Angeles. We collected data on psychosocial factors (low self-esteem, polysubstance use, victimization related to transgender identity, and intimate partner violence) and social marginalization indicators (history of commercial sex work, homelessness, and incarceration) through an interviewer-administered survey.Results. Syndemic factors were positively and additively related to sexual risk behavior and self-reported HIV infection. In addition, our syndemic index was significantly related to 2 indicators of social marginalization: a history of sex work and previous incarceration.Conclusions. These findings provide evidence for a syndemic of co-occurring psychosocial and health problems in young transgender women, taking place in a context of social marginalization.Transgender women (i.e., male-to-female transgender persons) are individuals whose gender identities are discordant with the male gender they were assigned at birth. During the developmental period from early adolescence through young adulthood, many transgender women struggle to develop a coherent sense of self while addressing feelings of guilt and shame about their identities and pressures to conform to familial, peer, and gender norms. Many feel the need for secrecy, either to pass in their chosen gender or to hide their true feelings to avoid rejection and discrimination.1 Instead of support and understanding from family, friends, and other adults, these women often experience social rejection and marginalization because of their gender identity and expression, as well as perceived sexual orientation.2–4 Rejection and marginalization are particularly harmful during this period of developmental vulnerability and often result in severe consequences, as evidenced by high rates of homelessness, trading sexual intercourse for food and other basic needs, and incarceration.5–9 A growing body of literature suggests that the marginalization experienced by these young women contributes to a wide range of negative health outcomes, such as psychological distress, substance abuse, and victimization (e.g., from verbal, physical, and sexual abuse). All of these outcomes are related to sexual risk behavior and HIV infection.5–8The prevalence of HIV infection among transgender women is equal to or greater than that among other traditionally high-risk groups, such as men who have sex with men (MSM).10 In a review of 29 studies of HIV incidence, prevalence, and related risk behavior among transgender individuals completed between 1990 and 2003, the average laboratory-confirmed HIV prevalence for transgender women across age groups was 27.7% (4 studies), and the average self-reported HIV prevalence was 11.8% (18 studies that reported prevalence estimates).10 More recent data from local testing of more than 500 transgender women with no known previous positive HIV test results in Miami Beach, Florida, and San Francisco and Los Angeles, California, found a 12% HIV infection prevalence, which suggests a high percentage of unrecognized HIV infection in this population.11 In an analysis by age, the most new HIV infections, representing 45% of all cases, were detected among those aged 20 to 29 years.11Estimates of HIV prevalence among young transgender women are scarce and based on very small, nonprobability samples. A community-based study of ethnic minority transgender women (aged 16–24 years; n = 51) found 22% with self-reported HIV-positive status.6 A previous analysis of study data from young transgender women (aged 15–24 years; n = 151), found a comparable rate of 19% self-reported HIV infection.7 The higher rate of self-reported HIV infection among young transgender women than among transgender women more generally may result from relatively high rates of HIV testing. A total of 87% of young transgender women in this study had been tested for HIV infection at least once.7 However, self-reported prevalence of HIV infection among these young women is still likely to be underestimated in light of the evidence of unrecognized infection among those aged 20 to 29 years.11High rates of unprotected receptive anal intercourse among young transgender women10 place them at risk for both acquiring and transmitting HIV infection. In the review of 29 studies, 31.7% of transgender women reported multiple, primarily male, sexual partners, and 48.3% reported having sexual intercourse with casual partners.10 The average proportion of any unprotected receptive anal intercourse was 44.1%, and the proportion of unprotected insertive anal intercourse was 27.4% (assessed across various recall periods).10 In the community-based study of young transgender women (n = 51), 59% reported having unprotected anal intercourse (receptive or insertive) in the past 12 months.6Multiple psychosocial health problems, including psychological distress, substance use, violence, and victimization are common among transgender women. For example, community surveys suggest rates of depression and suicidality that are up to 3 times as high as in the general population.3,12–14 Evidence indicates that substance use is common (previous 30-day use of alcohol = 50% and of marijuana = 38%)15 and that sexual intercourse under the influence of drugs and alcohol is also highly prevalent.15–17 Studies of violence and victimization among transgender women estimate that 21% to 68% have experienced forced sexual intercourse,9,18 and between 37% and 65% have experienced physical abuse, as either a child or an adult.9,15,18Similarly, evidence suggests that psychosocial health problems are prevalent among young transgender women. Garofalo et al., in their community-based study of 51 ethnic minority young transgender women, found that although self-esteem and depression were within the normal range on average, both were independently associated with unprotected anal intercourse.5 In another study, past-year alcohol and marijuana use were reported by 65% and 71% of participants, respectively.6 Wilson et al. reported that more than 90% of young transgender women in their study sample had used substances in their lifetime (88% had used alcohol; 63%, marijuana; 30%, cocaine; 32%, ecstasy; and 30%, methamphetamine).7 Sexual intercourse under the influence of alcohol or drugs was reported to be 50% in one study5 and 53% in another8 and was significantly associated with unprotected anal intercourse.5 Garofalo et al. found that more than half of participants reported a history of forced sexual intercourse, which was significantly associated with sexual risk behavior.5 Reported fear of partner anger and rejection were also given as reasons young transgender women engaged in unsafe sexual intercourse.6Psychological distress and substance abuse, as well as frequent experiences of violence and other forms of victimization, may contribute to HIV risk in this population, potentially fueling heightened rates of HIV infection. In light of the high HIV prevalence rates and the complexity of risk factors associated with risk behaviors and HIV acquisition, a leading group of experts in transgender health has suggested examining HIV risk among young transgender women within the framework of syndemic theory.19 Singer and Snipes coined the term syndemic for the health crisis (co-occurrence of substance use, AIDS, and violence) among poor and underserved inner-city women in the early 1990s.20 As described by Singer, a syndemic involves

a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions that increase vulnerability, significantly affect the overall disease status of a population.21^(p15)

Thus, a syndemic is more than the interaction of diseases; rather, it is the mutually reinforcing interaction of disease and social conditions.21–23 Singer and Clair describe syndemics as occurring in “noxious social conditions” and posits that they are often produced by “structural violence of social inequality.”22^(p434)Stall et al. applied syndemic theory to the study of HIV-related sexual risk among urban MSM. They found that increasing numbers of psychosocial health problems, polysubstance use, depression, partner violence, and childhood sexual abuse were significantly and positively associated with high-risk sexual behavior and HIV infection.24 Similarly, in an urban sample of ethnically diverse MSM aged 16 to 24 years, Mustanski et al. found that increasing numbers of psychosocial health problems, including binge drinking, street drug use, psychological distress, intimate partner violence, and sexual assault, increased the odds of multiple anal intercourse partners, unprotected anal intercourse, and HIV-positive status.25To our knowledge, syndemic theory has not previously been applied to the study of HIV risk among young transgender women; however, their marked social and economic marginalization and high prevalence of psychosocial health problems and HIV infection suggest that the principles underlying this theory may well apply. The syndemic model, therefore, served as a framework guiding our analysis. We chose specific psychosocial health problems for inclusion in our syndemic model—as the data would allow—that were similar to factors examined among both urban poor and underserved women and urban MSM and that reflected the life circumstances of young transgender women.We hypothesized that a syndemic of co-occurring health and psychosocial factors such as low self-esteem, polysubstance use, victimization related to transgender identity (e.g., verbal threats and insults, harrassment by chasing or following respondents or damaging their property, and physical assaults), and intimate partner violence (e.g., partner-controlling actions, verbal harassment, threats to physical safety, sexual violence, and pressure or coercion to hide female gender identity) are additive and associated with HIV infection and sexual risk for HIV infection. That is, the more psychosocial health problems reported, the greater the risk for both unsafe sexual behavior and HIV infection. In addition, Singer specified that a syndemic develops in a context of deleterious social conditions that increase vulnerability. Thus, we further tested indicators of social marginalization as correlates of this clustering of psychosocial factors. Our objectives were to (1) assess whether multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status among young transgender women (i.e., could be characterized as a syndemic) and (2) assess the relationship of indicators of social marginalization, such as a history of commercial sex work, homelessness, and incarceration, to these psychosocial factors.     

Sexual Orientation–Related Differences in Tobacco Use and Secondhand Smoke Exposure Among US Adults Aged 20 to 59 Years: 2003–2010 National Health and Nutrition Examination Surveys

Objectives. We investigated sexual orientation–related differences in tobacco use and secondhand smoke (SHS) exposure in a nationally representative sample of US adults.Methods. The 2003–2010 National Health and Nutrition Examination Surveys assessed 11 744 individuals aged 20 to 59 years for sexual orientation, tobacco use, and SHS exposure (cotinine levels ≥ 0.05 ng/mL in a nonsmoker). We used multivariate methods to compare tobacco use prevalence and SHS exposure among gay or lesbian (n = 180), bisexual (n = 273), homosexually experienced (n = 388), and exclusively heterosexual (n = 10 903) individuals, with adjustment for demographic confounding.Results. Lesbian and bisexual women evidenced higher rates of tobacco use than heterosexual women. Among nonsmokers, SHS exposure was more prevalent among lesbian and homosexually experienced women than among heterosexual women. Nonsmoking lesbians reported greater workplace exposure and bisexual women greater household exposure than heterosexual women did. Identical comparisons among men were not significant except for lower workplace exposure among nonsmoking gay men than among heterosexual men.Conclusions. Nonsmoking sexual-minority women are more likely to be exposed to SHS than nonsmoking heterosexual women. Public health efforts to reduce SHS exposure in this vulnerable population are needed.In 2006, the US Surgeon General1 concluded that secondhand smoke (SHS) exposure causes premature death and disease in nonsmoking persons2,3 and that there is no risk-free level of exposure.4 Although public health efforts to lower the rates of cigarette smoking have been generally successful over the years, cigarette smoking nevertheless remains one of the leading causes of death.5 Among nonsmokers, minority sexual orientation (i.e., lesbian, gay, bisexual, and homosexually experienced status) may be an unrecognized risk indicator for SHS exposure. Sexual minority individuals are more likely, as a group, to smoke tobacco than heterosexual men and women are.6–20 Indeed, estimates indicate that smoking rates may be twice as high among persons with a minority sexual orientation than among heterosexual individuals.21 Women with minority sexual orientation, in particular, consistently show elevation in risk compared with their same-gender heterosexual counterparts.10,13,22,23 Overall, this greater prevalence of tobacco use among friends and relationship partners of sexual minorities may inadvertently lead to higher levels of SHS exposure among nonsmoking sexual minorities.Although there is evidence that sexual minorities share similar levels of concern as heterosexuals do about the risk of SHS exposure,21 whether SHS exposure is nonetheless greater in this subpopulation is currently unknown, though there is reasoned suspicion that this might be so.24 We investigated possible sexual orientation–related differences in prevalence of primary tobacco use and SHS exposure by using information available from the 2003–2010 National Health and Nutrition Examination Surveys (NHANES). During these years, the NHANES assessed both respondents’ sexual orientation status and markers of tobacco use and SHS exposure. Consistent with previous studies, we hypothesized that individuals with minority sexual orientation, especially women, will show elevated tobacco use compared with their same-gender heterosexual counterparts. However, we also anticipated that, among nonsmokers, evidence of secondhand exposure to tobacco would be positively associated with minority sexual orientation.     

Community Influences on Young People's Sexual Behavior in 3 African Countries

Objectives. I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.Methods. I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.Results. The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people''s sexual behaviors.Conclusions. These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.Countries in sub-Saharan Africa are home to only 10% of the world''s population but account for approximately 85% of AIDS deaths worldwide.^1,2 Previous studies have highlighted high levels of sexual activity among young people (i.e., those aged 15–24 years) in many sub-Saharan African countries,^3–7 paralleled by increasing rates of HIV infection among young people.^1,8,9 Although young people in these countries have been shown to have high levels of knowledge regarding HIV/AIDS, studies have demonstrated significant deviation between such knowledge and reported sexual behaviors,^10–12 with high levels of risky sexual activity reported (e.g., failing to use a condom,¹³ engaging in transactional sex,^13,14 having multiple partners.^3,6,15).The health hazards associated with sexual risk taking among young people are well documented, but little is known about the factors associated with sexual behaviors among adolescents in developing countries.^13,15–20 In the few studies that have examined young people''s sexual behavior in these countries, a micro-level approach has been adopted, with a focus on individual characteristics as predictors of behavior²¹ and little consideration of the potential pathways through which the wider community may shape behavior.Condom use has often been the outcome of interest in studies of adolescent sexual behavior,^7,22–25 which is not surprising given the emphasis of many HIV prevention strategies on promoting condom use; other studies have examined factors associated with sexual activity or sexual debut.^1,15,17,26 Higher levels of risky sexual activity have been shown among young people (both male and female) and adult men^24,26 than among adult women.^4,6,27 In many sub-Saharan African countries, young women''s lack of negotiating power in sexual relationships is influenced by the large age differences common in many relationships,^3,14,27,28 the presence of violence or coercion,²⁵ and economic incentives to participate in risky sexual activities.¹⁴Educational attainment has been shown to be associated with young people''s sexual behaviors.^5–7,29 This relationship is more than simply a function of increased knowledge leading to positive health behaviors; the type of educational institution attended and the place of residence of the student have been shown to be influential in determining sexual behaviors,⁵ suggesting that these behaviors are also influenced by the degree of freedom afforded to the young person.Young women from poor households have been shown to be at particular risk of sexual risk taking, with their economic status motivating them to partake in transactional sex and serving as another limitation in their negotiating power with respect to condom use.^6,14 In terms of the influence of knowledge on behavior, some studies have demonstrated a disparity between knowledge regarding HIV risk and sexual behavior^12,22,30 such that many young people, despite knowing the risks associated with unprotected sexual activities, still engage in these activities. There is a limited amount of evidence suggesting that risk knowledge is a more protective factor against risky sexual activity among women than among men,³¹ with fear of unplanned pregnancy providing a greater deterrent for women than for men.Although much is known about the individual characteristics associated with sexual risk taking among young people, the role of the community in shaping such behaviors has been largely overlooked. In a study of adolescents residing in the United States, Billy et al.²¹ suggested that young people''s sexual behavior is strongly influenced by a community''s opportunity structure (i.e., presence of social and economic opportunities), which is composed of 3 key elements. The first element is the presence in the community of reproductive and sexual health services, which determines a young person''s access to information and services. The second element is the demographic profile of the community, which determines the presence of potential sexual partners. The final element is the presence or absence of economic or social opportunities, which influences young people''s perceptions regarding the opportunity costs of sexual behavior.Studies testing the theory of Billy et al. have largely been restricted to developed countries.^21,32 Although some studies have addressed the influence of community factors on young people''s sexual behavior in developing countries, these investigations have focused primarily on indicators of the presence of economic opportunities for young people,^33,34 failing to examine the roles of the cultural and social environments in shaping behavior.I examined community-level factors associated with risky sexual behaviors among young people in the African countries of Burkina Faso, Ghana, and Zambia. The goal of the study was to advance understanding of how the community environment shapes young people''s sexual behavior by considering a broad range of potential community influences, including social, behavioral, and demographic dimensions of the community environment.     

Sexual Orientation Disparities in Papanicolaou Test Use Among US Women: The Role of Sexual and Reproductive Health Services

We investigated sexual orientation disparities in Papanicolaou screening among US women aged 21 to 44 years (n = 9581) in the 2006 to 2010 National Survey of Family Growth. The odds ratios for lesbian versus heterosexual women and women with no versus only male sexual partners were 0.40 and 0.32, respectively, and were attenuated after adjustment for sexual and reproductive health (SRH) care indicators. Administering Papanicolaou tests through mechanisms other than SRH services would promote cervical cancer screening among all women.Cervical cancer, a deadly disease primarily caused by human papillomavirus infection,1 can be prevented through regular Papanicolaou (Pap) test use and appropriate follow-up.2,3 Although lesbians and women who have sex with women are at risk for human papillomavirus4–14 from both past and present sexual partners, limited evidence derived from convenience15,16 and subnational population-based16,17 samples suggests that they are less likely than heterosexual women and women with only male sexual partners, respectively, to receive Pap tests.8,9,15,17–22 We accordingly investigated sexual orientation disparities in Pap test use in a large US national probability sample, which no previous study has done, and assessed the contribution of sexual and reproductive health (SRH) services to sexual orientation disparities in Pap test use.     

Trends in Sexual Orientation Missing Data Over a Decade of the California Health Interview Survey

Objectives. We explored changes in sexual orientation question item completion in a large statewide health survey.Methods. We used 2003 to 2011 California Health Interview Survey data to investigate sexual orientation item nonresponse and sexual minority self-identification trends in a cross-sectional sample representing the noninstitutionalized California household population aged 18 to 70 years (n = 182 812 adults).Results. Asians, Hispanics, limited-English-proficient respondents, and those interviewed in non-English languages showed the greatest declines in sexual orientation item nonresponse. Asian women, regardless of English-proficiency status, had the highest odds of item nonresponse. Spanish interviews produced more nonresponse than English interviews and Asian-language interviews produced less nonresponse when we controlled for demographic factors and survey cycle. Sexual minority self-identification increased in concert with the item nonresponse decline.Conclusions. Sexual orientation nonresponse declines and the increase in sexual minority identification suggest greater acceptability of sexual orientation assessment in surveys. Item nonresponse rate convergence among races/ethnicities, language proficiency groups, and interview languages shows that sexual orientation can be measured in surveys of diverse populations.Measuring sexual orientation in health surveys facilitates comprehensive public health surveillance. Accumulating evidence suggests that some lesbians, gay men, and bisexual individuals, compared with heterosexual persons, have higher smoking rates,1,2 greater second-hand smoke exposure,3 more psychological distress4–6 and depression,7 higher suicide attempt rates,8 worse general health status9 and higher disability rates,10 and lower preventive care use.11 As a reflection on these emerging findings, calls for greater collection of sexual orientation data abound,12–17 but the validity of sexual-minority research is threatened if survey respondents cannot or will not provide these data.Several large health surveys now routinely measure sexual orientation. Since 2001, the California Health Interview Survey (CHIS) has included questions assessing self-identified sexual orientation.18 Twelve Behavioral Risk Factor Surveillance System state surveys also asked sexual orientation questions at least once between 2000 and 2014.19 Other large-scale surveys currently asking sexual orientation include the Los Angeles County Health Survey,20 National Health Interview Survey (NHIS),21 National Health and Nutrition Examination Survey,22 and General Social Survey.23Results from these surveys indicate that most respondents provide a codeable sexual orientation response. One percent of NHIS respondents in 2013 did not respond when asked their sexual orientation. “Don’t know” responses comprised 0.4% and refusals made up 0.6%.24 In 2003 to 2010 Washington State Behavioral Risk Factor Surveillance System data, 0.74% responded “don’t know” or “not sure,” and 1.12% refused.25 Yet, African Americans, Asian Americans, and Hispanics in that study had higher odds of nonresponse than Whites. This raises questions about possible sociodemographic differences in sexual orientation measurement, but there have been few assessments of the combined roles of race/ethnicity and language in sexual orientation item nonresponse, and changes in those effects over time.25,26 The independent effects of English proficiency and interview language remain largely unexplored as well. Linguistic and ethnic minorities who are also sexual minorities may be underrepresented in routine public health surveillance efforts if they are differentially likely to answer sexual orientation questions.25 Understanding the relationship among sexual orientation item nonresponse, race/ethnicity, and language proficiency is important because these sociodemographic domains correlate with health disparities.27-29Sexual orientation nonresponse is likely attributable to social stigma of identification and a lack of understanding of the terminology used to discuss the topic.30 Secular trends in lesbian, gay, and bisexual (LGB) social and legal recognition31 may increase LGB individuals’ willingness to disclose their sexual orientation in surveys. The non-LGB public may also become more comfortable with and knowledgeable about the topic as a result. Public opinion surveys now show majority support for gay marriage and LGB people in general.32,33 Sexual orientation item nonresponse should decline, and the percentage of respondents identifying as LGB may increase as stigma recedes and familiarity grows. These potential effects may be more pronounced among racial, ethnic, and linguistic minorities.25,26Two primary research questions guided this study:

• (1) Does the sexual orientation item nonresponse rate change over time?
• a. If so, is this change constant across races/ethnicities, English proficiency levels, and interview languages?
• b. How strongly do race/ethnicity, English proficiency, and interview language predict sexual orientation nonresponse?
• (2) Does LGB identification vary over the same time period?

     

Impact of an Exercise Intervention on Physical Activity During Pregnancy: The Behaviors Affecting Baby and You Study

Objectives. We examined the impact of a prenatal exercise intervention on physical activity in 260 women at risk for gestational diabetes mellitus.Methods. We randomized participants in the Behaviors Affecting Baby and You (BABY) Study, which took place from 2007 to 2012, to either a 12-week individually tailored, motivationally matched exercise intervention (n = 132) or to a comparison health and wellness intervention (n = 128). We assessed physical activity with the Pregnancy Physical Activity Questionnaire. We used linear mixed models to evaluate the impact of the interventions on change in physical activity according to intensity and type, total walking, and sedentary behavior.Results. Compared with the health and wellness arm, the exercise arm had significantly greater increases in sports or exercise activity (0.3 vs 5.3 metabolic equivalent of task [MET] hours/week; P < .001), and smaller declines in total activity (–42.7 vs –2.1 MET hours/week; P = .02) and activities of moderate to vigorous intensity (–30.6 vs −10.6 MET hours/week; P = .05), and was more likely to achieve recommended guidelines for physical activity (odds ratio = 2.12; 95% confidence interval = 1.45, 3.10).Conclusions. These findings extend the previous literature by demonstrating the benefits of a clinically feasible exercise intervention in an ethnically and socio-economically diverse population. Given the increased risk of adverse maternal health outcomes in ethnic minority groups, these findings may have important implications for reducing health disparities.The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who are free from medical or obstetric complications engage in 30 minutes or more of moderate intensity physical activity on most days of the week.1 Physical activity during pregnancy is associated with reduced risk for excess gestational weight gain,2–4 and a reduced risk of gestational diabetes mellitus (GDM)5 and preeclampsia.6 Despite the benefits of physical activity, pregnant women are less likely to meet physical activity recommendations than nonpregnant women of childbearing age.7,8 Furthermore, physical activity levels decline throughout pregnancy, even in women who were active before pregnancy.9,10 Physical activity levels are even lower in Hispanic women; Hispanic women are 40% less likely to meet recommended levels of physical activity than are non-Hispanic White women.11 These numbers are concerning because of the excess risk of adverse maternal outcomes, such as GDM, in Hispanic women.12 Thus, it is important to develop culturally adapted interventions that can engage pregnant women in more active lifestyles.The impact of exercise interventions during pregnancy has been conflicting. Several interventions have been successful at attenuating the decrease in physical activity levels over the course of pregnancy13–15; however, most studies have observed no impact.16–20 In addition, the majority of the successful interventions to date have been conducted in predominantly White non-Hispanic study populations or have used intensive interventions that may not be feasible in clinical practice.21Individually tailored, motivationally matched interventions have been shown to be cost-effective approaches to increasing physical activity in nonpregnant women in community settings.22,23 These interventions are also readily translatable to clinical practice. However, whether these programs are effective at increasing physical activity during pregnancy is unknown. Therefore, we assessed the effectiveness of an individually tailored, motivationally matched exercise intervention on physical activity levels in an ethnically diverse sample of pregnant women at high risk for GDM.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.